Factors influencing nurse and pharmacist willingness to take or not take responsibility for non-medical prescribing.

PubMed

Maddox, C; Halsall, D; Hall, J; Tully, M P

2016-01-01

In the UK, the majority of non-medical prescribers (NMPs) are nurses or pharmacists working in community or primary care. However, little is known about what influences their decisions to prescribe, unlike with medical prescribing. It is also unclear whether the medical findings can be extrapolated, given their very different prescribing training. To explore the factors influencing whether nurse and pharmacist NMPs in community and primary care settings take responsibility for prescribing. Initially, 20 NMPs (15 nurses and 5 pharmacists) were purposively selected and interviewed using the critical incident technique about situations where they felt it was inappropriate for them to take responsibility for prescribing or where they were uneasy about doing so. In addition, more general factors influencing their decision to take or not take prescribing responsibility were discussed. Subsequently, the themes from the interview analysis were validated in three focus groups with a total of 10 nurse NMPs. All data were analyzed using a constant comparison approach. Fifty-two critical incidents were recorded--12 from pharmacist NMPs and 40 from nurse NMPs. Participants experienced situations where they were reluctant to accept responsibility for prescribing. Perceptions of competency, role and risk influenced their decision to prescribe. Workarounds such as delaying the prescribing decision or refer the patient to a doctor were used. For NMPs to feel more confident about taking responsibility for prescribing, these issues of competency, role and perceived risk need to be addressed. Roles of NMPs must be clear to colleagues, doctors and patients. Training and support must be provided to enable professional development and increasing competence of NMPs. Copyright © 2016 Elsevier Inc. All rights reserved.

Models and theories of prescribing decisions: A review and suggested a new model.

PubMed

Murshid, Mohsen Ali; Mohaidin, Zurina

2017-01-01

To date, research on the prescribing decisions of physician lacks sound theoretical foundations. In fact, drug prescribing by doctors is a complex phenomenon influenced by various factors. Most of the existing studies in the area of drug prescription explain the process of decision-making by physicians via the exploratory approach rather than theoretical. Therefore, this review is an attempt to suggest a value conceptual model that explains the theoretical linkages existing between marketing efforts, patient and pharmacist and physician decision to prescribe the drugs. The paper follows an inclusive review approach and applies the previous theoretical models of prescribing behaviour to identify the relational factors. More specifically, the report identifies and uses several valuable perspectives such as the 'persuasion theory - elaboration likelihood model', the stimuli-response marketing model', the 'agency theory', the theory of planned behaviour,' and 'social power theory,' in developing an innovative conceptual paradigm. Based on the combination of existing methods and previous models, this paper suggests a new conceptual model of the physician decision-making process. This unique model has the potential for use in further research.

What female patients feel about the offer of a chaperone by a male sexual health practitioner.

PubMed

Simanjuntak, C; Cummings, R; Chen, M Y; Williams, H; Snow, A; Fairley, C K

2009-03-01

The aim of this study was to determine the experience and views of female patients when they were offered a chaperone by a male sexual health practitioner for a genital examination. Between November 2007 and January 2008, an anonymous survey was administered to female patients seen by male practitioners at Melbourne Sexual Health Centre. None of the 79 (95% CI 0-5%) patients who were offered a chaperone and declined one reported that they were uncomfortable declining the offer. The qualitative analysis showed that some participants appreciated being offered the option of a chaperone even if they did not want one and that the professional attributes of the practitioner influenced their decision not to have a chaperone. Only 8% (95%CI 4-15%) felt uncomfortable when asked if they would like a chaperone. The results reassure that when a female patient declines the offer of a chaperone within a sexual health clinic, the male practitioner can feel confident that this is the expression of the patient's wish.

Qualitative interviews regarding pharmacist prescribing in the community setting.

PubMed

Feehan, Michael; Durante, Richard; Ruble, Jim; Munger, Mark A

2016-09-15

The perceived demand for and barriers to pharmacist prescribing in the community pharmacy setting were studied. Qualitative interviews were conducted with 19 consumers, 20 community pharmacists, and 8 reimbursement decision-makers from payer organizations between April and June 2015. Respondents were invited to participate in a daylong interview process online. Interviews with consumers and pharmacists were conducted using online bulletin board technology. Telephone interviews were conducted with reimbursement decision-makers. As with all qualitative research, the sample sizes used were restrictive and sufficient to gauge the perceptions of those respondents only. Interview responses were not intended to be generalizable to the groups or populations from which the respondents came. There was a continuum of interest in pharmacist prescribing across the three constituencies. Consumers were predominantly resistant to the notion; however, one third were more positive about the idea. Community pharmacists were more open, particularly when prescribing was restricted to a limited set of conditions or medications. Reimbursement decision-makers were most receptive to the notion. Key barriers to pharmacist prescribing included low awareness of current pharmacist prescribing authority among consumers, concerns about the adequacy of pharmacist training, potential conflicts of interest when the prescriber was also a dispenser, and potential liability issues. Consumer respondents were generally resistant to the notion of pharmacist prescribing, with most viewing pharmacists as dispensers and not prescribers. Community pharmacists were more open to the idea, while reimbursement decision-makers were the most receptive to the notion of pharmacist prescribing. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Factors influencing secondary care pharmacist and nurse independent prescribers' clinical reasoning: An interprofessional analysis.

PubMed

Abuzour, Aseel S; Lewis, Penny J; Tully, Mary P

2018-03-01

In the United Kingdom, pharmacist and nurse independent prescribers are responsible for both the clinical assessment of and prescribing for patients. Prescribing is a complex skill that entails the application of knowledge, skills, and clinical reasoning to arrive at a clinically appropriate decision. Decision-making is influenced and informed by many factors. This study, the first of its kind, explores what factors influence pharmacist and nurse independent prescribers during the process of clinical reasoning. A think-aloud methodology immediately followed by a semi-structured interview was conducted with 11 active nurse and 10 pharmacist independent prescribers working in secondary care. Each participant was presented with validated clinical vignettes for the think-aloud stage. Participants chose the clinical therapeutic areas for the vignettes, based on their self-perceived competencies. Data were audio-recorded, transcribed verbatim, and a constant-comparative approach was used for analysis. Influences on clinical reasoning were broadly categorised into themes: social interaction, intrinsic, and contextual factors. These themes showed that intrinsic, sociocultural, and contextual aspects heavily influenced the clinical reasoning processes of prescribers. For example, prescribers were aware of treatment pathways, but chose to refer patient cases to avoid making the final prescribing decision. Exploration of this behaviour in the interviews revealed that previous experience and attitudes such as confidence and cautiousness associated with responsibility were strong influencers within the decision-making process. In addition, strengthening the professional identity of prescribers could be achieved through collaborative work with interprofessional healthcare teams to orient their professional practice from within the profession. Findings from this study can be used to inform the education, training, and practice of independent prescribers to improve healthcare services by improving their professional and interprofessional development.

Factors influencing antibiotic-prescribing decisions among inpatient physicians: a qualitative investigation

PubMed Central

Livorsi, D; Comer, AR; Matthias, MS; Perencevich, EN; Bair, MJ

2016-01-01

Objective To understand the professional and psychosocial factors that influence physicians' antibiotic-prescribing habits in the inpatient setting. Design We conducted semi-structured interviews with 30 inpatient physicians. Interviews consisted of open-ended questions and flexible probes based on participants' responses. Interviews were audio recorded, transcribed, de-identified, and reviewed for accuracy and completeness. Data were analyzed using emergent thematic analysis. Setting Two teaching hospitals in Indianapolis, IN Participants Thirty inpatient physicians (10 physicians-in-training, 20 supervising staff) Results Participants recognized that antibiotics are over-used, and many admitted to prescribing antibiotics even when the clinical evidence of infection was uncertain. Over-prescription was largely driven by anxiety about missing an infection while potential adverse effects of antibiotics did not strongly influence decision-making. Participants did not routinely disclose potential adverse effects of antibiotics to inpatients. Physicians-in-training were strongly influenced by the antibiotic prescribing behavior of their supervising staff physicians. Participants sometimes questioned their colleagues' antibiotic-prescribing decisions but frequently avoided providing direct feedback or critique, citing obstacles of hierarchy, infrequent face-to-face encounters, and the awkwardness of these conversations. Conclusion There is a physician-based culture of prescribing antibiotics, which involves over-using antibiotics and not challenging colleagues' decisions. The potential adverse effects of antibiotics do not strongly influence decision-making in this sample. A better understanding of these factors could be leveraged in future efforts to improve antibiotic-prescribing in the inpatient setting. PMID:26078017

GPs' decision-making when prescribing medicines for breastfeeding women: Content analysis of a survey.

PubMed

Jayawickrama, Hiranya S; Amir, Lisa H; Pirotta, Marie V

2010-03-23

Many breastfeeding women seek medical care from general practitioners (GPs) for various health problems and GPs may consider prescribing medicines in these consultations. Prescribing medicines to a breastfeeding mother may lead to untimely cessation of breastfeeding or a breastfeeding mother may be denied medicines due to the possible risk to her infant, both of which may lead to unwanted consequences. Information on factors governing GPs' decision-making and their views in such situations is limited. GPs providing shared maternity care at the Royal Women's Hospital, Melbourne were surveyed using an anonymous postal survey to determine their knowledge, attitudes and practices on medicines and breastfeeding, in 2007/2008 (n = 640). Content analysis of their response to a question concerning decision-making about the use of medicine for a breastfeeding woman was conducted. A thematic network was constructed with basic, organising and global themes. 335 (52%) GPs responded to the survey, and 253 (76%) provided information on the last time they had to decide about the use of medicine for a breastfeeding woman. Conditions reported were mastitis (24%), other infections (24%) and depressive disorders (21%). The global theme that emerged was "complexity of managing risk in prescribing for breastfeeding women". The organising themes were: certainty around decision-making; uncertainty around decision-making; need for drug information to be available, consistent and reliable; joint decision-making; the vulnerable "third party" and infant feeding decision. Decision-making is a spectrum from a straight forward decision, such as treatment of mastitis, to a complicated one requiring multiple inputs and consideration. GPs use more information seeking and collaboration in decision-making when they perceive the problem to be more complex, for example, in postnatal depression. GPs feel that prescribing medicines for breastfeeding women is a contentious issue. They manage the risk of prescribing by gathering information and assessing the possible effects on the breastfed infant. Without evidence-based information, they sometimes recommend cessation of breastfeeding unnecessarily.

Building a standards-based and collaborative e-prescribing tool: MyRxPad.

PubMed

Nelson, Stuart J; Zeng, Kelly; Kilbourne, John

2011-01-01

MyRxPad (rxp.nlm.nih.gov) is a prototype application intended to enable a practitioner-patient collaborative approach towards e-prescribing: patients play an active role by maintaining up-to-date and accurate medication lists. Prescribers make well-informed and safe prescribing decisions based on personal medication records contributed by patients. MyRxPad is thus the vehicle for collaborations with patients using MyMedicationList (MML). Integration with personal medication records in the context of e-prescribing is thus enabled. We present our experience in applying RxNorm in an e-prescribing setting: using standard names and codes to capture prescribed medication as well as extracting information from RxNorm to support medication-related clinical decision.

International Atomic Energy Agency study with referring physicians on patient radiation exposure and its tracking: a prospective survey using a web-based questionnaire

PubMed Central

Rehani, Madan M; Berris, Theocharis

2012-01-01

Objectives To assess the following themes among referring physicians: (A) importance of acquiring information about previous diagnostic exposures; (B) knowledge about radiation doses involved, familiarity with radiation units and, age-related radiosensitivity; (C) opinion on whether patients should be provided information about radiation dose and (D) self-assessment of appropriateness of referrals. Design A prospective survey using a web-based questionnaire. Setting International survey among referring physicians. Participants Referring physicians from 28 countries. Main outcome measures Knowledge, opinion and practice of the four themes of the survey. Results All 728 responses from 28 countries (52.3% from developed and 47.7% from developing countries) indicated that while the vast majority (71.7%) of physicians feel that being aware of history of CT scans would always or mostly lead them to a better decision on referring patients for CT scans, only 43.4% often enquire about it. The majority of referring physicians (60.5%) stated that having a system that provides quick information about patient exposure history would be useful. The knowledge about radiation doses involved is poor, as only one-third (34.7%) of respondents chose the correct option of the number of chest x-rays with equivalence of a CT scan. In total, 70.9% of physicians stated that they do not feel uncomfortable when patients ask about radiation risk from CT scans they prescribe. Most physicians (85.6%) assessed that they have rarely prescribed CT scans of no clinical use in patient management. Conclusions This first ever multinational survey among referring physicians from 28 countries indicates support for a system that provides radiation exposure history of the patient, demonstrates poor knowledge about radiation doses, supports radiation risk communication with patients and mandatory provisions for justification of a CT examination. PMID:22997065

Models and theories of prescribing decisions: A review and suggested a new model

PubMed Central

Mohaidin, Zurina

2017-01-01

To date, research on the prescribing decisions of physician lacks sound theoretical foundations. In fact, drug prescribing by doctors is a complex phenomenon influenced by various factors. Most of the existing studies in the area of drug prescription explain the process of decision-making by physicians via the exploratory approach rather than theoretical. Therefore, this review is an attempt to suggest a value conceptual model that explains the theoretical linkages existing between marketing efforts, patient and pharmacist and physician decision to prescribe the drugs. The paper follows an inclusive review approach and applies the previous theoretical models of prescribing behaviour to identify the relational factors. More specifically, the report identifies and uses several valuable perspectives such as the ‘persuasion theory - elaboration likelihood model’, the stimuli–response marketing model’, the ‘agency theory’, the theory of planned behaviour,’ and ‘social power theory,’ in developing an innovative conceptual paradigm. Based on the combination of existing methods and previous models, this paper suggests a new conceptual model of the physician decision-making process. This unique model has the potential for use in further research. PMID:28690701

Using E-Learning to Improve Prescribing Practice in Emerging Prescribers

ERIC Educational Resources Information Center

Baskett, Karen

2011-01-01

This paper reports on "The National Prescribing Curriculum" (NPC), a series of online, case-based modules designed to improve prescribing performance and confidence in emerging Australian prescribers. The modules mirror the decision-making process outlined in the "WHO Guide to Good Prescribing" (de Vries "et al.",…

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors

PubMed Central

Shah, Priya; Wyatt, Jeremy C; Makubate, Boikanyo; Cross, Frank W

2011-01-01

Objective Expert authorities recommend clinical decision support systems to reduce prescribing error rates, yet large numbers of insignificant on-screen alerts presented in modal dialog boxes persistently interrupt clinicians, limiting the effectiveness of these systems. This study compared the impact of modal and non-modal electronic (e-) prescribing alerts on prescribing error rates, to help inform the design of clinical decision support systems. Design A randomized study of 24 junior doctors each performing 30 simulated prescribing tasks in random order with a prototype e-prescribing system. Using a within-participant design, doctors were randomized to be shown one of three types of e-prescribing alert (modal, non-modal, no alert) during each prescribing task. Measurements The main outcome measure was prescribing error rate. Structured interviews were performed to elicit participants' preferences for the prescribing alerts and their views on clinical decision support systems. Results Participants exposed to modal alerts were 11.6 times less likely to make a prescribing error than those not shown an alert (OR 11.56, 95% CI 6.00 to 22.26). Those shown a non-modal alert were 3.2 times less likely to make a prescribing error (OR 3.18, 95% CI 1.91 to 5.30) than those not shown an alert. The error rate with non-modal alerts was 3.6 times higher than with modal alerts (95% CI 1.88 to 7.04). Conclusions Both kinds of e-prescribing alerts significantly reduced prescribing error rates, but modal alerts were over three times more effective than non-modal alerts. This study provides new evidence about the relative effects of modal and non-modal alerts on prescribing outcomes. PMID:21836158

Physician Attitudes toward Adopting Genome-Guided Prescribing through Clinical Decision Support

PubMed Central

Overby, Casey Lynnette; Erwin, Angelika Ludtke; Abul-Husn, Noura S.; Ellis, Stephen B.; Scott, Stuart A.; Obeng, Aniwaa Owusu; Kannry, Joseph L.; Hripcsak, George; Bottinger, Erwin P.; Gottesman, Omri

2014-01-01

This study assessed physician attitudes toward adopting genome-guided prescribing through clinical decision support (CDS), prior to enlisting in the Clinical Implementation of Personalized Medicine through Electronic Health Records and Genomics pilot pharmacogenomics project (CLIPMERGE PGx). We developed a survey instrument that includes the Evidence Based Practice Attitude Scale, adapted to measure attitudes toward adopting genome-informed interventions (EBPAS-GII). The survey also includes items to measure physicians’ characteristics (awareness, experience, and perceived usefulness), attitudes about personal genome testing (PGT) services, and comfort using technology. We surveyed 101 General Internal Medicine physicians from the Icahn School of Medicine at Mount Sinai (ISMMS). The majority were residency program trainees (~88%). Prior to enlisting into CLIPMERGE PGx, most physicians were aware of and had used decision support aids. Few physicians, however, were aware of and had used genome-guided prescribing. The majority of physicians viewed decision support aids and genotype data as being useful for making prescribing decisions. Most physicians had not heard of, but were willing to use, PGT services and felt comfortable interpreting PGT results. Most physicians were comfortable with technology. Physicians who perceived genotype data to be useful in making prescribing decisions, had more positive attitudes toward adopting genome-guided prescribing through CDS. Our findings suggest that internal medicine physicians have a deficit in their familiarity and comfort interpreting and using genomic information. This has reinforced the importance of gathering feedback and guidance from our enrolled physicians when designing genome-guided CDS and the importance of prioritizing genomic medicine education at our institutions. PMID:25562141

Prescription drug abuse communication: A qualitative analysis of prescriber and pharmacist perceptions and behaviors.

PubMed

Hagemeier, Nicholas E; Tudiver, Fred; Brewster, Scott; Hagy, Elizabeth J; Hagaman, Angela; Pack, Robert P

Interpersonal communication is inherent in a majority of strategies seeking to engage prescriber and pharmacist health care professionals (HCPs) in the reduction and prevention of prescription drug abuse (PDA). However, research on HCP PDA communication behavioral engagement and factors that influence it is limited. This study quantitatively examined communication behaviors and trait-level communication metrics, and qualitatively described prescription drug abuse-related communication perceptions and behaviors among primary care prescribers and community pharmacists. Five focus groups (N = 35) were conducted within the Appalachian Research Network (AppNET), a rural primary care practice-based research network (PBRN) in South Central Appalachia between February and October, 2014. Focus groups were structured around the administration of three previously validated trait-level communication survey instruments, and one instrument developed by the investigators to gauge HCP prescription drug abuse communication engagement and perceived communication importance. Using a grounded theory approach, focus group themes were inductively derived and coded independently by study investigators. Member-checking interviews were conducted to validate derived themes. Respondents' trait-level communication self-perceptions indicated low communication apprehension, high self-perceived communication competence, and average willingness to communicate as compared to instrument specific criteria and norms. Significant variation in HCP communication behavior engagement was noted specific to PDA. Two overarching themes were noted for HCP-patient communication: 1) influencers of HCP communication and prescribing/dispensing behaviors, and 2) communication behaviors. Multiple sub-themes were identified within each theme. Similarities were noted in perceptions and behaviors across both prescribers and pharmacists. Despite the perceived importance of engaging in PDA communication, HCPs reported that prescription drug abuse communication is uncomfortable, variable, multifactorial, and often avoided. The themes that emerged from this analysis support the utility of communication science and health behavior theories to better understand and improve PDA communication behaviors of both prescribers and pharmacists, and thereby improve engagement in PDA prevention and treatment. Copyright © 2015 Elsevier Inc. All rights reserved.

Prescription Drug Abuse Communication: A Qualitative Analysis of Prescriber and Pharmacist Perceptions and Behaviors

PubMed Central

Hagemeier, Nicholas E.; Tudiver, Fred; Brewster, Scott; Hagy, Elizabeth J.; Hagaman, Angela; Pack, Robert P.

2016-01-01

Background Interpersonal communication is inherent in a majority of strategies seeking to engage prescriber and pharmacist health care professionals (HCPs) in the reduction and prevention of prescription drug abuse (PDA). However, research on HCP PDA communication behavioral engagement and factors that influence it is limited. Objectives This study quantitatively examined communication behaviors and trait-level communication metrics, and qualitatively described prescription drug abuse-related communication perceptions and behaviors among primary care prescribers and community pharmacists. Methods Five focus groups (N=35) were conducted within the Appalachian Research Network (AppNET), a rural primary care practice-based research network (PBRN) in South Central Appalachia between February and October, 2014. Focus groups were structured around the administration of three previously validated trait-level communication survey instruments, and one instrument developed by the investigators to gauge HCP prescription drug abuse communication engagement and perceived communication importance. Using a grounded theory approach, focus group themes were inductively derived and coded independently by study investigators. Member-checking interviews were conducted to validate derived themes. Results Respondents’ trait-level communication self-perceptions indicated low communication apprehension, high self-perceived communication competence, and average willingness to communicate as compared to instrument specific criteria and norms. Significant variation in HCP communication behavior engagement was noted specific to PDA. Two overarching themes were noted for HCP-patient communication: 1) influencers of HCP communication and prescribing/dispensing behaviors, and 2) communication behaviors. Multiple sub-themes were identified within each theme. Similarities were noted in perceptions and behaviors across both prescribers and pharmacists. Conclusions Despite the perceived importance of engaging in PDA communication, HCPs reported that prescription drug abuse communication is uncomfortable, variable, multifactorial, and often avoided. The themes that emerged from this analysis support the utility of communication science and health behavior theories to better understand and improve PDA communication behaviors of both prescribers and pharmacists, and thereby improve engagement in PDA prevention and treatment. PMID:26806859

Influences on GPs' decision to prescribe new drugs-the importance of who says what.

PubMed

Prosser, Helen; Almond, Solomon; Walley, Tom

2003-02-01

The aim of this study was to understand the range of factors that influence GPs' uptake of new drugs A total of 107 GPs selected purposively from high, medium and low new drug prescribing practices in two health authorities in the north west of England were interviewed using the critical incident technique with semi-structured interviews. Interview topics included reasons for prescribing new drugs launched between January 1998 and May 1999; reasons for prescribing the new drug rather than alternatives; and sources of information used for each prescribed drug. Important biomedical influences were the failure of current therapy and adverse effect profile. More influential than these, however, was the pharmaceutical representative. Hospital consultants and observation of hospital prescribing was cited next most frequently. Patient request for a drug, and patient convenience and acceptability were also likely to influence new drug uptake. Written information was of limited importance except for local guidelines. GPs were largely reactive and opportunistic recipients of new drug information, rarely reporting an active information search. The decision to initiate a new drug is heavily influenced by 'who says what', in particular the pharmaceutical industry, hospital consultants and patients. The decision to 'adopt' a new drug is clinched by subsequent personal clinical experience. Prescribing of new drugs is not simply related to biomedical evaluation and critical appraisal but, more importantly, to the mode of exposure to pharmacological information and social influences on decision making. Viewed within this broad context, prescribing variation becomes more understandable. Findings have implications for the implementation of evidence-based medicine, which requires a multifaceted approach.

Generic medicines: Greek physicians' perceptions and prescribing practices.

PubMed

Tsiantou, V; Zavras, D; Kousoulakou, H; Geitona, M; Kyriopoulos, J

2009-10-01

The penetration of generic drugs in the Greek pharmaceutical market is placed among the weakest in the EU. The Greek regulatory framework does not systematically support the development of this subsector and physicians are not provided with incentives for prescribing generics. The aim of this study was to investigate the prescribing profile of physicians in Greece with a focus on the factors that influence their decision on generics prescribing. A structured questionnaire was sent by mail to a random national sample of 1463 physicians, stratified by sex, specialty and geographical region. The response rate was 82.3%. Greek physicians have a positive view on generics but they prefer to prescribe the original products. According to our analysis, physician's age and their opinion on generics' efficacy and effectiveness are identified as important determinants of their prescribing decision. The primary reason that could make them change their prescribing habits is the appearance of side-effects. Patients' insurance coverage and income, as well as the drug cost are also referred as factors that influence their prescribing decision. Despite the fact that they do not usually prescribe generics in their clinical practice, they are willing to substitute an original drug by a generic product. Our findings suggest that Greek physicians could be persuaded to prescribe generic medicines, if a generic promotion policy was introduced in the country. To develop such a policy, a set of supply side and demand-side measures should be implemented along with provision of information on generics to physicians during their education and clinical practice.

Factors influencing antibiotic prescribing in long-term care facilities: a qualitative in-depth study.

PubMed

van Buul, Laura W; van der Steen, Jenny T; Doncker, Sarah M M M; Achterberg, Wilco P; Schellevis, François G; Veenhuizen, Ruth B; Hertogh, Cees M P M

2014-12-16

Insight into factors that influence antibiotic prescribing is crucial when developing interventions aimed at a more rational use of antibiotics. We examined factors that influence antibiotic prescribing in long-term care facilities, and present a conceptual model that integrates these factors. Semi-structured qualitative interviews were conducted with physicians (n = 13) and nursing staff (n = 13) in five nursing homes and two residential care homes in the central-west region of the Netherlands. An iterative analysis was applied to interviews with physicians to identify and categorize factors that influence antibiotic prescribing, and to integrate these into a conceptual model. This conceptual model was triangulated with the perspectives of nursing staff. The analysis resulted in the identification of six categories of factors that can influence the antibiotic prescribing decision: the clinical situation, advance care plans, utilization of diagnostic resources, physicians' perceived risks, influence of others, and influence of the environment. Each category comprises several factors that may influence the decision to prescribe or not prescribe antibiotics directly (e.g. pressure of patients' family leading to antibiotic prescribing) or indirectly via influence on other factors (e.g. unfamiliarity with patients resulting in a higher physician perceived risk of non-treatment, in turn resulting in a higher tendency to prescribe antibiotics). Our interview study shows that several non-rational factors may affect antibiotic prescribing decision making in long-term care facilities, suggesting opportunities to reduce inappropriate antibiotic use. We developed a conceptual model that integrates the identified categories of influencing factors and shows the relationships between those categories. This model may be used as a practical tool in long-term care facilities to identify local factors potentially leading to inappropriate prescribing, and to subsequently intervene at the level of those factors to promote appropriate antibiotic prescribing.

Antibiotic prescribing for acute lower respiratory tract infections (LRTI) – guideline adherence in the German primary care setting: An analysis of routine data

PubMed Central

Pelzl, Steffen; Szecsenyi, Joachim; Laux, Gunter

2017-01-01

Objectives Antibiotic overprescribing in primary care has major impacts on the development of antibiotic resistance. The objective of this study is to provide insight in antibiotics prescriptions for patients suffering from cough, acute bronchitis or community acquired pneumonia in primary care. Methods Data from 2009 to 2013 of electronic health records of 12,880 patients in Germany were obtained from a research database. The prescription of antibiotics for acute lower respiratory tract infections was compared to the national S3 guideline cough from the German Society of General Practitioners and Family Medicine. Results Antibiotics were prescribed in 41% of consultations. General practitioners’ decision of whether or not to prescribe an antibiotic was congruent with the guideline in 52% of consultations and the antibiotic choice congruence was 51% of antibiotic prescriptions. Hence, a congruent prescribing decision and a prescription of recommendation was found in only 25% of antibiotic prescriptions. Split by diagnosis we found that around three quarters of antibiotics prescribed for cough (73%) and acute bronchitis (78%) were not congruent to the guidelines. In contrast to that around one quarter of antibiotics prescribed for community acquired pneumonia (28%) were not congruent to the guidelines. Conclusions Our results show that there is a big gap between guideline recommendation and actual prescribing, in the decision to prescribe and the choice of antibiotic agent. This gap could be closed by periodic quality circles on antibiotic prescribing for GPs. PMID:28350820

Nurse prescriber-patient consultations: a case study in dermatology.

PubMed

Courtenay, Molly; Carey, Nicola; Stenner, Karen

2009-06-01

This paper is a report of a study exploring the content and processes in consultations between nurse prescribers and patients with dermatological conditions. Communication skills, consultation time, information and follow-up are central to the treatment and management of patients with dermatological conditions. The contribution nurses make to the care of these patients has great potential. A multiple case study was conducted with 10 practice settings across England in which nurses prescribed medicines for patients with dermatological conditions. Data were collected between June 2006 and September 2007 using semi-structured interviews (n = 40), patient questionnaires (n = 165/200) and videotaped observations of nurse consultations (n = 40). Data analysis included thematic analysis, descriptive statistics, chi-square and non-parametric tests. Nurses believed that their holistic approach to assessment, combined with their prescribing knowledge, improved prescribing decisions. Listening and explanation of treatments were aspects of nurse communication that were rated highly by patients. Listening and dealing sensitively with emotions were also aspects of the videotaped consultations that were rated highly by assessors. Nurses were less consistent in providing information about medicines. Triangulated data from this study suggest that nurse prescribing enhances the care of patients with dermatological conditions through improved prescribing decisions. If patients are to be more involved in this decision-making, nurses must give them more information about their medicines. The benefits of prescribing were most evident in the practices of dermatology specialist nurses. Further evidence is required to identify whether prescribing by specialist nurses offers similar benefits in other therapeutic areas.

Antibiotic prescribing for acute lower respiratory tract infections (LRTI) - guideline adherence in the German primary care setting: An analysis of routine data.

PubMed

Kraus, Eva Maria; Pelzl, Steffen; Szecsenyi, Joachim; Laux, Gunter

2017-01-01

Antibiotic overprescribing in primary care has major impacts on the development of antibiotic resistance. The objective of this study is to provide insight in antibiotics prescriptions for patients suffering from cough, acute bronchitis or community acquired pneumonia in primary care. Data from 2009 to 2013 of electronic health records of 12,880 patients in Germany were obtained from a research database. The prescription of antibiotics for acute lower respiratory tract infections was compared to the national S3 guideline cough from the German Society of General Practitioners and Family Medicine. Antibiotics were prescribed in 41% of consultations. General practitioners' decision of whether or not to prescribe an antibiotic was congruent with the guideline in 52% of consultations and the antibiotic choice congruence was 51% of antibiotic prescriptions. Hence, a congruent prescribing decision and a prescription of recommendation was found in only 25% of antibiotic prescriptions. Split by diagnosis we found that around three quarters of antibiotics prescribed for cough (73%) and acute bronchitis (78%) were not congruent to the guidelines. In contrast to that around one quarter of antibiotics prescribed for community acquired pneumonia (28%) were not congruent to the guidelines. Our results show that there is a big gap between guideline recommendation and actual prescribing, in the decision to prescribe and the choice of antibiotic agent. This gap could be closed by periodic quality circles on antibiotic prescribing for GPs.

The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents.

PubMed

Kistler, Christine E; Zimmerman, Sheryl; Scales, Kezia; Ward, Kimberly; Weber, David; Reed, David; McClester, Mallory; Sloane, Philip D

2017-08-01

Due to the high rates of inappropriate antibiotic prescribing for presumed urinary tract infections (UTIs) in nursing home (NH) residents, we sought to examine the antibiotic prescribing pathway and the extent to which it agrees with the Loeb criteria; findings can suggest strategies for antibiotic stewardship. Chart review of 260 randomly-selected cases from 247 NH residents treated with an antibiotic for a presumed UTI in 31 NHs in North Carolina. We examined the prescribing pathway from presenting illness, to the prescribing event, illness work-up and subsequent clinical events including emergency department use, hospitalization, and death. Analyses described the decision-making processes and outcomes and compared decisions made with Loeb criteria for initiation of antibiotics. Of 260 cases, 60% had documented signs/symptoms of the presenting illness and 15% met the Loeb criteria. Acute mental status change was the most commonly documented sign/symptom (24%). NH providers (81%) were the most common prescribers and ciprofloxacin (32%) was the most commonly prescribed antibiotic. Fourteen percent of presumed UTI cases included a white blood cell count, 71% included a urinalysis, and 72% had a urine culture. Seventy-five percent of cultures grew at least one organism with ≥100,000 colony-forming units/milliliter and 12% grew multi-drug resistant organisms; 28% of antibiotics were prescribed for more than 7 days, and 7% of cases had a subsequent death, emergency department visit, or hospitalization within 7 days. Non-specific signs/symptoms appeared to influence prescribing more often than urinary tract-specific signs/symptoms. Prescribers rarely stopped antibiotics, and a minority prescribed for overly long periods. Providers may need additional support to guide the decision-making process to reduce antibiotic overuse and antibiotic resistance. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Missed Opportunities to Prescribe HIV Pre-Exposure Prophylaxis by Primary Care Providers in Saint Louis, Missouri

PubMed Central

Chan, Philip A.; Harrison, Laura C.; Mayer, Kenneth H.; Nunn, Amy; Mena, Leandro A.; Powderly, William G.

2018-01-01

Abstract Purpose: Optimal HIV pre-exposure prophylaxis (PrEP) scale-up in the United States requires prescribing by primary care providers (PCPs). We assessed barriers to patients obtaining PrEP from their PCPs. Methods: Patients seeking PrEP at an Infectious Diseases (ID) Clinic in St. Louis, Missouri from 2014 to 2016 were asked about demographics, sexual behaviors, whether PrEP was initially sought from their PCP, and barriers to obtaining PrEP from their PCP. Multivariable logistic regression was performed to identify predictors for having asked a PCP for PrEP. Results: Among 102 patients, the median age was 29 years, 58% were white, and 88% were men who have sex with men. Most (65%) had a PCP and, of these, 48% had asked their PCP for PrEP, but were not prescribed it. About half (52%) reported that their PCPs perceived prescribing PrEP as specialty care. Many (39%) indicated that they felt uncomfortable discussing their sexual behaviors with their PCP. Patients with an HIV-positive sex partner in the last 3 months were less likely to ask for PrEP from their PCPs than others (Adjusted Odds Ratio: 0.07; 95% CI: 0.01–0.53). Eighty-three percent of patients were referred to a new PCP with whom they could feel more comfortable discussing PrEP. Conclusions: During initial PrEP implementation, ID specialists can play an important role in providing education and linking PrEP patients to PCPs. However, PCPs may need additional training about PrEP and how to provide culturally sensitive sexual healthcare, if widespread scale-up is to be effective in decreasing HIV incidence. PMID:29688800

Physicians' decisions to prescribe antidepressant therapy in older patients with depression in a US managed care plan.

PubMed

Ivanova, Jasmina I; Bienfait-Beuzon, Catherine; Birnbaum, Howard G; Connolly, Cristina; Emani, Srinivas; Sheehy, Michael

2011-01-01

Published studies indicate that depression in older adults is severely under-recognized and under-treated. To characterize primary-care physicians' decisions to prescribe antidepressants to older patients with depression. Electronic medical record (EMR) notes from office visits of older patients (aged ≥65 years), treated in a central Massachusetts multi-specialty medical group practice, were screened every 2 weeks between August 2007 and July 2008 for mention of depression. Electronic surveys containing questions about depression severity and onset, and antidepressant treatment, were sent to physicians whose EMR notes indicated that they had treated an older patient with depression, until approximately 400 responses had been received. Physicians were asked about whether they prescribed antidepressants or made changes to antidepressant treatment and were asked about the extent to which they agreed with a set of pre-specified reasons for treatment recommendations. Physicians were also allowed to document any other reasons that influenced their decision. Patient characteristics and treatment were identified from administrative claims. Univariate analyses were used to describe patient characteristics and physician survey responses. Physicians responded to the survey and confirmed a depression diagnosis for 396 patients, for whom the average age was 77.1 years and 76.5% were female. Most patients had physician-reported depression onset after age 60 years (72.2%) and moderately severe depression (58.8%). Physicians reported that 62.9% of patients were already being treated with antidepressants prior to their visit, 28.5% were recommended antidepressant initiation and 8.6% were not prescribed antidepressants. Selective serotonin reuptake inhibitors were most frequently prescribed. Maintaining prior therapy was recommended for 81.1% of treated patients and treatment modification for 18.9%. Almost all physicians (>92%) agreed that experience in use of prescription drugs, safety/tolerability and patient improvement influenced their decision to maintain prior therapy or recommend new therapy. 85.8% of physicians agreed that availability of efficacy data in the elderly influenced their decision to prescribe new therapy. 38.9% of patients who were recommended new therapy initiation did not fill an antidepressant prescription. Despite previous reports of under-treatment of depression in the elderly, this study suggests that physicians are comfortable prescribing antidepressants to the elderly, and the majority of older patients with depression were prescribed antidepressants. Rather than a physician's prescribing decision, it may be patient factors, such as refusal to accept diagnosis/treatment and noncompliance, that may lead to under-treatment--approximately 40% of patients who were recommended new antidepressant therapy did not fill an antidepressant prescription.

Barriers to electronic prescribing: Nebraska pharmacists' perspective.

PubMed

Lander, Lina; Klepser, Donald G; Cochran, Gary L; Lomelin, Daniel E; Morien, Marsha

2013-01-01

Electronic prescribing (e-prescribing) and its accompanying clinical decision support capabilities have been promoted as means for reducing medication errors and improving efficiency. The objectives of this study were to identify the barriers to adoption of e-prescribing among nonparticipating Nebraska pharmacies and to describe how the lack of pharmacy participation impacts the ability of physicians to meet meaningful use criteria. We interviewed pharmacists and/or managers from nonparticipating pharmacies to determine barriers to the adoption of e-prescribing. We used open-ended questions and a structured questionnaire to capture participants' responses. Of the 23 participants, 10 (43%) reported plans to implement e-prescribing sometime in the future but delayed participation due to transaction fees and maintenance costs, as well as lack of demand from customers and prescribers to implement e-prescribing. Nine participants (39%) reported no intention to e-prescribe in the future, citing start-up costs for implementing e-prescribing, transaction fees and maintenance costs, happiness with the current system, and lack of understanding about e-prescribing's benefits and how to implement e-prescribing. The barriers to e-prescribing identified by both late adopters and those not willing to accept e-prescriptions were similar and were mainly initial costs and transaction fees associated with each new prescription. For some rural pharmacies, not participating in e-prescribing may be a rational business decision. To increase participation, waiving or reimbursing transaction fees, based on demographic or financial characteristics of the pharmacy, may be warranted. © 2012 National Rural Health Association.

Automation bias: empirical results assessing influencing factors.

PubMed

Goddard, Kate; Roudsari, Abdul; Wyatt, Jeremy C

2014-05-01

To investigate the rate of automation bias - the propensity of people to over rely on automated advice and the factors associated with it. Tested factors were attitudinal - trust and confidence, non-attitudinal - decision support experience and clinical experience, and environmental - task difficulty. The paradigm of simulated decision support advice within a prescribing context was used. The study employed within participant before-after design, whereby 26 UK NHS General Practitioners were shown 20 hypothetical prescribing scenarios with prevalidated correct and incorrect answers - advice was incorrect in 6 scenarios. They were asked to prescribe for each case, followed by being shown simulated advice. Participants were then asked whether they wished to change their prescription, and the post-advice prescription was recorded. Rate of overall decision switching was captured. Automation bias was measured by negative consultations - correct to incorrect prescription switching. Participants changed prescriptions in 22.5% of scenarios. The pre-advice accuracy rate of the clinicians was 50.38%, which improved to 58.27% post-advice. The CDSS improved the decision accuracy in 13.1% of prescribing cases. The rate of automation bias, as measured by decision switches from correct pre-advice, to incorrect post-advice was 5.2% of all cases - a net improvement of 8%. More immediate factors such as trust in the specific CDSS, decision confidence, and task difficulty influenced rate of decision switching. Lower clinical experience was associated with more decision switching. Age, DSS experience and trust in CDSS generally were not significantly associated with decision switching. This study adds to the literature surrounding automation bias in terms of its potential frequency and influencing factors. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

A qualitative study of community nurses' decision-making around the anticipatory prescribing of end-of-life medications.

PubMed

Bowers, Ben; Redsell, Sarah A

2017-10-01

The aim of this study was to explore community nurses' decision-making processes around the prescribing of anticipatory medications for people who are dying. Community nurses frequently initiate the prescribing of anticipatory medications to help control symptoms in those who are dying. However, little is known about their decision-making processes in relation to when they instigate anticipatory prescribing and their discussions with families and General Practitioners. A qualitative interpretive descriptive enquiry. A purposive sample of 11 Community Palliative Nurses and District Nurses working in one geographical area participated. Data were collected between March and June 2016 via audio recorded semi-structured interviews and analysed inductively using Braun and Clarke's thematic analysis. Three themes were identified: (1) Drugs as a safety net. Anticipatory medications give nurses a sense of control in last days of life symptom management; (2) Reading the situation. The nurse judges when to introduce conversations around anticipatory medications, balancing the need for discussion with the dying person and their family's likely response; (3) Playing the game. The nurse owns the decision to initiate anticipatory medication prescribing and carefully negotiates with the General Practitioner. Nurses view pain control through prescribed medication as key to symptom management for dying people. Consequently, they own the role of ascertaining when to initiate discussions with families about anticipatory medicines. Nurses believe they advocate for dying person and their families' needs and lead negotiations with General Practitioners for medications to go into the home. This nurse led care alters the traditional boundaries of the General Practitioners-nurse professional relationship. © 2017 John Wiley & Sons Ltd.

Factors affecting caregivers' use of antibiotics available without a prescription in Peru.

PubMed

Ecker, Lucie; Ochoa, Theresa J; Vargas, Martha; Del Valle, Luis J; Ruiz, Joaquim

2013-06-01

To determine factors that affect caregivers' decisions about antibiotic use in children in settings where antibiotics are available without prescription. In a house-to-house survey, 1200 caregivers in 3 periurban districts of Lima, Peru, were asked about antibiotic use in young children. In this sample, 87.2% of children aged <5 years had received an antibiotic drug in their lives; 70.3% had received antibiotics before 1 year of age, and 98.8% of those had been prescribed by a physician. Given hypothetical cases of common cold and nondysenteric diarrhea, caregivers would seek medical advice in 76.4% and 87.1%, respectively, and 84.6% of caregivers said they respected medical decisions even if an antibiotic was not prescribed. Caregivers with high school-level education accepted 80% more medical decisions of not using an antibiotic and used fewer pharmacist-recommended antibiotics. For each additional year of life, the risk of self-medicated antibiotic use and the use of pharmacist-recommended antibiotics increased in 30%. (OR: 1.3, 95% CI: 1.1-1.4, P = .001 and OR: 1.3, 95% CI: 1.2-1.5, P < .001, respectively). Caregivers respected a medical decision of not prescribing an antibiotic 5 times more when physicians had explained the reason for their advice (OR: 5.0, 95% CI: 3.2-7.8, P < .001). Prescribed antibiotic use in these young children is common. Even if they are available without prescription, caregivers usually comply with medical advice and follow physicians' recommendations when antibiotics are not prescribed. Improving physician prescribing habits could reduce irrational antibiotic use, decreasing future caregiver-driven misuse.

Thinking in Pharmacy Practice: A Study of Community Pharmacists’ Clinical Reasoning in Medication Supply Using the Think-Aloud Method

PubMed Central

Croft, Hayley; Gilligan, Conor; Rasiah, Rohan; Levett-Jones, Tracy; Schneider, Jennifer

2017-01-01

Medication review and supply by pharmacists involves both cognitive and technical skills related to the safety and appropriateness of prescribed medicines. The cognitive ability of pharmacists to recall, synthesise and memorise information is a critical aspect of safe and optimal medicines use, yet few studies have investigated the clinical reasoning and decision-making processes pharmacists use when supplying prescribed medicines. The objective of this study was to examine the patterns and processes of pharmacists’ clinical reasoning and to identify the information sources used, when making decisions about the safety and appropriateness of prescribed medicines. Ten community pharmacists participated in a simulation in which they were required to review a prescription and make decisions about the safety and appropriateness of supplying the prescribed medicines to the patient, whilst at the same time thinking aloud about the tasks required. Following the simulation each pharmacist was asked a series of questions to prompt retrospective thinking aloud using video-stimulated recall. The simulated consultation and retrospective interview were recorded and transcribed for thematic analysis. All of the pharmacists made a safe and appropriate supply of two prescribed medicines to the simulated patient. Qualitative analysis identified seven core thinking processes used during the supply process: considering prescription in context, retrieving information, identifying medication-related issues, processing information, collaborative planning, decision making and reflection; and align closely with other health professionals. The insights from this study have implications for enhancing awareness of decision making processes in pharmacy practice and informing teaching and assessment approaches in medication supply. PMID:29301223

Thinking in Pharmacy Practice: A Study of Community Pharmacists' Clinical Reasoning in Medication Supply Using the Think-Aloud Method.

PubMed

Croft, Hayley; Gilligan, Conor; Rasiah, Rohan; Levett-Jones, Tracy; Schneider, Jennifer

2017-12-31

Medication review and supply by pharmacists involves both cognitive and technical skills related to the safety and appropriateness of prescribed medicines. The cognitive ability of pharmacists to recall, synthesise and memorise information is a critical aspect of safe and optimal medicines use, yet few studies have investigated the clinical reasoning and decision-making processes pharmacists use when supplying prescribed medicines. The objective of this study was to examine the patterns and processes of pharmacists' clinical reasoning and to identify the information sources used, when making decisions about the safety and appropriateness of prescribed medicines. Ten community pharmacists participated in a simulation in which they were required to review a prescription and make decisions about the safety and appropriateness of supplying the prescribed medicines to the patient, whilst at the same time thinking aloud about the tasks required. Following the simulation each pharmacist was asked a series of questions to prompt retrospective thinking aloud using video-stimulated recall. The simulated consultation and retrospective interview were recorded and transcribed for thematic analysis. All of the pharmacists made a safe and appropriate supply of two prescribed medicines to the simulated patient. Qualitative analysis identified seven core thinking processes used during the supply process: considering prescription in context, retrieving information, identifying medication-related issues, processing information, collaborative planning, decision making and reflection; and align closely with other health professionals. The insights from this study have implications for enhancing awareness of decision making processes in pharmacy practice and informing teaching and assessment approaches in medication supply.

Effect of electronic prescribing with formulary decision support on medication use and cost.

PubMed

Fischer, Michael A; Vogeli, Christine; Stedman, Margaret; Ferris, Timothy; Brookhart, M Alan; Weissman, Joel S

2008-12-08

Electronic prescribing (e-prescribing) with formulary decision support (FDS) prompts prescribers to prescribe lower-cost medications and may help contain health care costs. In April 2004, 2 large Massachusetts insurers began providing an e-prescribing system with FDS to community-based practices. Using 18 months (October 1, 2003, to March 31, 2005) of administrative data, we conducted a pre-post study with concurrent controls. We first compared the change in the proportion of prescriptions for 3 formulary tiers before and after e-prescribing began, then developed multivariate longitudinal models to estimate the specific effect of e-prescribing when controlling for baseline differences between intervention and control prescribers. Potential savings were estimated using average medication costs by formulary tier. More than 1.5 million patients filled 17.4 million prescriptions during the study period. Multivariate models controlling for baseline differences between prescribers and for changes over time estimated that e-prescribing corresponded to a 3.3% increase (95% confidence interval, 2.7%-4.0%) in tier 1 prescribing. The proportion of prescriptions for tiers 2 and 3 (brand-name medications) decreased correspondingly. e-Prescriptions accounted for 20% of filled prescriptions in the intervention group. Based on average costs for private insurers, we estimated that e-prescribing with FDS at this rate could result in savings of $845,000 per 100,000 patients. Higher levels of e-prescribing use would increase these savings. Clinicians using e-prescribing with FDS were significantly more likely to prescribe tier 1 medications, and the potential financial savings were substantial. Widespread use of e-prescribing systems with FDS could result in reduced spending on medications.

Systematic Review of Medical Informatics-Supported Medication Decision Making.

PubMed

Melton, Brittany L

2017-01-01

This systematic review sought to assess the applications and implications of current medical informatics-based decision support systems related to medication prescribing and use. Studies published between January 2006 and July 2016 which were indexed in PubMed and written in English were reviewed, and 39 studies were ultimately included. Most of the studies looked at computerized provider order entry or clinical decision support systems. Most studies examined decision support systems as a means of reducing errors or risk, particularly associated with medication prescribing, whereas a few studies evaluated the impact medical informatics-based decision support systems have on workflow or operations efficiency. Most studies identified benefits associated with decision support systems, but some indicate there is room for improvement.

Supporting shared decision making beyond consumer-prescriber interactions: Initial development of the CommonGround fidelity scale

PubMed Central

Fukui, Sadaaki; Salyers, Michelle P.; Rapp, Charlie; Goscha, Rick; Young, Leslie; Mabry, Ally

2015-01-01

Shared decision-making has become a central tenet of recovery-oriented, person-centered mental health care, yet the practice is not always transferred to the routine psychiatric visit. Supporting the practice at the system level, beyond the interactions of consumers and medication prescribers, is needed for successful adoption of shared decision-making. CommonGround is a systemic approach, intended to be part of a larger integration of shared decision-making tools and practices at the system level. We discuss the organizational components that CommonGround uses to facilitate shared decision-making, and we present a fidelity scale to assess how well the system is being implemented. PMID:28090194

Improving specialist drug prescribing in primary care using task and error analysis: an observational study.

PubMed

Chana, Narinder; Porat, Talya; Whittlesea, Cate; Delaney, Brendan

2017-03-01

Electronic prescribing has benefited from computerised clinical decision support systems (CDSSs); however, no published studies have evaluated the potential for a CDSS to support GPs in prescribing specialist drugs. To identify potential weaknesses and errors in the existing process of prescribing specialist drugs that could be addressed in the development of a CDSS. Semi-structured interviews with key informants followed by an observational study involving GPs in the UK. Twelve key informants were interviewed to investigate the use of CDSSs in the UK. Nine GPs were observed while performing case scenarios depicting requests from hospitals or patients to prescribe a specialist drug. Activity diagrams, hierarchical task analysis, and systematic human error reduction and prediction approach analyses were performed. The current process of prescribing specialist drugs by GPs is prone to error. Errors of omission due to lack of information were the most common errors, which could potentially result in a GP prescribing a specialist drug that should only be prescribed in hospitals, or prescribing a specialist drug without reference to a shared care protocol. Half of all possible errors in the prescribing process had a high probability of occurrence. A CDSS supporting GPs during the process of prescribing specialist drugs is needed. This could, first, support the decision making of whether or not to undertake prescribing, and, second, provide drug-specific parameters linked to shared care protocols, which could reduce the errors identified and increase patient safety. © British Journal of General Practice 2017.

Opinions of clinical veterinarians at a US veterinary teaching hospital regarding antimicrobial use and antimicrobial-resistant infections.

PubMed

Jacob, Megan E; Hoppin, Jane A; Steers, Nicola; Davis, Jennifer L; Davidson, Gigi; Hansen, Bernie; Lunn, Katharine F; Murphy, K Marcia; Papich, Mark G

2015-10-15

To determine opinions of faculty members with clinical appointments, clinical veterinarians, residents, and interns at a US veterinary teaching hospital regarding antimicrobial use and antimicrobial-resistant infections. Cross-sectional survey. 71 veterinarians. An online questionnaire was sent to all veterinarians with clinical service responsibilities at the North Carolina State University veterinary teaching hospital (n = 167). The survey included 23 questions regarding demographic information, educational experiences, current prescribing practices, and personal opinions related to antimicrobial selection, antimicrobial use, restrictions on antimicrobial use, and antimicrobial resistance. Of the 167 veterinarians eligible to participate, 71 (43%) responded. When respondents were asked to rate their level of concern (very concerned = 1; not concerned = 5) about antimicrobial-resistant infections, most (41/70 [59%]) assigned a score of 1, with mean score for all respondents being 1.5. Most survey participants rated their immediate colleagues (mean score, 1.9) as more concerned than other veterinary medical professionals (mean score, 2.3) and their clients (mean score, 3.4). Fifty-nine of 67 (88%) respondents felt that antimicrobials were overprescribed at the hospital, and 32 of 69 (46%) respondents felt uncomfortable prescribing at least one class of antimicrobials (eg, carbapenems or glycopeptides) because of public health concerns. Findings indicated that veterinarians at this teaching hospital were concerned about antimicrobial resistance, thought antimicrobials were overprescribed, and supported restricting use of certain antimicrobial classes in companion animals. Findings may be useful in educating future veterinarians and altering prescribing habits and antimicrobial distribution systems in veterinary hospitals.

Factors affecting the uptake of new medicines in secondary care - a literature review.

PubMed

Chauhan, D; Mason, A

2008-08-01

The rate of uptake of new medicines in the UK is slower than in many other OECD countries. The majority of new medicines are introduced initially in secondary care and prescribed by specialists. However, the reasons for relatively low precribing levels are poorly understood. This review explores the determinants of uptake of new medicines in secondary care. Nine electronic databases were searched covering the period 1992-2006. Once the searches had been run, records were downloaded and those which evaluated uptake of new medicines in secondary care were identified. UK studies were of primary interest, although research conducted in other countries was also reviewed if relevant. With the exception of 'think pieces', eligibility was not limited by study design. Studies published in languages other than English were excluded from the review. Determinants of uptake in secondary care were classified using Bonair and Persson's typology for determinants of the diffusion of innovation. Almost 1400 records were screened for eligibility, and 29 studies were included in the review. Prescribing of new medicines in secondary care was found to be subject to a number of interacting influences. The support structures which exist within secondary care facilitate access to other colleagues and shape prescribing practices. Clinical trial investigators and physicians who sit on decision-making bodies such as Drug and Therapeutic Committees (DTCs) appear to have a special influence due to their proximity to their research and understanding of evidence base. Pharmaceutical representatives may also influence prescribing decisions through funding of meetings and academic detailing, but clinicians are wary of potential bias. Little evidence on the influence of patients upon prescribing decisions was identified. The impact of clinical guidelines has been variable. Some guidelines have significantly increased the uptake of new medicines, but others have had little discernible impact despite extensive dissemination. However given the increasing influence of the National Institute for Health and Clinical Excellence, guidelines may become more important. The impact of financial prescribing incentives on secondary care prescribing is unclear. Although cost and budget may influence hospital prescribing of new drugs, they are of secondary importance to the safety and effectiveness profile of the medicine. If a drug has a novel mechanism of action, or belongs to a class with few alternatives, clinicians are more likely to consider it favourably as a prescribing option. Although price does not appear to be a primary factor behind prescribing decision-making, in secondary care there has long been a historical need for formal purchasing decisions through the DTC, which differentiates it from primary care. This, in addition to increasing pressures for cost-effectiveness within the NHS means that cost will appear more frequently on clinician consciousness. As a result, guidelines are more likely to be implemented using the strong professional networks in existence within secondary care, and although the influence of patients has not been addressed by the literature, they are likely to have an increasing input into the prescribing decision, given the importance of patient involvement in current UK policy.

Parents' preferences strongly influence their decisions to withhold prescribed opioids when faced with analgesic trade-off dilemmas for children: a prospective observational study.

PubMed

Voepel-Lewis, Terri; Zikmund-Fisher, Brian J; Smith, Ellen Lavoie; Zyzanski, Sarah; Tait, Alan R

2015-08-01

Despite parents' stated desire to treat pain in their children, recent studies have critiqued their underuse of prescribed analgesics to treat pain in their children after painful procedures. Parents' analgesic preferences, including their perceived importance of providing pain relief or avoiding adverse drug effects may have important implications for their analgesic decisions, yet no studies have evaluated the influence of preferences on decisions to withhold prescribed opioids for children. We prospectively explored how parents' preferences influenced decisions to withhold prescribed opioids when faced with hypothetical dilemmas and after hospital discharge. Prospective Observational Study Design: Phase 1 included hypothetical analgesic decisions and Phase 2, real analgesic decisions after hospital discharge. Large tertiary care pediatric hospital in the Midwest of the United States. Five-hundred seven parents whose children underwent a painful surgical procedure requiring an opioid prescription were included. At baseline, parents completed surveys assessing their pain relief preference (i.e., their rated importance of pain relief relative to adverse drug event avoidance), preferred treatment thresholds (i.e., pain level at which they would give an opioid), adverse drug event understanding, and hypothetical trade-off decisions (i.e., scenarios presenting variable pain and adverse drug event symptoms in a child). After discharge, parents recorded all analgesics they gave their child as well as pain scores at the time of administration. Higher preference to provide pain relief (over avoid analgesic risk) lessened the likelihood that parents would withhold the prescribed opioid when adverse drug event symptoms were present together with high pain scores in the hypothetical scenarios. Additionally, higher preferred treatment thresholds increased the likelihood of parents withholding opioids during their hypothetical decision-making as well as at home. The strong influence of these preferences weakened the effect of opioid ADE understanding on decisions to withhold opioids when ADEs (i.e., nausea/vomiting or oversedation) were present together with high pain. Findings from this study suggest that preferences strongly influence and may interfere with parents' effective and safe analgesic decision-making when conflicting symptoms (i.e., high pain and an ADE) are present. To improve effective analgesic use, there is a need to shape parents' preferences and improve their understanding of safe actions that will treat pain when ADE symptoms are present. Copyright © 2015 Elsevier Ltd. All rights reserved.

Cognitive Analysis of Decision Support for Antibiotic Prescribing at the Point of Ordering in a Neonatal Intensive Care Unit

PubMed Central

Sheehan, Barbara; Kaufman, David; Stetson, Peter; Currie, Leanne M.

2009-01-01

Computerized decision support systems have been used to help ensure safe medication prescribing. However, the acceptance of these types of decision support has been reported to be low. It has been suggested that decreased acceptance may be due to lack of clinical relevance. Additionally, cognitive fit between the user interface and clinical task may impact the response of clinicians as they interact with the system. In order to better understand clinician responses to such decision support, we used cognitive task analysis methods to evaluate clinical alerts for antibiotic prescribing in a neonatal intensive care unit. Two methods were used: 1) a cognitive walkthrough; and 2) usability testing with a ‘think-aloud’ protocol. Data were analyzed for impact on cognitive effort according to categories of cognitive distance. We found that responses to alerts may be context specific and that lack of screen cues often increases cognitive effort required to use a system. PMID:20351922

Clinical, information and business process modeling to promote development of safe and flexible software.

PubMed

Liaw, Siaw-Teng; Deveny, Elizabeth; Morrison, Iain; Lewis, Bryn

2006-09-01

Using a factorial vignette survey and modeling methodology, we developed clinical and information models - incorporating evidence base, key concepts, relevant terms, decision-making and workflow needed to practice safely and effectively - to guide the development of an integrated rule-based knowledge module to support prescribing decisions in asthma. We identified workflows, decision-making factors, factor use, and clinician information requirements. The Unified Modeling Language (UML) and public domain software and knowledge engineering tools (e.g. Protégé) were used, with the Australian GP Data Model as the starting point for expressing information needs. A Web Services service-oriented architecture approach was adopted within which to express functional needs, and clinical processes and workflows were expressed in the Business Process Execution Language (BPEL). This formal analysis and modeling methodology to define and capture the process and logic of prescribing best practice in a reference implementation is fundamental to tackling deficiencies in prescribing decision support software.

Making pharmacogenomic-based prescribing alerts more effective: A scenario-based pilot study with physicians.

PubMed

Overby, Casey Lynnette; Devine, Emily Beth; Abernethy, Neil; McCune, Jeannine S; Tarczy-Hornoch, Peter

2015-06-01

To facilitate personalized drug dosing (PDD), this pilot study explored the communication effectiveness and clinical impact of using a prototype clinical decision support (CDS) system embedded in an electronic health record (EHR) to deliver pharmacogenomic (PGx) information to physicians. We employed a conceptual framework and measurement model to access the impact of physician characteristics (previous experience, awareness, relative advantage, perceived usefulness), technology characteristics (methods of implementation-semi-active/active, actionability-low/high) and a task characteristic (drug prescribed) on communication effectiveness (usefulness, confidence in prescribing decision), and clinical impact (uptake, prescribing intent, change in drug dosing). Physicians performed prescribing tasks using five simulated clinical case scenarios, presented in random order within the prototype PGx-CDS system. Twenty-two physicians completed the study. The proportion of physicians that saw a relative advantage to using PGx-CDS was 83% at the start and 94% at the conclusion of our study. Physicians used semi-active alerts 74-88% of the time. There was no association between previous experience with, awareness of, and belief in a relative advantage of using PGx-CDS and improved uptake. The proportion of physicians reporting confidence in their prescribing decisions decreased significantly after using the prototype PGx-CDS system (p=0.02). Despite decreases in confidence, physicians perceived a relative advantage to using PGx-CDS, viewed semi-active alerts on most occasions, and more frequently changed doses toward doses supported by published evidence. Specifically, sixty-five percent of physicians reduced their dosing, significantly for capecitabine (p=0.002) and mercaptopurine/thioguanine (p=0.03). These findings suggest a need to improve our prototype such that PGx CDS content is more useful and delivered in a way that improves physician's confidence in their prescribing decisions. The greatest increases in communication effectiveness and clinical impact of PGx-CDS are likely to be realized through continued focus on content, content delivery, and tailoring to physician characteristics. Copyright © 2015 Elsevier Inc. All rights reserved.

What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study.

PubMed

Rochefort, Christian M; Morlec, Julia; Tamblyn, Robyn M

2012-02-29

Thiazide diuretics are cost-effective for the treatment of mild to moderate hypertension, but physicians often opt for more expensive treatment options such as angiotensin II receptor blockers or angiotensin converting enzyme inhibitors. With escalating health care costs, there is a need to elucidate the factors influencing physicians' treatment choices for this highly prevalent chronic condition. The purpose of this study was to describe the characteristics of physicians' decision-making process regarding hypertension treatment choices. A comparative qualitative study was conducted in 2009 in the Canadian province of Quebec. Overall, 29 primary care physicians--who are also participating in an electronic health record research program--participated in a semi-structured interview about their prescribing decisions. Physicians were categorized into two groups based on their patterns of prescribing antihypertensive drugs: physicians who predominantly prescribe diuretics, and physicians who predominantly prescribe drug classes other than diuretics. Cases of hypertension that were newly started on antihypertensive therapy were purposely selected from each physician's electronic health record database. Chart stimulated recall interview, a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinical encounters, was used to elucidate reasons for treatment choices. Interview transcripts were synthesized using content analysis techniques, and factors influencing physicians' decision making were inductively generated from the data. We identified three themes that differentiated physicians who predominantly prescribe diuretics from those who predominantly prescribe other drug classes for the initial treatment of mild to moderate hypertension: a) perceptions about the efficacy of diuretics, b) preferred approach to hypertension management and, c) perceptions about hypertension guidelines. Specifically, physicians had differences in beliefs about the efficacy, safety and tolerability of diuretics, the most effective approach for managing mild to moderate hypertension, and in aggressiveness to achieve treatment targets. Marketing strategies employed by the pharmaceutical industry and practice experience appear to contribute to these differences in management approach. Physicians preferring more expensive treatment options appear to have several misperceptions about the efficacy, safety and tolerability of diuretics. Efforts to increase physicians' prescribing of diuretics may need to be directed at overcoming these misperceptions.

The prescribing of specialist medicines: what factors influence GPs' decision making?

PubMed

Crowe, Sarah; Tully, Mary P; Cantrill, Judith A

2009-08-01

As Governments worldwide strive to integrate efficient health care delivery across the primary-secondary care divide, particular significance has been placed on the need to understand GPs' prescribing of specialist drugs. To explore the factors which influence GPs' decision-making process when requested to prescribe specialist drugs. A qualitative approach was used to explore the perspectives of a wide range of practice-, primary care trust-, strategic health authority-level staff and other relevant stakeholders in the North-West of England. All semi-structured interviews (n = 47) were analysed comprehensively using the five-stage 'framework' approach. Six diverse factors were identified as having a crucial bearing on how GPs evaluate initial requests and subsequently decide whether or not to prescribe. These include GPs' lack of knowledge and expertise in using specialist drugs, the shared care arrangement, the influence of a locally agreed advisory list, financial and resource considerations, patient convenience and understanding and GPs' specific areas of interest. This exploration of GPs' decision-making process is needed to support future integrated health care delivery.

Continuing professional development needs of nursing and allied health professionals with responsibility for prescribing.

PubMed

Weglicki, Robert S; Reynolds, Julie; Rivers, Peter H

2015-01-01

Continuing professional development (CPD) for non-medical prescribers is recognised as being pivotal in maintaining up -to -date knowledge and skills influencing prescribing competence. This study was, therefore, designed to ascertain the aspirations, priorities and preferred mode of CPD for non-medical prescribers. Qualitative data were derived from semi-structured in-depth interviews and a focus group given by 16 allied health professionals working in primary and secondary care settings. A topic guide was used to cover clinical decision-making (including difficult decisions), legal aspects of prescribing and diagnostic issues. A content analysis of the verbatim transcripts enabled four key emerging themes to be identified, thus offering a basis for developing a greater understanding of the CPD needs of non-medical prescribers. The four key emerging themes identified are the following: Theme 1: "Personal anxiety undermining confidence to prescribe", Theme 2: "External barriers and other factors that exacerbate anxiety", Theme 3: "Need for support identified through coping strategies", and Theme 4: "Preferred mode or style of learning". The findings suggest that anxiety and lack of confidence in non-medical prescribing pose a significant challenge for CPD. Strategies that are most likely to improve prescribing confidence are through a blended learning approach. Local higher education and workplace employer collaboration is an appropriate step forward to achieve this. Copyright © 2014 Elsevier Ltd. All rights reserved.

Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care.

PubMed

Coxeter, Peter; Del Mar, Chris B; McGregor, Leanne; Beller, Elaine M; Hoffmann, Tammy C

2015-11-12

Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care. To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care. We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization. Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care. Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available. We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients.The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this.We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively.There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms. Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death.

Predicting dynamic range and intensity discrimination for electrical pulse-train stimuli using a stochastic auditory nerve model: the effects of stimulus noise.

PubMed

Xu, Yifang; Collins, Leslie M

2005-06-01

This work investigates dynamic range and intensity discrimination for electrical pulse-train stimuli that are modulated by noise using a stochastic auditory nerve model. Based on a hypothesized monotonic relationship between loudness and the number of spikes elicited by a stimulus, theoretical prediction of the uncomfortable level has previously been determined by comparing spike counts to a fixed threshold, Nucl. However, no specific rule for determining Nucl has been suggested. Our work determines the uncomfortable level based on the excitation pattern of the neural response in a normal ear. The number of fibers corresponding to the portion of the basilar membrane driven by a stimulus at an uncomfortable level in a normal ear is related to Nucl at an uncomfortable level of the electrical stimulus. Intensity discrimination limens are predicted using signal detection theory via the probability mass function of the neural response and via experimental simulations. The results show that the uncomfortable level for pulse-train stimuli increases slightly as noise level increases. Combining this with our previous threshold predictions, we hypothesize that the dynamic range for noise-modulated pulse-train stimuli should increase with additive noise. However, since our predictions indicate that intensity discrimination under noise degrades, overall intensity coding performance may not improve significantly.

Cluster-randomized, controlled trial of computer-based decision support for selecting long-term anti-thrombotic therapy after acute ischaemic stroke.

PubMed

Weir, C J; Lees, K R; MacWalter, R S; Muir, K W; Wallesch, C-W; McLelland, E V; Hendry, A

2003-02-01

Identifying the appropriate long-term anti-thrombotic therapy following acute ischaemic stroke is a challenging area in which computer-based decision support may provide assistance. To evaluate the influence on prescribing practice of a computer-based decision support system (CDSS) that provided patient-specific estimates of the expected ischaemic and haemorrhagic vascular event rates under each potential anti-thrombotic therapy. Cluster-randomized controlled trial. We recruited patients who presented for a first investigation of ischaemic stroke or TIA symptoms, excluding those with a poor prognosis or major contraindication to anticoagulation. After observation of routine prescribing practice (6 months) in each hospital, centres were randomized for 6 months to either control (routine practice observed) or intervention (practice observed while the CDSS provided patient-specific information). We compared, between control and intervention centres, the risk reduction (estimated by the CDSS) in ischaemic and haemorrhagic vascular events achieved by long-term anti-thrombotic therapy, and the proportions of subjects prescribed the optimal therapy identified by the CDSS. Sixteen hospitals recruited 1952 subjects. When the CDSS provided information, the mean relative risk reduction attained by prescribing increased by 2.7 percentage units (95%CI -0.3 to 5.7) and the odds ratio for the optimal therapy being prescribed was 1.32 (0.83 to 1.80). Some 55% (5/9) of clinicians believed the CDSS had influenced their prescribing. Cluster-randomized trials provide excellent frameworks for evaluating novel clinical management methods. Our CDSS was feasible to implement and acceptable to clinicians, but did not substantially influence prescribing practice for anti-thrombotic drugs after acute ischaemic stroke.

Decision-making about prenatal genetic testing among pregnant Korean-American women.

PubMed

Jun, Myunghee; Thongpriwan, Vipavee; Choi, Jeeyae; Sook Choi, Kyung; Anderson, Gwen

2018-01-01

to understand the prenatal genetic testing decision-making processes among pregnant Korean-American women. a qualitative, descriptive research design. referrals and snowball sampling techniques were used to recruit 10 Korean-American women who had been recommended for amniocentesis during pregnancy in the United States (U.S.). All participants were born in Korea and had immigrated to the U.S. The number of years living in the U.S. ranged from 4 to 11 (M=5.7). various regional areas of the U.S. the researchers conducted face-to-face or phone interviews using semi-structured interview guides. The interviews were conducted in the Korean language and lasted approximately 50-100minutes. The interview guides focused on the decision-making process and experiences with prenatal genetic testing, as well as reflections on the decisions. Four core themes emerged related to the participants' decision-making processes, according to their descriptions. These themes are (1) facing the challenges of decision-making, (2) seeking support, (3) determining one's preferred role in the decision-making process, and (4) feeling uncomfortable with the degree of patient autonomy in U.S. health care. researchers concluded that many distinctive factors influence the decision-making processes used by pregnant Korean-American women. The results have the potential to improve shared decision-making practices regarding prenatal genetic testing. clinicians need to understand the sociocultural underpinnings of pregnant Korean-American immigrants regarding prenatal genetic screening and testing as an initial step to engage these patients in shared decision-making. Published by Elsevier Ltd.

Nurses' reported influence on the prescription and use of medication.

PubMed

Jutel, A; Menkes, D B

2010-03-01

To identify the activities senior nurses report undertaking that may influence the prescription and use of medicines. While much attention has focused on the role of nurse prescribing, little is known about the extent to which non-prescribing nurses influence medication decision making. The pharmaceutical industry recognizes this influence in its marketing strategies, and courts nurses by provision of promotional material and sponsorship of nursing professional development. We undertook parallel web- and paper-based surveys of 100 senior registered nurses employed by government-funded health boards in two distinct New Zealand regions. Only 2/96 (2%) of nurses had prescribing rights, yet 74/94 (79%) reported recommending treatments to the prescribing doctor, 74/95 (79%) stated they provided advice to patients about over-the-counter medications and 71/92 (77%) participated in the development of guidelines or policies that include the use of medications. All nurses in this sample reported influencing the prescription of medicines in one way or another. From actually writing prescriptions to providing feedback on treatment outcomes, there are many opportunities for nurses to influence the decision making of medical and other prescribers, which open nurses to exploitation from commercial forces. Policy and education regarding prescriber relationships with the pharmaceutical industry should also recognize the role of non-prescribing nurses.

The Systematic Tool to Reduce Inappropriate Prescribing (STRIP): Combining implicit and explicit prescribing tools to improve appropriate prescribing.

PubMed

Drenth-van Maanen, A Clara; Leendertse, Anne J; Jansen, Paul A F; Knol, Wilma; Keijsers, Carolina J P W; Meulendijk, Michiel C; van Marum, Rob J

2018-04-01

Inappropriate prescribing is a major health care issue, especially regarding older patients on polypharmacy. Multiple implicit and explicit prescribing tools have been developed to improve prescribing, but these have hardly ever been used in combination. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) combines implicit prescribing tools with the explicit Screening Tool to Alert physicians to the Right Treatment and Screening Tool of Older People's potentially inappropriate Prescriptions criteria and has shared decision-making with the patient as a critical step. This article describes the STRIP and its ability to identify potentially inappropriate prescribing. The STRIP improved general practitioners' and final-year medical students' medication review skills. The Web-application STRIP Assistant was developed to enable health care providers to use the STRIP in daily practice and will be incorporated in clinical decision support systems. It is currently being used in the European Optimizing thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly (OPERAM) project, a multicentre randomized controlled trial involving patients aged 75 years and older using multiple medications for multiple medical conditions. In conclusion, the STRIP helps health care providers to systematically identify potentially inappropriate prescriptions and medication-related problems and to change the patient's medication regimen in accordance with the patient's needs and wishes. This article describes the STRIP and the available evidence so far. The OPERAM study is investigating the effect of STRIP use on clinical and economic outcomes. © 2017 John Wiley & Sons, Ltd.

Use of pharmacoeconomics in prescribing research. Part 1: costs--moving beyond the acquisition price for drugs.

PubMed

Robertson, J; Lang, D; Hill, S

2003-02-01

This paper addresses pharmacoeconomics in prescribing research and reflects the increasing use of techniques of economic evaluation to aid drug purchasing decisions in a variety of settings -- for national drug subsidization programmes, provincial purchasing plans, insurance programmes, and for hospital and area health authority formulary decisions. First, we focus on the cost component of an economic evaluation and discuss methodological issues that are relevant to all pharmacoeconomic analyses.

Biases in medication prescribing: the case of second-generation antipsychotics.

PubMed

Makhinson, Michael

2010-01-01

The shift from first-generation antipsychotic medications to second-generation antipsychotic medications initially caused a wave of excitement about the potential for improved and broader efficacy of these medications concurrent with an improved side-effect profile. Recent data from high-quality research analyses have subsequently raised significant questions about these claims. This research evidence has, however, not altered prescribing behavior in a way that would be expected from fully rational evaluation of the evidence. Prescribing decisions represent poorly understood, complex behaviors influenced by a number of external and internal forces, some of which may be elucidated by advances in social and cognitive psychology. In this article, the decision to prescribe first- versus second-generation antipsychotic medications is examined, and specific social psychological biases and individual cognitive biases are hypothesized to be significant influences on clinicians. These biases may perpetuate disparity between research evidence and clinical practice.

Rational Risk-Benefit Decision-Making in the Setting of Military Mefloquine Policy.

PubMed

Nevin, Remington L

2015-01-01

Mefloquine is an antimalarial drug that has been commonly used in military settings since its development by the US military in the late 1980s. Owing to the drug's neuropsychiatric contraindications and its high rate of inducing neuropsychiatric symptoms, which are contraindications to the drug's continued use, the routine prescribing of mefloquine in military settings may be problematic. Due to these considerations and to recent concerns of chronic and potentially permanent psychiatric and neurological sequelae arising from drug toxicity, military prescribing of mefloquine has recently decreased. In settings where mefloquine remains available, policies governing prescribing should reflect risk-benefit decision-making informed by the drug's perceived benefits and by consideration both of the risks identified in the drug's labeling and of specific military risks associated with its use. In this review, these risks are identified and recommendations are made for the rational prescribing of the drug in light of current evidence.

Drug reimbursement and GPs' prescribing decisions: a randomized case-vignette study about the pharmacotherapy of obesity associated with type 2 diabetes: how GPs react to drug reimbursement.

PubMed

Verger, Pierre; Rolland, Sophie; Paraponaris, Alain; Bouvenot, Julien; Ventelou, Bruno

2010-08-01

This study sought to identify the effect of drug reimbursability--a decision made in France by the National Authority for Health--on physicians' prescribing practices for a diet drug such as rimonabant, approved for obese or overweight patients with type-2 diabetes. A cross-sectional survey of French general practitioners (GPs) presented a case-vignette about a patient for whom this drug is indicated in two alternative versions, differing only in its reimbursability, to two separate randomized subsamples of GPs in early 2007, before any decision was made about reimbursement. The results indicate that (i) more than 20% of GPs in private practice would be willing to prescribe a non-reimbursed diet drug for patients with obesity complicated by type 2 diabetes; (ii) the number of GPs willing to prescribe it would increase by 47.6% if the drug were reimbursed, and (iii) such a drug would be adopted at a higher rate by GPs who have regular contacts with pharmaceutical sales representatives. In France, unlike most other countries, drug reimbursement status is a signal of quality. However, our results suggest that a significant proportion of GPs would spontaneously adopt anti-obesity drugs even if they were not reimbursed. Decisions about reimbursement of pharmaceutical products should be made taking into account that reimbursement is likely to intensify prescription.

A model of methods for influencing prescribing: Part I. A review of prescribing models, persuasion theories, and administrative and educational methods.

PubMed

Raisch, D W

1990-04-01

The purpose of this literature review is to develop a model of methods to be used to influence prescribing. Four bodies of literature were identified as being important for developing the model: (1) Theoretical prescribing models furnish information concerning factors that affect prescribing and how prescribing decisions are made. (2) Theories of persuasion provide insight into important components of educational communications. (3) Research articles of programs to improve prescribing identify types of programs that have been found to be successful. (4) Theories of human inference describe how judgments are formulated and identify errors in judgment that can play a role in prescribing. This review is presented in two parts. This article reviews prescribing models, theories of persuasion, studies of administrative programs to control prescribing, and sub-optimally designed studies of educational efforts to influence drug prescribing.

Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial.

PubMed

Berner, Eta S; Houston, Thomas K; Ray, Midge N; Allison, Jeroan J; Heudebert, Gustavo R; Chatham, W Winn; Kennedy, John I; Glandon, Gerald L; Norton, Patricia A; Crawford, Myra A; Maisiak, Richard S

2006-01-01

To evaluate the effectiveness of a personal digital assistant (PDA)-based clinical decision support system (CDSS) on nonsteroidal anti-inflammatory drug (NSAID) prescribing safety in the outpatient setting. The design was a randomized, controlled trial conducted in a university-based resident clinic. Internal medicine residents received a PDA-based CDSS suite. For intervention residents, the CDSS included a prediction rule for NSAID-related gastrointestinal risk assessment and treatment recommendations. Unannounced standardized patients (SPs) trained to portray musculoskeletal symptoms presented to study physicians. Safety outcomes were assessed from the prescriptions given to the SPs. Each prescription was reviewed by a committee of clinicians blinded to participant, intervention group assignment, and baseline or follow-up status. Prescriptions were judged as safe or unsafe. The main outcome measure was the differential change in unsafe prescribing of NSAIDs for the intervention versus the control group. At baseline, the mean proportion of cases per physician with unsafe prescriptions for the two groups was similar (0.27 vs. 0.29, p > 0.05). Controlling for baseline performance, intervention participants prescribed more safely than controls after receiving the CDSS (0.23 vs. 0.45 [F = 4.24, p < 0.05]). With the CDSS, intervention participants documented more complete assessment of patient gastrointestinal risk from NSAIDs. PARTICIPANTS provided with a PDA-based CDSS for NSAID prescribing made fewer unsafe treatment decisions than participants without the CDSS.

Multiscale simulation of a prescribed fire event in the New Jersey Pine Barrens using ARPS-CANOPY

Treesearch

Michael T. Kiefer; Warren E. Heilman; Shiyuan Zhong; Joseph J. Charney; Xindi Bian; Nicholas S. Skowronski; John L. Hom; Kenneth L. Clark; Matthew Patterson; Michael R. Gallagher

2014-01-01

Smoke prediction products are one of the tools used by land management personnel for decision making regarding prescribed fires. This study documents the application to a prescribed fire of a smoke prediction system that employs ARPS-CANOPY, a modified version of the Advanced Regional Prediction System (ARPS) model containing a canopy submodel, as the meteorological...

Consumer satisfaction with psychiatric services: The role of shared decision making and the therapeutic relationship.

PubMed

Klingaman, Elizabeth A; Medoff, Deborah R; Park, Stephanie G; Brown, Clayton H; Fang, Lijuan; Dixon, Lisa B; Hack, Samantha M; Tapscott, Stephanie L; Walsh, Mary Brighid; Kreyenbuhl, Julie A

2015-09-01

Although dissatisfaction is a primary reason for disengagement from outpatient psychiatric care among consumers with serious mental illnesses, little is known about predictors of their satisfaction with medication management visits. The primary purpose of this study was to explore how dimensions of consumer preferences for shared decision making (i.e., preferences for obtaining knowledge about one's mental illness, being offered and asked one's opinion about treatment options, and involvement in treatment decisions) and the therapeutic relationship (i.e., positive collaboration and type of clinician input) were related to visit satisfaction. Participants were 228 Veterans with serious mental illnesses who completed a 19-item self-report questionnaire assessing satisfaction with visits to prescribers (524 assessments) immediately after visits. In this correlational design, a 3-level mixed model with the restricted maximum likelihood estimation procedure was used to examine shared decision-making preferences and therapeutic alliance as predictors of visit satisfaction. Preferences for involvement in treatment decisions was the unique component of shared decision making associated with satisfaction, such that the more consumers desired involvement, the less satisfied they were. Positive collaboration and prescriber input were associated with greater visit satisfaction. When consumers with serious mental illnesses express preferences to be involved in shared decision making, it may not be sufficient to only provide information and treatment options; prescribers should attend to consumers' interest in involvement in actual treatment decisions. Assessment and tailoring of treatment approaches to consumer preferences for shared decision making should occur within the context of a strong therapeutic relationship. (c) 2015 APA, all rights reserved).

The effect of cognitive load and patient race on physicians' decisions to prescribe opioids for chronic low back pain: a randomized trial.

PubMed

Burgess, Diana J; Phelan, Sean; Workman, Michael; Hagel, Emily; Nelson, David B; Fu, Steven S; Widome, Rachel; van Ryn, Michelle

2014-06-01

To test the hypothesis that racial biases in opioid prescribing would be more likely under high levels of cognitive load, defined as the amount of mental activity imposed on working memory, which may come from environmental factors such as stressful conditions, chaotic workplace, staffing insufficiency, and competing demands, one's own psychological or physiological state, as well as from demands inherent in the task at hand. Two (patient race: White vs Black) by two (cognitive load: low vs high) between-subjects factorial design. Ninety-eight primary care physicians from the Veterans Affairs Healthcare System. Web-based experimental study. Physicians were randomly assigned to read vignettes about either a Black or White patient, under low vs high cognitive load, and to indicate their likelihood of prescribing opioids. High cognitive load was induced by having physicians perform a concurrent task under time pressure. There was a three-way interaction between patient race, cognitive load, and physician gender on prescribing decisions (P = 0.034). Hypotheses were partially confirmed. Male physicians were less likely to prescribe opioids for Black than White patients under high cognitive load (12.5% vs 30.0%) and were more likely to prescribe opioids for Black than White patients under low cognitive load (30.8% vs 10.5%). By contrast, female physicians were more likely to prescribe opioids for Black than White patients in both conditions, with greater racial differences under high (39.1% vs 15.8%) vs low cognitive load (28.6% vs 21.7%). Physician gender affected the way in which patient race and cognitive load influenced decisions to prescribe opioids for chronic pain. Future research is needed to further explore the potential effects of physician gender on racial biases in pain treatment, and the effects of physician cognitive load on pain treatment. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

Future perspectives on nonmedical prescribing

PubMed Central

Stewart, Derek; Jebara, Tesnime; Cunningham, Scott; Awaisu, Ahmed; Pallivalapila, Abdulrouf; MacLure, Katie

2017-01-01

Many countries have implemented nonmedical prescribing (NMP) and many others are scoping prescribing practices with a view to developing NMP. This paper provides a future perspective on NMP in light of findings of an umbrella review of aspects of NMP. This is followed by coverage of the Scottish Government strategy of pharmacist prescribing and finally, consideration of two key challenges. The review identified seven systematic reviews of influences on prescribing decision-making, processes of prescribing, and barriers and facilitators to implementation. Decision making was reported as complex with many, and often conflicting, influences. Facilitators of NMP included perceived improved patient care and professional autonomy, while barriers included lack of defined roles and resource pressures. Three systematic reviews explored patient outcomes that were noted to be equivalent or better to physician prescribing. In particular, a Cochrane review of 46 studies of clinical, patient-reported, and resource-use outcomes of NMP compared with medical prescribing showed positive intervention-group effects. Despite positive findings, authors highlighted high bias, poor definition and description of ‘prescribing’ and the ‘prescribing process’ and difficulty in separating NMP effects from the contributions of other healthcare team members. While evidence of benefit and safety is essential to inform practice, for NMP to be implemented and sustained on a large scale, there needs to be clear commitment at the highest level. The approach being taken by the Scottish Government to pharmacist prescribing implementation may inform developments in other professions and countries. The vision is that by 2023, all pharmacists providing pharmaceutical care will be pharmacist-independent prescribers. There are, however, challenges to implementing NMP into working practice; two key challenges are the need for sustainable models of care and evaluation research. These challenges could be met by considering the theoretical basis for implementation, and robust and rigorous evaluation. PMID:28607668

Influencing physician prescribing.

PubMed

Segal, R; Wang, F

1999-10-01

The drug use process suffers from problems related to quality and cost that have not responded well to administrative or educational interventions. In many cases, attempts to improve the quality of physician prescribing have been clumsy, often based on intuition. This article begins by describing the drug use process and the role of prescribing in that process. In the following section, we describe what is known about how physicians make drug choice decisions. The paper concludes with suggestions, based on evidence, about the design of strategies for influencing prescribing.

What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study

PubMed Central

2012-01-01

Background Thiazide diuretics are cost-effective for the treatment of mild to moderate hypertension, but physicians often opt for more expensive treatment options such as angiotensin II receptor blockers or angiotensin converting enzyme inhibitors. With escalating health care costs, there is a need to elucidate the factors influencing physicians' treatment choices for this highly prevalent chronic condition. The purpose of this study was to describe the characteristics of physicians' decision-making process regarding hypertension treatment choices. Methods A comparative qualitative study was conducted in 2009 in the Canadian province of Quebec. Overall, 29 primary care physicians--who are also participating in an electronic health record research program--participated in a semi-structured interview about their prescribing decisions. Physicians were categorized into two groups based on their patterns of prescribing antihypertensive drugs: physicians who predominantly prescribe diuretics, and physicians who predominantly prescribe drug classes other than diuretics. Cases of hypertension that were newly started on antihypertensive therapy were purposely selected from each physician's electronic health record database. Chart stimulated recall interview, a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinical encounters, was used to elucidate reasons for treatment choices. Interview transcripts were synthesized using content analysis techniques, and factors influencing physicians' decision making were inductively generated from the data. Results We identified three themes that differentiated physicians who predominantly prescribe diuretics from those who predominantly prescribe other drug classes for the initial treatment of mild to moderate hypertension: a) perceptions about the efficacy of diuretics, b) preferred approach to hypertension management and, c) perceptions about hypertension guidelines. Specifically, physicians had differences in beliefs about the efficacy, safety and tolerability of diuretics, the most effective approach for managing mild to moderate hypertension, and in aggressiveness to achieve treatment targets. Marketing strategies employed by the pharmaceutical industry and practice experience appear to contribute to these differences in management approach. Conclusions Physicians preferring more expensive treatment options appear to have several misperceptions about the efficacy, safety and tolerability of diuretics. Efforts to increase physicians' prescribing of diuretics may need to be directed at overcoming these misperceptions. PMID:22375684

Antibiotic prescribing practices for catheter urine culture results.

PubMed

Chiu, Jonathan; Thompson, G William; Austin, Thomas W; Hussain, Zafar; John, Michael; Bombassaro, Anne Marie; Connelly, Sarah E; Elsayed, Sameer

2013-01-01

The literature suggests that positive results of catheter urine cultures frequently lead to unnecessary antimicrobial prescribing, which therefore represents an important target for stewardship. To assess the appropriateness of antibiotic prescribing in response to the results of urine cultures from patients with indwelling urinary catheters. This retrospective study was conducted at a tertiary care centre and involved adults with indwelling urinary catheters from whom urine specimens were obtained for culture. Patients with positive or negative culture results were identified from microbiology laboratory reports. The medical records of consecutive patients were screened to select a sample of 80 inpatients (40 per group). Abstracted patient histories were independently evaluated by an expert panel of 3 infectious diseases consultants blinded to the decisions of prescribers and of fellow panelists. The primary end point was concordance of each patient's treatment decision (with respect to the indication) between the expert panel (based on majority agreement, i.e., at least 2 of the 3 expert panelists) and the prescriber. The secondary end points were unnecessary days of therapy and selected outcomes over a predefined period after urine was obtained for culture. A total of 591 charts were screened to generate the targeted number of patients. Baseline demographic characteristics were comparable for the 2 groups, except antibiotic exposure before urine collection was significantly more frequent for the group with negative culture results. The treatment decision was concordant in 40% (16/40) of the patients with a positive culture result and 85% (34/40) of those with a negative culture result (p < 0.001). The most common reason for discordance was administration of antibiotics when not indicated (23 of 24 patients with a positive result and 5 of 6 patients with a negative result), which accounted for 165 and 32 unnecessary days of therapy per 1000 inpatient-days, respectively (p < 0.001). Adverse effects occurred in 2 of the 23 patients with a positive result who received antibiotics that were not indicated. Appropriateness of antibiotic prescribing, as measured by concordance of decisions between the expert panel and prescribers, was more common among patients with negative urine culture results than among those with positive results. However, there is an opportunity to improve prescribing for both groups through antimicrobial stewardship initiatives. Unnecessary days of therapy and adverse effects were more common in patients with a positive culture result.

Communication prompts donation: exploring the beliefs underlying registration and discussion of the organ donation decision.

PubMed

Hyde, Melissa K; White, Katherine M

2009-09-01

To use a theory of planned behaviour (TPB) framework to explore the beliefs underlying communication of the donation decision for people who had not previously registered their consent on a donor register or discussed their decision with significant others. Initially, a focus group study elicited the common TPB (behavioural, normative, and control) beliefs about registering and discussing the organ donation decision. The main study assessed the important TPB belief predictors of intentions to register and discuss the donation decision. University students and community members from Queensland, Australia (N=123) completed items assessing their intentions and the TPB behavioural, normative, and control beliefs for registering and discussing their donation decision. Structural equation modelling (SEM) analyses revealed significant paths between people's intentions to register their donation decisions and underlying behavioural (e.g. enabling efficient donation procedures), normative (e.g. friends, doctors/medical professionals), and control (e.g. lack of motivation, knowing details about transplant recipients) beliefs (R2=.30). There were also significant paths between people's intentions to discuss their donation decision and underlying behavioural (e.g. feeling uncomfortable talking about death related topics) and normative (e.g. partner/spouse, family members) beliefs, but not control beliefs (R2=.33). There was a significant path between intentions to register and intentions to discuss one's donation decision. Results highlight the importance of focusing on behavioural and normative beliefs about communicating the donation decision, specifically for people who have not previously communicated their decision, and suggest potential targets for interventions designed to promote decision communication.

Human Judgment and Decision Making: Models and Applications.

ERIC Educational Resources Information Center

Loke, Wing Hong

This document notes that researchers study the processes involved in judgment and decision making and prescribe theories and models that reflect the behavior of the decision makers. It addresses the various models that are used to represent judgment and decision making, with particular interest in models that more accurately represent human…

Using qualitative insights to change practice: exploring the culture of antibiotic prescribing and consumption for urinary tract infections

PubMed Central

Duane, Sinead; Domegan, Christine; Callan, Aoife; Galvin, Sandra; Cormican, Martin; Bennett, Kathleen; Murphy, Andrew W

2016-01-01

Objectives The aim of this paper is to explore the culture of antibiotic prescribing and consumption in the community for urinary tract infections (UTI) from the perspective of the general practitioners (GPs) and community member. Design Indepth interviews were conducted with GPs, and focus groups were held with community members. Setting General practice and community setting. Participants 15 GPs practising in rural and urban locations in Ireland participated in the indepth interviews. 6 focus groups (n=42) with participants who had direct or indirect experiences with UTI were also undertaken. Results The decision to prescribe or consume an antibiotic for a UTI is a set of complex processes including need recognition, information search and evaluation processes governed by the relationship and interactions between the GP and the patient. Different GP and patient decision-making profiles emerged emphasising the diversity and variety of general practice in real-life settings. The GP findings showed a requirement for more microbiological information on antibiotic resistance patterns to inform prescribing decisions. Focus group participants wanted a conversation with the GP about their illness and the treatment options available. Conclusions Collectively, this research identified the consultation as a priority intervention environment for stimulating change in relation to antibiotics. This paper demonstrates how qualitative research can identify the interacting processes which are instrumental to the decision to prescribe or consume an antibiotic for a suspected UTI. Qualitative research empowers researchers to investigate the what, how and why of interventions in real-life setting. Qualitative research can play a critical and instrumental role in designing behavioural change strategies with high impact on practice. The results of this research were used to design a complex intervention informed by social marketing. Trial registration number NCT01913860; Pre-results. PMID:26754175

Resisting Prescribed Opioids: A Qualitative Study of Decision Making in Patients Taking Opioids for Chronic Noncancer Pain.

PubMed

Paterson, Charlotte; Ledgerwood, Kay; Arnold, Carolyn; Hogg, Malcolm; Xue, Charlie; Zheng, Zhen

2016-04-01

Opioids are increasingly prescribed for chronic noncancer pain across the developed world. Clinical guidelines for management of these patients focus on over-use. However, research into other types of long-term medication indicates that many patients minimize drug use whenever possible. To identify the varying influences on patients' decisions about their use of prescribed opioids and explore whether concepts of resistance and minimization of intake apply to these patients. A multiprofessional team performed a qualitative interview study using the constant-comparative method. Patient's decision making was explored in depth and with a thematic analysis utilizing a published "Model of medicine-taking." A purposive sample of 20 participants drawn from two pain clinics in Melbourne, Australia. The sample was biased toward patients interested in nonmedication pain management options. Patients' needs to obtain relief from severe pain, maintain function, and minimize side effects could lead to under-use as well as over-use of prescribed opioids. In keeping with the published Model of medicine-taking, resistance to taking opioids was a common and important influence on behavior. In the face of severe chronic pain, many participants used a variety of strategies to evaluate, avoid, reduce, self-regulate, and replace opioids. Furthermore, participants perceived a resistance to opioids within the system and among some healthcare professionals. This sometimes adversely affected their adherence. Both patients and doctors exhibit aspects of resistance to the use of prescribed opioids for chronic noncancer pain, suggesting that this shared concern could be the basis of a productive therapeutic alliance to improve communication and shared decision making. Clinical guidelines for opioids use for chronic noncancer pain focus on over-use. Our qualitative interview study found that many patients resisted and minimized the use of opioids. Using a published "Model of medicine-taking," we identified various influences on patient decision making. Both patients and doctors had concerns about using opioids for chronic noncancer pain. These could be the basis of a productive therapeutic alliance to improve communication and shared decision making. © 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Influences on Decision-Making Regarding Antipsychotic Prescribing in Nursing Home Residents With Dementia: A Systematic Review and Synthesis of Qualitative Evidence.

PubMed

Walsh, Kieran A; Dennehy, Rebecca; Sinnott, Carol; Browne, John; Byrne, Stephen; McSharry, Jennifer; Coughlan, Eoin; Timmons, Suzanne

2017-10-01

Antipsychotic prescribing is prevalent in nursing homes for the management of behavioral and psychological symptoms of dementia (BPSD), despite the known risks and limited effectiveness. Many studies have attempted to understand this continuing phenomenon, using qualitative research methods, and have generated varied and sometimes conflicting findings. To date, the totality of this qualitative evidence has not been systematically collated and synthesized. To synthesize the findings from individual qualitative studies on decision-making and prescribing behaviors for antipsychotics in nursing home residents with dementia, with a view to informing intervention development and quality improvement in this field. A systematic review and synthesis of qualitative evidence was conducted (PROSPERO protocol registration CRD42015029141). Six electronic databases were searched systematically from inception through July 2016 and supplemented by citation, reference, and gray literature searching. Studies were included if they used qualitative methods for both data collection and analysis, and explored antipsychotic prescribing in nursing homes for the purpose of managing BPSD. The Critical Appraisal Skills Program assessment tool was used for quality appraisal. A meta-ethnography was conducted to synthesize included studies. The Confidence in the Evidence from Reviews of Qualitative research approach was used to assess the confidence in individual review findings. All stages were conducted by at least 2 independent reviewers. Of 1534 unique records identified, 18 met the inclusion criteria. Five key concepts emerged as influencing decision-making: organizational capacity; individual professional capability; communication and collaboration; attitudes; regulations and guidelines. A "line of argument" was synthesized and a conceptual model constructed, comparing this decision-making process to a dysfunctional negative feedback loop. Our synthesis indicates that when all stakeholders come together to communicate and collaborate as equal and empowered partners, this can result in a successful reduction in inappropriate antipsychotic prescribing. Antipsychotic prescribing in nursing home residents with dementia occurs in a complex environment involving the interplay of various stakeholders, the nursing home organization, and external influences. To improve the quality of antipsychotic prescribing in this cohort, a more holistic approach to BPSD management is required. Although we have found the issue of antipsychotic prescribing has been extensively explored using qualitative methods, there remains a need for research focusing on how best to change the prescribing behaviors identified. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Erecting Closets and Outing Ourselves: Uncomfortable Reflexivity and Community-Based Research

ERIC Educational Resources Information Center

Reed, Sarah J.; Miller, Robin Lin; Nnawulezi, Nkiru; Valenti, Maria T.

2012-01-01

Feminist scholars and community psychologists have argued that reflexivity is a necessary component to conducting socially conscious research. Reflexivity, however, is rarely evident in community psychology. In this article, we share the uncomfortable realities that surfaced during a community-based research project in which we adapted and…

A comprehensive guide to fuel management practices for dry mixed conifer forests in the northwestern United States: Prescribed fire

Treesearch

Theresa B. Jain; Mike A. Battaglia; Han-Sup Han; Russell T. Graham; Christopher R. Keyes; Jeremy S. Fried; Jonathan E. Sandquist

2014-01-01

Fire has had a profound historical role in shaping dry mixed conifer forests in the western United States. However, the uncertainty and complexity of prescribed fires raises the question “Is fire always the best option for treating fuels?” The decision to use prescribed fire is dependent upon several factors.

Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review

PubMed Central

Papoutsi, Chrysanthi; Mattick, Karen; Pearson, Mark; Brennan, Nicola; Briscoe, Simon; Wong, Geoff

2017-01-01

Abstract Background Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one’s reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians’ prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings. PMID:28859445

Consumer Satisfaction with Psychiatric Services: The Role of Shared Decision-Making and the Therapeutic Relationship

PubMed Central

Klingaman, Elizabeth A.; Medoff, Deborah R.; Park, Stephanie G.; Brown, Clayton H.; Fang, Lijuan; Dixon, Lisa B.; Hack, Samantha M.; Tapscott, Stephanie L.; Walsh, Mary Brighid; Kreyenbuhl, Julie A.

2017-01-01

Objective Although dissatisfaction is a primary reason for disengagement from outpatient psychiatric care among consumers with serious mental illnesses, little is known about predictors of their satisfaction with medication management visits. The primary purpose of the present study was to explore how dimensions of consumer preferences for shared decision-making (i.e., preferences for obtaining knowledge about one’s mental illness, being offered and asked one’s opinion about treatment options, and involvement in treatment decisions) and the therapeutic relationship (i.e., positive collaboration and type of clinician input) were related to visit satisfaction. Methods Participants were 228 Veterans with serious mental illnesses who completed a 19-item self-report questionnaire assessing satisfaction with visits to prescribers (n=524 assessments) immediately after visits. In this correlational design, a 3-level mixed model with the restricted maximum likelihood estimation procedure was used to examine shared decision-making preferences and therapeutic alliance as predictors of visit satisfaction. Results Preferences for involvement in treatment decisions was the unique component of shared decision-making associated with satisfaction, such that the more consumers desired involvement, the less satisfied they were. Positive collaboration and prescriber input were associated with greater visit satisfaction. Conclusions and Implications for Practice When consumers with serious mental illnesses express preferences to be involved in shared decision-making, it may not be sufficient to only provide information and treatment options; prescribers should attend to consumers’ interest in involvement in actual treatment decisions. Assessment and tailoring of treatment approaches to consumer preferences for shared decision-making should occur within the context of a strong therapeutic relationship. PMID:25664755

Precision medicine: does ethnicity information complement genotype-based prescribing decisions?

PubMed Central

Shah, Rashmi R.; Gaedigk, Andrea

2017-01-01

Inter-ethnic differences in drug response are all too well known. These are underpinned by a number of factors, including pharmacogenetic differences across various ethnic populations. Precision medicine relies on genotype-based prescribing decisions with the aim of maximizing efficacy and mitigating the risks. When there is no access to genotyping tests, ethnicity is frequently regarded as a proxy of the patient’s probable genotype on the basis of overall population-based frequency of genetic variations in the ethnic group the patient belongs to, with some variations being ethnicity-specific. However, ever-increasing transcontinental migration of populations and the resulting admixing of populations have undermined the utility of self-identified ethnicity in predicting the genetic ancestry, and therefore the genotype, of the patient. An example of the relevance of genetic ancestry of a patient is the inadequate performance of European-derived pharmacogenetic dosing algorithms of warfarin in African Americans, Brazilians and Caribbean Hispanics. Consequently, genotyping a patient potentially requires testing for all known clinically actionable variants that the patient may harbour, and new variants that are likely to be identified using state-of the art next-generation sequencing-based methods. Furthermore, self-identified ethnicity is associated with a number of ethnicity-related attributes and non-genetic factors that potentially influence the risk of phenoconversion (genotype–phenotype discordance), which may adversely impact the success of genotype-based prescribing decisions. Therefore, while genotype-based prescribing decisions are important in implementing precision medicine, ethnicity should not be disregarded. PMID:29318005

Principles of educational outreach ('academic detailing') to improve clinical decision making.

PubMed

Soumerai, S B; Avorn, J

1990-01-26

With the efficacy and costs of medications rising rapidly, it is increasingly important to ensure that drugs be prescribed as rationally as possible. Yet, physicians' choices of drugs frequently fall short of the ideal of precise and cost-effective decision making. Evidence indicates that such decisions can be improved in a variety of ways. A number of theories and principles of communication and behavior changes can be found that underlie the success of pharmaceutical manufacturers in influencing prescribing practices. Based on this behavioral science and several field trials, it is possible to define the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care. Some of the most important techniques of such "academic detailing" include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programs on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioral objectives, (4) establishing credibility through a respected organizational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages, and (8) providing positive reinforcement of improved practices in follow-up visits. Used by the nonprofit sector, the above techniques have been shown to reduce inappropriate prescribing as well as unnecessary health care expenditures.

Humor, Rapport, and Uncomfortable Moments in Interactions with Adults with Traumatic Brain Injury

ERIC Educational Resources Information Center

Kovarsky, Dana; Schiemer, Christine; Murray, Allison

2011-01-01

We examined uncomfortable moments that damaged rapport during group interactions between college students in training to become speech-language pathologists and adults with traumatic brain injury. The students worked as staff in a community-based program affiliated with a university training program that functioned as a recreational gathering…

Projecting the cost, utilization, and patient care impact of prescribing extended release non-abuse-deterrent opioids to chronic pain patients.

PubMed

Yenikomshian, Mihran Ara; White, Alan G; Carson, Michael E; Garrison, Louis P; Oderda, Gary M; Biskupiak, Joseph E; Hlavacek, Patrick R; Roland, Carl L

To estimate healthcare resource utilization, associated costs, and number needed to harm (NNH) from a physician's decision to prescribe extended-release (ER) non-abuse-deterrent opioids (non-ADO) as compared to ER ADOs in a chronic pain population. A 12-month probabilistic simulation model was developed to estimate the reduction of misuse and/or abuse from a physician's prescribing decisions for 10,000 patients. Model inputs included probabilities for opioid misuse and/or abuse-related events, opioid discontinuation, and switching from ADO to non-ADO. Estimated reductions in abuse associated with ADOs were obtained from positive subjective measures using human abuse liability studies. The model was run separately for commercial, Medicare, Medicaid, and Veterans Administration (VA) populations. The difference in healthcare resource utilization and associated costs (2015 USD) between the ADO and non-ADO simulations was calculated. NNH for non-ADO was also calculated. Misuse and/or abuse-related events for patients prescribed ER non-ADOs ranged from 223-1,410 and associated costs ranged from $20-$98 per patient for commercial and Medicare populations, respectively. Prescribing ER ADOs were associated with 87, 289, 264, and 417 fewer misuse and/or abuse-related events, saving $8, $35, $21, and $29 per patient in commercial, VA, Medicaid, and Medicare populations, respectively. NNH ranged from 185 in the commercial population to 40 in the Medicare population. Results were sensitive to decreases in the probability of misuse and/or abuse events but showed reductions. A physician's decision to prescribe ER ADOs could lead to large reductions in misuse and/or abuse-related events and associated costs across many patient populations.

Factors influencing family physicians' drug prescribing behaviour in asthma management in primary care.

PubMed

Tan, N C; Tay, I H; Ngoh, A; Tan, M

2009-03-01

Little is known about the decision pathway that family physicians (FP) take in considering drug therapy for their asthma patients. This study aimed to explore the factors that influence FPs' decisions in prescribing medications for their asthma patients. A qualitative method using focus group discussions (FGD) was used to gather qualitative data based on a semi-structured topic guide from FPs of different training backgrounds and practices. 29 Singapore FPs working as private general practitioners (GP), polyclinic doctors and locums were recruited into five FGDs. The FPs' asthma drug prescription decisions were related to the FPs' medical training and acquisition of asthma-related information and updates. Uncertainty of disease diagnosis, patients' beliefs and their perceptions of the disease and treatment, as well as the FPs' concerns about drug side effects, were significant considerations for the participants. Costs related to differential subsidies in the consultation fees and drugs between public polyclinics and GP clinics in the local primary healthcare system, was a key factor in influencing the FPs' asthma drug treatment decisions. FPs' asthma drug prescribing behaviour is influenced by their medical training, disease definition, patient factors and drug costs in the context of the local primary healthcare system and policy.

10 CFR 430.49 - Finality of decision.

Code of Federal Regulations, 2014 CFR

2014-01-01

... Finality of decision. (a) A decision to prescribe a rule that a State energy conservation standard, water conservation standard (in the case of faucets, showerheads, water closets, and urinals) or other requirement... DEPARTMENT OF ENERGY ENERGY CONSERVATION ENERGY CONSERVATION PROGRAM FOR CONSUMER PRODUCTS Petitions To...

10 CFR 430.49 - Finality of decision.

Code of Federal Regulations, 2013 CFR

2013-01-01

... DEPARTMENT OF ENERGY ENERGY CONSERVATION ENERGY CONSERVATION PROGRAM FOR CONSUMER PRODUCTS Petitions To... Finality of decision. (a) A decision to prescribe a rule that a State energy conservation standard, water conservation standard (in the case of faucets, showerheads, water closets, and urinals) or other requirement...

10 CFR 430.49 - Finality of decision.

Code of Federal Regulations, 2012 CFR

2012-01-01

... DEPARTMENT OF ENERGY ENERGY CONSERVATION ENERGY CONSERVATION PROGRAM FOR CONSUMER PRODUCTS Petitions To... Finality of decision. (a) A decision to prescribe a rule that a State energy conservation standard, water conservation standard (in the case of faucets, showerheads, water closets, and urinals) or other requirement...

10 CFR 430.49 - Finality of decision.

Code of Federal Regulations, 2010 CFR

2010-01-01

... DEPARTMENT OF ENERGY ENERGY CONSERVATION ENERGY CONSERVATION PROGRAM FOR CONSUMER PRODUCTS Petitions To... Finality of decision. (a) A decision to prescribe a rule that a State energy conservation standard, water conservation standard (in the case of faucets, showerheads, water closets, and urinals) or other requirement...

10 CFR 430.49 - Finality of decision.

Code of Federal Regulations, 2011 CFR

2011-01-01

... DEPARTMENT OF ENERGY ENERGY CONSERVATION ENERGY CONSERVATION PROGRAM FOR CONSUMER PRODUCTS Petitions To... Finality of decision. (a) A decision to prescribe a rule that a State energy conservation standard, water conservation standard (in the case of faucets, showerheads, water closets, and urinals) or other requirement...

First-Person Perspective Virtual Body Posture Influences Stress: A Virtual Reality Body Ownership Study

PubMed Central

Bergström, Ilias; Kilteni, Konstantina; Slater, Mel

2016-01-01

In immersive virtual reality (IVR) it is possible to replace a person’s real body by a life-sized virtual body that is seen from first person perspective to visually substitute their own. Multisensory feedback from the virtual to the real body (such as the correspondence of touch and also movement) can also be present. Under these conditions participants typically experience a subjective body ownership illusion (BOI) over the virtual body, even though they know that it is not their real one. In most studies and applications the posture of the real and virtual bodies are as similar as possible. Here we were interested in whether the BOI is diminished when there are gross discrepancies between the real and virtual body postures. We also explored whether a comfortable or uncomfortable virtual body posture would induce feelings and physiological responses commensurate with the posture. We carried out an experiment with 31 participants in IVR realized with a wide field-of-view head-mounted display. All participants were comfortably seated. Sixteen of them were embodied in a virtual body designed to be in a comfortable posture, and the remainder in an uncomfortable posture. The results suggest that the uncomfortable body posture led to lesser subjective BOI than the comfortable one, but that participants in the uncomfortable posture experienced greater awareness of their autonomic physiological responses. Moreover their heart rate, heart rate variability, and the number of mistakes in a cognitive task were associated with the strength of their BOI in the uncomfortable posture: greater heart rate, lower heart rate variability and more mistakes were associated with higher levels of the BOI. These findings point in a consistent direction—that the BOI over a body that is in an uncomfortable posture can lead to subjective, physiological and cognitive effects consistent with discomfort that do not occur with the BOI over a body in a comfortable posture. PMID:26828365

To Prescribe or Not to Prescribe? Consumer Access to Life-Enhancing Products

PubMed Central

Marinova, Detelina; Kozlenkova, Irina V; Cuttler, Leona; Silvers, J B

2017-01-01

Abstract With rapid biotechnological advances in specialty drugs and direct-to-consumer advertising, consumers are under tremendous pressure to look, perform, feel, and live better. This is often accomplished through the use of life-enhancing products, sometimes referred to as performance-enhancing products, which can be accessed only through a gatekeeper, such as a physician. Integrating consumer and medical research, this article investigates how physicians make trade-offs between objective medical and nonmedical factors to determine consumers’ access to life-enhancing products by examining US pediatric endocrinologists’ prescription decisions for growth hormone (GH) for healthy but short children. The results of a conjoint study indicate that consumer medical criteria have less impact on a physician’s decision to prescribe GH if the consumer requests a prescription or the physician believes in the intangible product benefits, and more impact when the product is more expensive. A physician’s length of experience increases the impact of consumer medical criteria and decreases the influence of a consumer’s preference for a prescription on the decision to prescribe. Overall, this research shows that not all consumers have equal access to life-enhancing products; their access depends on a complex combination of medical and nonmedical factors related to the consumer, product, and the physician. PMID:29928069

Twelve-month drug cost savings related to use of an electronic prescribing system with integrated decision support in primary care.

PubMed

McMullin, S Troy; Lonergan, Thomas P; Rynearson, Charles S

2005-05-01

We reported previously the results of a 6-month controlled trial in which the use of a commercially available electronic prescribing system with integrated clinical decision support and evidence-based message capability was associated with significantly lower primary care drug costs. The original study focused on new prescriptions, defined as claims for a medication that the patient had not received in the previous 12 months. The main objectives of this follow-up report were to (a) determine if the 6-month savings on new prescriptions were sustained during 12 months of follow-up, (b) evaluate the impact of the computerized decision support system (CDSS) on all pharmacy claims and per-member-per-month (PMPM) expenditures, and (c) evaluate the prescribing behaviors within 8 high-cost therapeutic categories that were frequently targeted by the electronic messages to prescribers to help verify that the drug cost savings were due to the recommendations in the electronic prescribing system. Two database queries were performed to identify additional pharmacy claims data for all Network Health Plan patients who were cared for by the 38 primary care clinicians (32 physicians, 4 nurse practitioners, and 2 physician assistants) included in our original 6-month study. This follow-up analysis (a) identified all new prescription claims for the 2 groups of clinicians throughout the 12-month follow-up period (June 2002 through May 2003) and (b) assessed all pharmacy claims during the same 12-month period to provide more complete savings estimates and to examine between-group differences in PMPM expenditures. During 12 months of follow-up, clinicians using the electronic prescribing system continued to have lower prescription costs than the controls. Clinicians using the electronic prescribing system had average costs for 26,674 new prescriptions that were dollar 4.12 lower (95% confidence interval, dollar 1.53-dollar 6.71; P=0.003) and PMPM expenditures that were dollar 0.57 lower than expected based on the changes observed for 24,507 new prescriptions written by clinicians in the control group. The average drug cost savings on new prescriptions were dollar 482 per prescriber per month (PPPM), based upon prescription cost and dollar 465 PPPM based upon PMPM analysis. When all pharmacy claims (156,429) were analyzed, the intervention group.s average prescription cost was dollar 2.57 lower and their PMPM expenditures were dollar 1.07 lower than expected based on the changes observed in the control group. The average drug cost savings on all pharmacy claims were dollar 863 PPPM based on average prescription cost and dollar 873 PPPM based on PMPM analysis. The proportion of prescriptions for highcost drugs that were the target of the CDSS messages to prescribers was a relative 17.5% lower among the intervention group (35.8%) compared with the control group (43.4%; P=0.03). An electronic prescribing system with integrated decision support shifted prescribing behavior away from high-cost therapies and significantly lowered prescription drug costs. The savings associated with altered prescribing behavior offset the monthly subscription cost of the system.

The role of prescribed burn associations in the application of prescribed fires in rangeland ecosystems.

PubMed

Toledo, David; Kreuter, Urs P; Sorice, Michael G; Taylor, Charles A

2014-01-01

Risk and liability concerns regarding fire affect people's attitudes toward fire and have led to human-induced alterations of fire regimes. This has, in turn, contributed to brush encroachment and degradation of many grasslands and savannas. Efforts to successfully restore such degraded ecosystems at the landscape scale in regions of the United States with high proportions of private lands require the reintroduction of fire. Prescribed Burn Associations (PBA) provide training, equipment, and labor to apply fire safely, facilitating the application of this rangeland management tool and thereby reducing the associated risk. PBAs help build networks and social capital among landowners who are interested in using fire. They can also change attitudes toward fire and enhance the social acceptability of using prescribed fire as a management practice. PBAs are an effective mechanism for promoting the widespread use of prescribed fire to restore and maintain the biophysical integrity of grasslands and savannas at the landscape scale. We report findings of a project aimed at determining the human dimensions of using prescribed fire to control woody plant encroachment in three different eco-regions of Texas. Specifically, we examine membership in PBAs as it relates to land manager decisions regarding the use of prescribed fire. Perceived risk has previously been identified as a key factor inhibiting the use of prescribed fire by landowners. Our results show that perceived constraints, due to lack of skill, knowledge, and access to equipment and membership in a PBAs are more important factors than risk perceptions in affecting landowner decisions about the use of fire. This emphasizes the potential for PBAs to reduce risk perceptions regarding the application of prescribed fire and, therefore, their importance for restoring brush-encroached grasslands and savannas. Published by Elsevier Ltd.

Delayed prescribing for upper respiratory tract infections: a qualitative study of GPs' views and experiences

PubMed Central

Høye, Sigurd; Frich, Jan; Lindbœk, Morten

2010-01-01

Background Delayed prescribing has been promoted as a strategy that meets patients' expectations and helps to avoid unnecessary use of antibiotics in upper respiratory tract infections. Aim To explore GPs' views on and experiences with delayed prescribing in patients with acute upper respiratory tract infections. Design of study Qualitative study involving focus groups. Setting Norwegian general practice. Method Qualitative analysis of data collected from five focus groups comprising 33 GPs who took part in a quality-improvement programme of antibiotic prescribing. Results The views of GPs differed on the usefulness of delayed prescribing. GPs who endorsed the strategy emphasised shared decision making and the creation of opportunities for educating patients, whereas GPs who were negative applied the strategy mainly when being pressed to prescribe. Mild and mainly harmless conditions of a possible bacterial origin, such as acute sinusitis and acute otitis, were considered most suitable for delayed prescribing. A key argument for issuing a wait-and-see prescription was that it helped patients avoid seeking after-hours care. For issuing a wait-and-see prescription, the GPs required that the patient was ‘knowledgeable’, able to understand the indications for antibiotics, and motivated for shared decision making. GPs emphasised that patients should be informed thoroughly when receiving a wait-and-see prescription. Conclusion Not all GPs endorse delayed prescribing; however, it appears to be a feasible approach for managing patients with early symptoms of mild upper respiratory tract infections of a possible bacterial origin. Informing the patients properly while issuing wait-and-see prescriptions is essential. PMID:21144201

New medicines in primary care: a review of influences on general practitioner prescribing.

PubMed

Mason, A

2008-02-01

The uptake of new medicines is slower in the UK than in many other countries. Previous research found that cost and price have little influence on general practitioner (GP) behaviour, but recent UK government policy may have heightened cost-consciousness. Focussing on new medicines, this review aimed to explore the determinants of uptake, the causes of geographical variations, and the influence of price, cost and financial incentives on prescribing behaviour. Two separate searches were conducted on nine electronic databases. Strategy 1, an update of a previous review, used key terms for primary care physicians, uptake, medicines and 'new'. Strategy 2 focussed on terms relating to incentives and prescribing. Records were screened for eligibility and data from relevant papers were extracted using Bonair and Persson's typology for determinants of the diffusion of innovation, which classified influences into three groups: actors, structural/environmental characteristics and product characteristics. The searches identified 550 records and 28 studies were included in the updated review. Prescribing of new medicines needs to be understood in the context of individual patient-centred care, which is characterized by stability and continuity. Hospital doctors, pharmaceutical representatives and prescribing advisers are all influential, but GP attitudes towards these actors vary and there are notable differences between high and low prescribers of new pharmaceuticals. Support systems can help provide appropriate guidance and increase the uptake of new medicines by identifying patients who may benefit from pharmaceutical therapy. There is evidence of a shift in GP attitudes towards central policy initiatives, with doctors slowly accepting the need for external scrutiny and national standards. Although cost does appear to inform prescribing decisions, it is typically of lower importance than both safety and efficacy concerns and does not represent a significant barrier to uptake of new medicines. The impact of financial incentives on prescribing behaviour remains unclear, but is unlikely to be straightforward. No evidence exploring the reasons for geographical variations in GP uptake of new medicines was found. General practitioner care has historically been patient-centred, and it is unclear whether and how GPs consider the impact of their decisions upon the wider patient population. Incorporating cost considerations into GP decision making is one way to reflect the broader impact of individual treatment decisions. Current UK government policies use incentives to improve quality and encourage financial responsibility. Although these initiatives may help foster cost-consciousness, there is a risk that unintended consequences may ensue. Therefore, future policy evaluations should assess benefits, harms and costs so that the overall impact is transparent.

Specialty training and the personal use of benzodiazepines by physicians affect their proneness to prescribe tranquilizers.

PubMed

Linden, M; Gothe, H

1998-03-01

The decision on how to treat a patient does not depend on clinical matters or illness characteristics alone, but also on patient, physician and setting variables such as personality, training, or reimbursement. No research has yet been carried out to answer the question whether personal experience with medications also influences prescribing behavior. In this study, 124 physicians stratified according to specialty (neuropsychiatrists vs. general practitioners), type of institution (private practice vs. hospital), years of professional experience (young vs. old), and region (rural vs. urban) participated in a structured interview to evaluate their proneness to prescribe benzodiazepines for sleep disorders as well as their personal experience in taking benzodiazepines for their own sleep problems. Both specialty and personal experience were significantly related to proneness to prescribe. Other variables tested (region, institution, age, gender) did not help to explain the variance in benzodiazepine prescribing practice. Thus physician variables and, importantly, their own personal experience in taking the medication significantly influence treatment choice. Rational medical decision making and treatment guidelines must therefore take into account medical knowledge as well as knowledge of personal treatment preferences and professional biases.

Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness.

PubMed

Coon, Eric R; Maloney, Christopher G; Shen, Mark W

2015-03-01

Imperfect diagnostic tools make it difficult to know the extent to which a bacterial process is contributing to respiratory illness, complicating the decision to prescribe antibiotics. We sought to quantify diagnostic and antibiotic prescribing disagreements between emergency department (ED) and pediatric hospitalist physicians for children admitted with respiratory illness. Manual chart review was used to identify testing, diagnostic, and antibiotic prescribing decisions for consecutive children admitted for respiratory illness in a winter (starting February 20, 2012) and a summer (starting August 20, 2012) season to a tertiary, freestanding children's hospital. Respiratory illness diagnoses were grouped into 3 categories: bacterial, viral, and asthma. A total of 181 children admitted for respiratory illness were studied. Diagnostic discordance was significant for all 3 types of respiratory illness but greatest for bacterial (P<.001). Antibiotic prescribing discordance was significant (P<.001), with pediatric hospitalists changing therapy for 93% of patients prescribed antibiotics in the ED, including stopping antibiotics altogether for 62% of patients. Significant diagnostic and antibiotic discordance between ED and pediatric hospitalist physicians exists for children admitted to the hospital for respiratory illness. Copyright © 2015 by the American Academy of Pediatrics.

Prescribing Clinicians’ Perspectives on Evidence-Based Psychotherapy for Posttraumatic Stress Disorder

PubMed Central

Barnett, Erin R.; Bernardy, Nancy C.; Jenkyn, Aaron B.; Parker, Louise E.; Lund, Brian C.; Alexander, Bruce; Friedman, Matthew J.

2014-01-01

Evidence-based psychotherapies (EBP) for Posttraumatic Stress Disorder are not utilized to their full extent within the Department of Veterans Affairs (VA). VA provides care to many persons with PTSD and has been in the forefront of clinical practice guidelines and EBP training and dissemination. Yet VA continues to find EBP implementation difficult. Veterans with PTSD often initially present to prescribing clinicians, who then help make care decisions. It is therefore critical that these clinicians correctly screen and triage appropriate mental health care. The purpose of this study was to assess VA prescribing clinicians’ knowledge, perceptions, and referral behaviors related to EBPs for PTSD and to identify facilitators and barriers to implementing EBPs within VA. We conducted qualitative interviews with 26 VA prescribing clinicians. Limited access to EBPs was the most commonly noted barrier. The clinicians we interviewed also held specific beliefs and behaviors that may delay or deter EBPs. Strategies to improve utilization also emerged. Findings suggest the need for increased access to EBPs, training to optimize the role of prescribing clinicians in helping Veterans with PTSD make appropriate care decisions, and specific organizational changes to facilitate access and effective referral systems for EBPs. PMID:25431445

HIV providers' likelihood to prescribe pre-exposure prophylaxis (PrEP) for HIV prevention differs by patient type: a short report.

PubMed

Adams, Leah M; Balderson, Benjamin H

2016-09-01

Pre-exposure prophylaxis (PrEP), the antiretroviral treatment regimen for HIV-negative people at high risk of acquiring HIV, has demonstrated efficacy across clinical trials in several patient populations. The Centers for Disease Control (CDC) have released detailed guidelines to aid providers in prescribing PrEP for their high-risk patients, including men who have sex with men (MSM), high-risk heterosexuals, and injection drug users (IDUs). Given that much attention in PrEP has focused on MSM patients, the present study used an online survey to assess factors involved in HIV care providers' (n = 363) decisions about prescribing PrEP, along with their willingness to prescribe PrEP to patients from various risk populations (e.g., MSM, heterosexuals, IDUs). The efficacy of PrEP was an important factor in providers' decisions about prescribing PrEP, as were considerations about patients' adherence to the regimen, regular follow-up for care, and medication costs. This survey's findings also suggest that providers' willingness to prescribe PrEP varies by patient group, with providers most willing to initiate the regimen with MSM who have an HIV-positive partner, and least willing to prescribe to high-risk heterosexuals or IDUs. In the context of the current CDC recommendations for PrEP that include MSM, heterosexuals, and IDUs, examining providers' rationales for and barriers against supporting this HIV prevention strategy across patient groups merits further attention.

Preparing to Prescribe: How Do Clerkship Students Learn in the Midst of Complexity?

ERIC Educational Resources Information Center

McLellan, Lucy; Yardley, Sarah; Norris, Ben; de Bruin, Anique; Tully, Mary P.; Dornan, Tim

2015-01-01

Prescribing tasks, which involve pharmacological knowledge, clinical decision-making and practical skill, take place within unpredictable social environments and involve interactions within and between endlessly changing health care teams. Despite this, curriculum designers commonly assume them to be simple to learn and perform. This research used…

Opportunistic screening of hospital staff using primary colonoscopy: participation, discomfort and willingness to repeat the procedure.

PubMed

Khalid-de Bakker, C A; Jonkers, D M; Hameeteman, W; de Ridder, R J; Masclee, A A; Stockbrügger, R W

2011-01-01

Participation in and tolerability of primary colonoscopy screening are presumed to be relatively low. The present study aimed to test its feasibility in a well-informed population of hospital staff using an intensive information campaign, and to identify factors associated with screening colonoscopy rated as uncomfortable. Data were collected using standardized forms. Out of 1,090 invited employees (50-65 years), 447 (41.0%) participated. Bowel preparation and colonoscopy were rated as 'somewhat to very uncomfortable' by 79.5 and 21.9%, respectively. 96.3% of participants were willing to repeat colonoscopy in the future. Participants rating colonoscopy as uncomfortable were more likely unwilling to repeat the procedure (OR 8.026, CI 2.667-24.154). Multivariate analysis (age- and gender-adjusted) showed an association of colonoscopy rated as uncomfortable with: abdominal pain during colonoscopy (OR 3.185, CI 1.642-6.178), other pain (OR 2.428, CI 1.335-4.416), flatulence (OR 2.175, CI 1.219-3.881), embarrassment (OR 2.843, CI 1.350-5.989), abdominal pain after colonoscopy (OR 1.976, CI 1.041-3.751), and a prolonged procedure time (OR 1.000, CI 1.000-1.001). Acceptance of primary colonoscopy screening for colorectal neoplasia was high, although participants with symptoms during and after colonoscopy were more likely to rate colonoscopy as uncomfortable. This type of opportunistic screening procedure is suitable for the introduction of screening programs and may be useful in areas that have no access to population-based screening. Copyright © 2011 S. Karger AG, Basel.

HL7 Structured Product Labeling - electronic prescribing information for provider order entry decision support.

PubMed

Schadow, Gunther

2005-01-01

Prescribing errors are an important cause of adverse events, and lack of knowledge of the drug is a root cause for prescribing errors. The FDA is issuing new regulations that will make the drug labels much more useful not only to physicians, but also to computerized order entry systems that support physicians to practice safe prescribing. For this purpose, FDA works with HL7 to create the Structured Product Label (SPL) standard that includes a document format as well as a drug knowledge representation, this poster introduces the basic concepts of SPL.

A Closer Look at Racism and Heterosexism in Medical Students' Clinical Decision-Making Related to HIV Pre-Exposure Prophylaxis (PrEP): Implications for PrEP Education.

PubMed

Calabrese, Sarah K; Earnshaw, Valerie A; Krakower, Douglas S; Underhill, Kristen; Vincent, Wilson; Magnus, Manya; Hansen, Nathan B; Kershaw, Trace S; Mayer, Kenneth H; Betancourt, Joseph R; Dovidio, John F

2018-04-01

Social biases among healthcare providers could limit PrEP access. In this survey study of 115 US medical students, we examined associations between biases (racism and heterosexism) and PrEP clinical decision-making and explored prior PrEP education as a potential buffer. After viewing a vignette about a PrEP-seeking MSM patient, participants reported anticipated patient behavior (condomless sex, extra-relational sex, and adherence), intention to prescribe PrEP to the patient, biases, and background characteristics. Minimal evidence for racism affecting clinical decision-making emerged. In unadjusted analyses, heterosexism indirectly affected prescribing intention via all anticipated behaviors, tested as parallel mediators. Participants expressing greater heterosexism more strongly anticipated increased risk behavior and adherence problems, which were associated with lower prescribing intention. The indirect effect via condomless sex remained significant adjusting for background characteristics. Prior PrEP education did not buffer any indirect effects. Heterosexism may compromise PrEP provision to MSM and should be addressed in PrEP-related medical education.

Prescribing antibiotics to ‘at-risk’ children with influenza-like illness in primary care: qualitative study

PubMed Central

Ashdown, Helen F; Räisänen, Ulla; Wang, Kay; Ziebland, Sue; Harnden, Anthony

2016-01-01

Objectives National Institute for Health and Care Excellence guidelines recommend immediate antibiotic treatment of respiratory tract infections in ‘at-risk’ individuals with comorbidities. Observational evidence suggests that influenza particularly predisposes children to bacterial complications. This study investigates general practitioners’ (GPs’) accounts of factors influencing their decision-making about antibiotic prescribing in the management of at-risk children with influenza-like illness (ILI). Design Qualitative interview study using a maximum variation sample with thematic analysis through constant comparison. Setting Semistructured telephone interviews with UK GPs using a case vignette of a child with comorbidities presenting with ILI. Participants There were 41 GPs (41.5% men; 40 from England, 1 from Northern Ireland) with a range of characteristics including length of time in practice, paediatrics experience, practice setting and deprivation. Results There was considerable uncertainty and variation in the way GPs responded to the case and difference of opinion about how long-term comorbidities should affect their antibiotic prescribing pattern. Factors influencing their decision included the child's case history and clinical examination; the GP's view of the parent's ability to self-manage; the GP's own confidence and experiences of managing sick children and assessment of individual versus abstract risk. GPs rarely mentioned potential influenza infection or asked about immunisation status. All said that they would want to see the child; views about delayed prescribing varied in relation to local health service provision including options for follow-up and paediatric services. Conclusions The study demonstrates diagnostic uncertainty and wide variation in GP decision-making about prescribing antibiotics to children with comorbidity. Future guidelines might encourage consideration of a specific diagnosis such as influenza, and risk assessment tools could be developed to allow clinicians to quantify the levels of risk associated with different types of comorbidity. However, the wide range of clinical and non-clinical factors involved in decision-making during these consultations should also be considered in future guidelines. PMID:27288385

Influences on the prescribing of new drugs.

PubMed

Tobin, Luke; de Almedia Neto, Abelio C; Wutzke, Sonia; Patterson, Craig; Mackson, Judith; Weekes, Lynn; Williamson, Margaret

2008-01-01

The aim of this study was to identify the factors that influence prescribing of new drugs among general practitioners, endocrinologists and psychiatrists. Four focus groups were conducted with GPs, endocrinologists and psychiatrists on sources of awareness and influences on prescribing of new drugs. Pharmaceutical companies were the most important source for becoming aware of new drugs. There were many influences on the decision to prescribe a new drug, the most important being efficacy, safety, cost and advantage over existing therapies. Endocrinologists placed greater emphasis on evidence from clinical trials and scientific conferences, and psychiatrists and GPs placed more weight on pharmaceutical representatives, colleagues and specialists. New drug prescribing occurs in a complex environment with many influences. Effective interventions to promote rational, safe and effective prescribing of new drugs will need to be cognisant of these factors.

What are the qualities of dilemmas experienced when prescribing opioids in general practice?

PubMed

Bendtsen, P; Hensing, G; Ebeling, C; Schedin, A

1999-07-01

The decision process preceding prescribing analgesics is complex and the physician is often struggling to balance several disparate considerations in order to work out what is rational. Several factors--medical, intellectual, emotional and logistic--influence the decision whether or not to prescribe, and the decision itself influences how the physicians feel about themselves. In this study the 'critical incident technique' was used for exploring the qualities of dilemmas among general physicians prior to prescribing analgesics to patients in primary health care. The study displayed two main types of problems in connection with prescription of opioids. The first main problem was a concern about abuse and addiction with no proper indication for the drug. The second main type of problem was related to the appropriateness of the drug, although the indication as such might be correct, i.e. acute or chronic pain. An important consequence of the dilemmas experienced influenced the physicians' self-esteem negatively, including failures in the patient-physician relationship. This results in emotional strain and is often experienced as a personal defeat. Only a few physicians denied prescription despite the experience of a dilemma, which might indicate an ambivalence or lack of knowledge among physicians with regard to proper indications for opioid prescription. However, it may also suggest that physicians need more training in saying no, or skills in deciding proper indications for opioids, which needs to be addressed during educational programmes.

Teaching Decision Making to Adolescents: A Critical Review.

ERIC Educational Resources Information Center

Beyth-Marom, Ruth; And Others

A conceptual framework derived from formal and behavioral theories was used to describe and evaluate a sample of the best developed programs for teaching decision making to adolescents. The internal validity of the programs was evaluated in terms of the adequacy of their coverage of the normatively prescribed steps to good decision making. The…

[Rational drug use: an economic approach to decision making].

PubMed

Mota, Daniel Marques; da Silva, Marcelo Gurgel Carlos; Sudo, Elisa Cazue; Ortún, Vicente

2008-04-01

The present article approaches rational drug use (RDU) from the economical point of view. The implementation of RDU implies in costs and involves acquisition of knowledge and behavioral changes of several agents. The difficulties in implementing RDU may be due to shortage problems, information asymmetry, lack of information, uncertain clinical decisions, externalities, time-price, incentives for drug prescribers and dispensers, drug prescriber preferences and marginal utility. Health authorities, among other agencies, must therefore regularize, rationalize and control drug use to minimize inefficiency in pharmaceutical care and to prevent exposing the population to unnecessary health risks.

Accounting for medical variation: the case of prescribing activity in a New Zealand general practice sample.

PubMed

Davis, P B; Yee, R L; Millar, J

1994-08-01

Medical practice variation is extensive and well documented, particularly for surgical interventions, and raises important questions for health policy. To date, however, little work has been carried out on interpractitioner variation in prescribing activity in the primary care setting. An analytical model of medical variation is derived from the literature and relevant indicators are identified from a study of New Zealand general practice. The data are based on nearly 9,500 completed patient encounter records drawn from over a hundred practitioners in the Waikato region of the North Island, New Zealand. The data set represents a 1% sample of all weekday general practice office encounters in the Hamilton Health District recorded over a 12-month period. Overall levels of prescribing, and the distribution of drug mentions across diagnostic groupings, are broadly comparable to results drawn from international benchmark data. A multivariate analysis is carried out on seven measures of activity in the areas of prescribing volume, script detail, and therapeutic choice. The analysis indicates that patient, practitioner and practice attributes exert little systematic influence on the prescribing task. The principal influences are diagnosis, followed by practitioner identity. The pattern of findings suggests also that the prescribing task cannot be viewed as an undifferentiated activity. It is more usefully considered as a process of decision-making in which 'core' judgements--such as the decision to prescribe and the choice of drug--are highly predictable and strongly influenced by diagnosis, while 'peripheral' features of the task--such as choosing a combination drug or prescribing generically--are less determinate and more subject to the exercise of clinical discretion.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of a spring prescribed burn on the soil seed bank in sagebrush steppe exhibiting pinyon-juniper expansion

Treesearch

Elizabeth A. Allen; Jeanne C. Chambers; Robert S. Nowak

2008-01-01

Pinyon-juniper (Pinus monophylla-Juniperus osteosperma) woodlands are expanding into shrubsteppe ecosystems in western portions of the Great Basin. Often, highly competitive trees displace the understory, and prescribed fire is increasingly used as a restoration tool. To inform management decisions about post-fire recovery, we...

Controlling pain and reducing misuse of opioids

PubMed Central

Kotalik, Jaro

2012-01-01

Abstract Objective To help family physicians achieve an ethical balance in their opioid prescribing practices. Quality of evidence MEDLINE was searched for English-language articles published between 1985 and 2011. Most available evidence was level III. Main message It is essential to follow practice guidelines when prescribing opioids, except when another course of action is demonstrably justified. In addition, when considering the appropriateness of an opioid prescription, with its many ethical implications, the decision can be usefully guided by the application of the ethical principles of beneficence, nonmaleficence, respect for autonomy, and justice. As well, it is essential to keep current about legal and regulatory changes and provincial electronic registries of opioid prescriptions. Conclusion Physicians need to ensure that their patients’ pain is properly assessed and managed. Reaching optimal pain control might necessitate prescribing opioids. But the obligation to provide pain relief needs to be balanced with an equally important responsibility not to expose patients to risk of addiction and not to create opportunities for drug diversion, trafficking, and the addiction of others. Basic ethical principles can provide a framework to help physicians make ethically appropriate decisions about opioid prescribing. PMID:22611604

When is rational to order a diagnostic test, or prescribe treatment: the threshold model as an explanation of practice variation.

PubMed

Djulbegovic, Benjamin; van den Ende, Jef; Hamm, Robert M; Mayrhofer, Thomas; Hozo, Iztok; Pauker, Stephen G

2015-05-01

The threshold model represents an important advance in the field of medical decision-making. It is a linchpin between evidence (which exists on the continuum of credibility) and decision-making (which is a categorical exercise - we decide to act or not act). The threshold concept is closely related to the question of rational decision-making. When should the physician act, that is order a diagnostic test, or prescribe treatment? The threshold model embodies the decision theoretic rationality that says the most rational decision is to prescribe treatment when the expected treatment benefit outweighs its expected harms. However, the well-documented large variation in the way physicians order diagnostic tests or decide to administer treatments is consistent with a notion that physicians' individual action thresholds vary. We present a narrative review summarizing the existing literature on physicians' use of a threshold strategy for decision-making. We found that the observed variation in decision action thresholds is partially due to the way people integrate benefits and harms. That is, explanation of variation in clinical practice can be reduced to a consideration of thresholds. Limited evidence suggests that non-expected utility threshold (non-EUT) models, such as regret-based and dual-processing models, may explain current medical practice better. However, inclusion of costs and recognition of risk attitudes towards uncertain treatment effects and comorbidities may improve the explanatory and predictive value of the EUT-based threshold models. The decision when to act is closely related to the question of rational choice. We conclude that the medical community has not yet fully defined criteria for rational clinical decision-making. The traditional notion of rationality rooted in EUT may need to be supplemented by reflective rationality, which strives to integrate all aspects of medical practice - medical, humanistic and socio-economic - within a coherent reasoning system. © 2015 Stichting European Society for Clinical Investigation Journal Foundation.

Healthcare professionals' dilemmas: judging patient's decision making competence in day-to-day care of patients suffering from Korsakoff's syndrome.

PubMed

van den Hooff, Susanne; Buijsen, Martin

2014-11-01

Patient's decision making competence (PDMC) is a widely discussed subject. Issues of competence, autonomy, well-being and protection of the patient come up every day. In this article we analyse what role PDMC plays in Dutch legislation and what dilemmas healthcare professionals may experience, notably in patients suffering from Korsakoff's syndrome. Dilemmas emerge if professionals want to meet the requirements mentioned in Dutch law and the desires of their patients. The autonomy of the patient and the healthcare professionals' duty to take care of their patient's best interests, create a tension and lead to uncomfortable situations. Healthcare professionals describe difficulty finding a balance between these issues and assessing the degree of mental competence still present. In long term care situations, quality of the relationship between healthcare professionals and their patients seems to be of much more importance in decision making on minor issues of competence than simply relying on legal or house rules. In being committed to their cases, professionals will be more sensitive to individuals habits, abilities, welfare and dignity, which will make it easier to decide on issues of competence, and to find creative solutions to their dilemmas.

Effective communication during difficult conversations.

PubMed

Polito, Jacquelyn M

2013-06-01

A strong interest and need exist in the workplace today to master the skills of conducting difficult conversations. Theories and strategies abound, yet none seem to have found the magic formula with universal appeal and success. If it is such an uncomfortable skill to master is it better to avoid or initiate such conversations with employees? Best practices and evidence-based management guide us to the decision that quality improvement dictates effective communication, even when difficult. This brief paper will offer some suggestions for strategies to manage difficult conversations with employees. Mastering the skills of conducting difficult conversations is clearly important to keeping lines of communication open and productive. Successful communication skills may actually help to avert confrontation through employee engagement, commitment and appropriate corresponding behavior

Financial incentives and physicians' prescription decisions on the choice between brand-name and generic drugs: evidence from Taiwan.

PubMed

Liu, Ya-Ming; Yang, Yea-Huei Kao; Hsieh, Chee-Ruey

2009-03-01

This paper tests the hypothesis of whether or not financial incentives affect a physician's prescription decision on the choice of generic versus brand-name drugs within a system in which physicians prescribe and dispense drugs. By using data obtained from Taiwan and focusing on diabetic patients, our empirical results provide several consistent findings in support of the hypothesis that profit incentives do affect the physician's prescribing decision, suggesting that physicians act as imperfect agents. An important implication of our findings is that rent seeking for profit margin between the reimbursement and the acquisition price instead of reducing costs is the major driving force behind generic substitution. As a result, the providers instead of the payers or consumers reap the financial benefits of generic substitution.

A survey of the views and capabilities of community pharmacists in Western Australia regarding the rescheduling of selected oral antibiotics in a framework of pharmacist prescribing

PubMed Central

Sinkala, Fatima; Parsons, Richard; Sunderland, Bruce; Hoti, Kreshnik

2018-01-01

Background Antibiotic misuse in the community contributes to antimicrobial resistance. One way to address this may be by better utilizing community pharmacists’ skills in antibiotic prescribing. The aims of this study were to examine the level of support for “down-scheduling” selected antibiotics and to evaluate factors determining the appropriateness of community pharmacist prescribing for a limited range of infections, including their decision to refer to a doctor. Methods Self-administered questionnaires, including graded case vignette scenarios simulating real practice, were sent to Western Australian community pharmacists. In addition to descriptive statistics and chi-square testing, a General Estimating Equation (GEE) was used to identify factors associated with appropriateness of therapy and the decision to refer, for each of the seven vignettes. Results Of the 240 pharmacists surveyed, 90 (37.5%) responded, yielding 630 responses to seven different case vignettes. There was more than 60% respondent support for expanded prescribing (rescheduling) of commonly prescribed antibiotics. Overall 426/630 (67.6%) chose to treat the patient while the remaining 204/630 (32.4%) referred the patient to a doctor. Of those electing to treat, 380/426 (89.2%) opted to use oral antibiotics, with 293/380 (77.2%) treating with an appropriate selection and regimen. The GEE model indicated that pharmacists were more likely to prescribe inappropriately for conditions such as otitis media (p = 0.0060) and urinary tract infection in pregnancy (p < 0.0001) compared to more complex conditions. Over 80% of all pharmacists would refer the patient to a doctor following no improvement within 3 days, or within 24 h in the case of community acquired pneumonia. It was more common for younger pharmacists to refer the patient to a doctor (p = 0.0165). Discussion This study adds further insight into community pharmacy/pharmacist characteristics associated with appropriateness of oral antibiotic selection and the decision to refer to doctors. These findings require consideration in designing pharmacist over-the-counter prescribing models for oral antibiotics. PMID:29761047

A survey of the views and capabilities of community pharmacists in Western Australia regarding the rescheduling of selected oral antibiotics in a framework of pharmacist prescribing.

PubMed

Sinkala, Fatima; Parsons, Richard; Sunderland, Bruce; Hoti, Kreshnik; Czarniak, Petra

2018-01-01

Antibiotic misuse in the community contributes to antimicrobial resistance. One way to address this may be by better utilizing community pharmacists' skills in antibiotic prescribing. The aims of this study were to examine the level of support for "down-scheduling" selected antibiotics and to evaluate factors determining the appropriateness of community pharmacist prescribing for a limited range of infections, including their decision to refer to a doctor. Self-administered questionnaires, including graded case vignette scenarios simulating real practice, were sent to Western Australian community pharmacists. In addition to descriptive statistics and chi-square testing, a General Estimating Equation (GEE) was used to identify factors associated with appropriateness of therapy and the decision to refer, for each of the seven vignettes. Of the 240 pharmacists surveyed, 90 (37.5%) responded, yielding 630 responses to seven different case vignettes. There was more than 60% respondent support for expanded prescribing (rescheduling) of commonly prescribed antibiotics. Overall 426/630 (67.6%) chose to treat the patient while the remaining 204/630 (32.4%) referred the patient to a doctor. Of those electing to treat, 380/426 (89.2%) opted to use oral antibiotics, with 293/380 (77.2%) treating with an appropriate selection and regimen. The GEE model indicated that pharmacists were more likely to prescribe inappropriately for conditions such as otitis media ( p = 0.0060) and urinary tract infection in pregnancy ( p  < 0.0001) compared to more complex conditions. Over 80% of all pharmacists would refer the patient to a doctor following no improvement within 3 days, or within 24 h in the case of community acquired pneumonia. It was more common for younger pharmacists to refer the patient to a doctor ( p  = 0.0165). This study adds further insight into community pharmacy/pharmacist characteristics associated with appropriateness of oral antibiotic selection and the decision to refer to doctors. These findings require consideration in designing pharmacist over-the-counter prescribing models for oral antibiotics.

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2011 CFR

2011-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2010 CFR

2010-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2012 CFR

2012-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2014 CFR

2014-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2013 CFR

2013-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

Combined assessment of clinical and patient factors on doctors' decisions to prescribe antibiotics.

PubMed

Strumiło, Julia; Chlabicz, Sławomir; Pytel-Krolczuk, Barbara; Marcinowicz, Ludmiła; Rogowska-Szadkowska, Dorota; Milewska, Anna Justyna

2016-06-03

Antibiotic overprescription is a worldwide problem. Decisions regarding antibiotic prescription for respiratory tract infections (RTIs) are influenced by medical and non-medical factors. In family medicine practices in Białystok, Poland, family medicine residents directly observed consultations with patients with RTI symptoms. The observing residents completed a questionnaire including patient data, clinical symptoms, diagnosis, any prescribed antibiotic, and assessment of ten patient pressure factors. Of 1546 consultations of patients with RTIs, 54.26 % resulted in antibiotic prescription. Antibiotic prescription was strongly associated with rales (OR 26.90, 95 % CI 9.00-80.40), tonsillar exudates (OR 13.03, 95 % CI 7.10-23.80), and wheezing (OR 14.72, 95 % CI 7.70-28.10). The likelihood of antibiotic prescription was increased by a >7-day disease duration (OR 3.94, 95 % CI 2.80-5.50), purulent nasal discharge (OR 3.87, 95 % CI 2.40-6.10), starting self-medication with antibiotics (OR 4.11, 95 % CI 2.30-7.30), and direct request for antibiotics (OR 1.87, 95 % CI 1.30-2.80). Direct request not to prescribe antibiotics decreased the likelihood of receiving antibiotics (OR 0.34, 95 % CI 0.27-0.55). While clinical signs and symptoms principally impact prescribing decisions, patient factors also contribute. The most influential patient pressure factors were starting self-medication with antibiotics, and directly requesting antibiotic prescription or no antibiotic prescription. Interventions aiming to improve clinical sign and symptom interpretation and to help doctors resist direct patient pressure could be beneficial for reducing unnecessary antibiotic prescribing.

A Primer on Decision Analysis for Individually Prescribed Instruction. ACT Technical Bulletin No. 17.

ERIC Educational Resources Information Center

Davis, Charles E.; And Others

A coherent system of decision making is described that may be incorporated into an instructional sequence to provide a supplement to the experience-based judgment of the classroom teacher. The elements of this decision process incorporate prior information such as a teacher's past experience, experimental results such as a test score, and…

Prescribing regeneration treatments for mixed-oak forests in the Mid-Atlantic region

Treesearch

Patrick H. Brose; Kurt W. Gottschalk; Stephen B. Horsley; Peter D. Knopp; James N. Kochenderfer; Barbara J. McGuinness; Gary W. Miller; Todd E. Ristau; Scott H. Stoleson; Susan L. Stout

2008-01-01

Includes guidelines for using the SILVAH decision-support system to perpetuate oak forests in the Mid-Atlantic region. Six chapters provide information on values of oak forests, inventory methods, key decision variables, decision charts, and silvicultural prescriptions, as well as guidance on fostering young stands. Sample tally sheets and SILVAH computer printouts are...

Access to point-of-care tests reduces the prescription of antibiotics among antibiotic-requesting subjects with respiratory tract infections.

PubMed

Llor, Carl; Bjerrum, Lars; Munck, Anders; Cots, Josep M; Hernández, Silvia; Moragas, Ana

2014-12-01

General practitioners (GPs) often feel uncomfortable when patients request an antibiotic when there is likely little benefit. This study evaluates the effect of access to point-of-care tests on decreasing the prescription of antibiotics in respiratory tract infections in subjects who explicitly requested an antibiotic prescription. Spanish GPs registered all cases of respiratory tract infections over a 3-week period before and after an intervention undertaken in 2008 and 2009. Patients with acute sinusitis, pneumonia, and exacerbations of COPD were excluded. Two types of interventions were performed: the full intervention group received prescriber feedback with discussion of the results of the first registry, courses for GPs, guidelines, patient information leaflets, workshops, and access to point-of-care tests (rapid streptococcal antigen detection test and C-reactive protein test); and the partial intervention group underwent all of the above interventions except for the workshop and access to point-of-care tests. A total of 210 GPs were assigned to the full intervention group and 71 to the partial intervention group. A total of 25,479 subjects with respiratory tract infections were included, of whom 344 (1.4%) requested antibiotic prescribing. Antibiotics were more frequently prescribed to subjects requesting them compared with those who did not (49.1% vs 18.5%, P < .001). In the group of GPs assigned to the partial intervention group, 53.1% of subjects requesting antibiotics received a prescription before and 60% after the intervention, without statistical differences being observed. In the group of GPs assigned to the full intervention group, the percentages were 55.1% and 36.2%, respectively, with a difference of 18.9% (95% CI: 6.4%-30.6%, P < .05). Access to point-of-care tests reduces antibiotic use in subjects who explicitly request an antibiotic prescription. Copyright © 2014 by Daedalus Enterprises.

Physicians' Trust in the FDA's Use of Product-Specific Pathways for Generic Drug Approval.

PubMed

Kesselheim, Aaron S; Eddings, Wesley; Raj, Tara; Campbell, Eric G; Franklin, Jessica M; Ross, Kathryn M; Fulchino, Lisa A; Avorn, Jerry; Gagne, Joshua J

2016-01-01

Generic drugs are cost-effective versions of brand-name drugs approved by the Food and Drug Administration (FDA) following proof of pharmaceutical equivalence and bioequivalence. Generic drugs are widely prescribed by physicians, although there is disagreement over the clinical comparability of generic drugs to brand-name drugs within the physician community. The objective of this survey was to assess physicians' perceptions of generic drugs and the generic drug approval process. A survey was administered to a national sample of primary care internists and specialists between August 2014 and January 2015. In total, 1,152 physicians comprising of internists with no reported specialty certification and those with specialty certification in hematology, infectious diseases, and endocrinology were surveyed. The survey assessed physicians' perceptions of the FDA's generic drug approval process, as well as their experiences prescribing six generic drugs approved between 2008 and 2012 using product-specific approval pathways and selected comparator drugs. Among 718 respondents (62% response rate), a majority were comfortable with the FDA's process in ensuring the safety and effectiveness of generic drugs overall (91%) and with letting the FDA determine which tests were necessary to determine bioequivalence in a particular drug (92%). A minority (13-26%) still reported being uncomfortable prescribing generic drugs approved using product-specific pathways. Overall, few physicians heard reports of concerns about generic versions of the study drugs or their comparators, with no differences between the two groups. Physicians tended to hear about concerns about the safety or effectiveness of generic drugs from patients, pharmacists, and physician colleagues. Physicians hold largely positive views of the FDA's generic drug approval process even when some questioned the performance of certain generic drugs in comparison to brand-name drugs. Better education about the generic drug approval process and standards may alleviate concerns among the physician community and support the delivery of cost-effective health care.

Users Guide to VSMOKE-GIS for Workstations

Treesearch

Mary F. Harms; Leonidas G. Lavdas

1997-01-01

VSMOKE-GIS was developed to help prescribed burners in the national forests of the Southeastern United States visualize smoke dispersion and to plan prescribed burns. Developed for use on workstations, this decision-support system consists of a graphical user interface, written in Arc/Info Arc Macro Language, and is linked to a FORTRAN computer program. VSMOKE-GIS...

Why do health workers give anti-malarials to patients with negative rapid test results? A qualitative study at rural health facilities in western Uganda.

PubMed

Altaras, Robin; Nuwa, Anthony; Agaba, Bosco; Streat, Elizabeth; Tibenderana, James K; Strachan, Clare E

2016-01-11

The large-scale introduction of malaria rapid diagnostic tests (RDTs) promises to improve management of fever patients and the rational use of valuable anti-malarials. However, evidence on the impact of RDT introduction on the overprescription of anti-malarials has been mixed. This study explored determinants of provider decision-making to prescribe anti-malarials following a negative RDT result. A qualitative study was conducted in a rural district in mid-western Uganda in 2011, ten months after RDT introduction. Prescriptions for all patients with negative RDT results were first audited from outpatient registers for a two month period at all facilities using RDTs (n = 30). Facilities were then ranked according to overall prescribing performance, defined as the proportion of patients with a negative RDT result prescribed any anti-malarial. Positive and negative deviant facilities were sampled for qualitative investigation; positive deviants (n = 5) were defined ex post facto as <0.75% and negative deviants (n = 7) as >5%. All prescribing clinicians were targeted for qualitative observation and in-depth interview; 55 fever cases were observed and 22 providers interviewed. Thematic analysis followed the 'framework' approach. 8344 RDT-negative patients were recorded at the 30 facilities (prescription audit); 339 (4.06%) were prescribed an anti-malarial. Of the 55 observed patients, 38 tested negative; one of these was prescribed an anti-malarial. Treatment decision-making was influenced by providers' clinical beliefs, capacity constraints, and perception of patient demands. Although providers generally trusted the accuracy of RDTs, anti-malarial prescription was driven by perceptions of treatment failure or undetectable malaria in patients who had already taken artemisinin-based combination therapy prior to facility arrival. Patient assessment and other diagnostic practices were minimal and providers demonstrated limited ability to identify alternative causes of fever. Provider perceptions of patient expectations sometimes appeared to influence treatment decisions. The study found high provider adherence to RDT results, but that providers believed in certain clinical exceptions and felt they lacked alternative options. Guidance on how the RDT works and testing following partial treatment, better methods for assisting providers in diagnostic decision-making, and a context-appropriate provider behaviour change intervention package are needed.

Modelling decision-making by pilots

NASA Technical Reports Server (NTRS)

Patrick, Nicholas J. M.

1993-01-01

Our scientific goal is to understand the process of human decision-making. Specifically, a model of human decision-making in piloting modern commercial aircraft which prescribes optimal behavior, and against which we can measure human sub-optimality is sought. This model should help us understand such diverse aspects of piloting as strategic decision-making, and the implicit decisions involved in attention allocation. Our engineering goal is to provide design specifications for (1) better computer-based decision-aids, and (2) better training programs for the human pilot (or human decision-maker, DM).

Breast cancer treatment decision making among Latinas and non-Latina Whites: a communication model predicting decisional outcomes and quality of life.

PubMed

Yanez, Betina; Stanton, Annette L; Maly, Rose C

2012-09-01

Deciding among medical treatment options is a pivotal event following cancer diagnosis, a task that can be particularly daunting for individuals uncomfortable with communication in a medical context. Few studies have explored the surgical decision-making process and associated outcomes among Latinas. We propose a model to elucidate pathways through which acculturation (indicated by language use) and reports of communication effectiveness specific to medical decision making contribute to decisional outcomes (i.e., congruency between preferred and actual involvement in decision making, treatment satisfaction) and quality of life among Latinas and non-Latina White women with breast cancer. Latinas (N = 326) and non-Latina Whites (N = 168) completed measures six months after breast cancer diagnosis, and quality of life was assessed 18 months after diagnosis. Structural equation modeling was used to examine relationships between language use, communication effectiveness, and outcomes. Among Latinas, 63% reported congruency in decision making, whereas 76% of non-Latina Whites reported congruency. In Latinas, greater use of English was related to better reported communication effectiveness. Effectiveness in communication was not related to congruency in decision making, but several indicators of effectiveness in communication were related to greater treatment satisfaction, as was greater congruency in decision making. Greater treatment satisfaction predicted more favorable quality of life. The final model fit the data well only for Latinas. Differences in quality of life and effectiveness in communication were observed between racial/ethnic groups. Findings underscore the importance of developing targeted interventions for physicians and Latinas with breast cancer to enhance communication in decision making. PsycINFO Database Record (c) 2012 APA, all rights reserved.

C-A4-01: Computerized Clinical Decision Support During Drug Ordering for Long-term Care Residents With Renal Insufficiency

PubMed Central

Field, Terry S; Rochon, Paula; Lee, Monica; Gavendo, Linda; Baril, Joann L; Gurwitz, Jerry H

2010-01-01

Objective: To determine whether a computerized clinical decision support system (CDSS) providing patient specific recommendations in real- time improves the quality of prescribing for long-term care residents with renal insufficiency. Design: A randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units. Measurement: The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: recommended medication doses; recommended administration frequencies; recommendations to avoid the drug; 4) warnings of missing information. Results: The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1). For the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often than a relative risk 1.2 (1.0, 1.4). By tracking personnel time and expenditures, we estimated the cost of developing the CDSS as $48,668.57. Drug costs saved during the 12 months of the trial are estimated at $2,137. Conclusion: Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions. However, patient well-being and quality of care rather than the business case related to cost savings are likely to be the key drivers for adoption of this HIT application.

48 CFR 653.219-70 - DOS form DS-1910, Small Business Agency Review-Actions Above the Simplified Acquisition Threshold.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 48 Federal Acquisition Regulations System 4 2012-10-01 2012-10-01 false DOS form DS-1910, Small Business Agency Review-Actions Above the Simplified Acquisition Threshold. 653.219-70 Section 653.219-70... Threshold. As prescribed in 619.501(c), DS-1910 is prescribed for use in documenting set-aside decisions...

Predictive Modeling of Physician-Patient Dynamics That Influence Sleep Medication Prescriptions and Clinical Decision-Making

NASA Astrophysics Data System (ADS)

Beam, Andrew L.; Kartoun, Uri; Pai, Jennifer K.; Chatterjee, Arnaub K.; Fitzgerald, Timothy P.; Shaw, Stanley Y.; Kohane, Isaac S.

2017-02-01

Insomnia remains under-diagnosed and poorly treated despite its high economic and social costs. Though previous work has examined how patient characteristics affect sleep medication prescriptions, the role of physician characteristics that influence this clinical decision remains unclear. We sought to understand patient and physician factors that influence sleep medication prescribing patterns by analyzing Electronic Medical Records (EMRs) including the narrative clinical notes as well as codified data. Zolpidem and trazodone were the most widely prescribed initial sleep medication in a cohort of 1,105 patients. Some providers showed a historical preference for one medication, which was highly predictive of their future prescribing behavior. Using a predictive model (AUC = 0.77), physician preference largely determined which medication a patient received (OR = 3.13 p = 3 × 10-37). In addition to the dominant effect of empirically determined physician preference, discussion of depression in a patient’s note was found to have a statistically significant association with receiving a prescription for trazodone (OR = 1.38, p = 0.04). EMR data can yield insights into physician prescribing behavior based on real-world physician-patient interactions.

“Cleansing” anatomical collections: The politics of removing specimens from German anatomical and medical collections 1988–92

PubMed Central

Weindling, Paul

2015-01-01

SUMMARY In 1989–90 an intense debate erupted in the Federal Republic of Germany over the status of anatomical specimens from the period of National Socialism. Pressure was brought on the German universities and research institutes to remove body parts. The solution was deemed rapid burial of all specimens whose provenance was in doubt. A range of options was considered, and the eventual decision to bury cremated remains was deemed the best way to draw a line under an uncomfortable past of Nazi medical atrocities. The aim was to achieve closure on this issue by a rapid “cleansing” of collections. However, identification of victims was left unresolved amidst the heated debates at the time. PMID:22445542

Evaluation of prescriber responses to pharmacogenomics clinical decision support for thiopurine S-methyltransferase testing.

PubMed

Ubanyionwu, Samuel; Formea, Christine M; Anderson, Benjamin; Wix, Kelly; Dierkhising, Ross; Caraballo, Pedro J

2018-02-15

Results of a study of prescribers' responses to a pharmacogenomics-based clinical decision support (CDS) alert designed to prompt thiopurine S -methyltransferase (TPMT) status testing are reported. A single-center, retrospective, chart review-based study was conducted to evaluate prescriber compliance with a pretest CDS alert that warned of potential thiopurine drug toxicity resulting from deficient TPMT activity due to TPMT gene polymorphism. The CDS alert was triggered when prescribers ordered thiopurine drugs for patients whose records did not indicate TPMT status or when historical thiopurine use was documented in the electronic health record. The alert pop-up also provided a link to online educational resources to guide thiopurine dosing calculations. During the 9-month study period, 500 CDS alerts were generated: in 101 cases (20%), TPMT phenotyping or TPMT genotyping was ordered; in 399 cases (80%), testing was not ordered. Multivariable regression analysis indicated that documentation of historical thiopurine use was the only independent predictor of test ordering. Among the 99 patients tested subsequent to CDS alerts, 70 (71%) had normal TPMT activity, 29 (29%) had intermediate activity, and none had deficient activity. The online resources provided thiopurine dosing recommendations applicable to 24 patients, but only 3 were prescribed guideline-supported doses after CDS alerts. The pretest CDS rule resulted in a large proportion of neglected alerts due to poor alerting accuracy and consequent alert fatigue. Prescriber usage of online thiopurine dosing resources was low. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Core drug-drug interaction alerts for inclusion in pediatric electronic health records with computerized prescriber order entry.

PubMed

Harper, Marvin B; Longhurst, Christopher A; McGuire, Troy L; Tarrago, Rod; Desai, Bimal R; Patterson, Al

2014-03-01

The study aims to develop a core set of pediatric drug-drug interaction (DDI) pairs for which electronic alerts should be presented to prescribers during the ordering process. A clinical decision support working group composed of Children's Hospital Association (CHA) members was developed. CHA Pharmacists and Chief Medical Information Officers participated. Consensus was reached on a core set of 19 DDI pairs that should be presented to pediatric prescribers during the order process. We have provided a core list of 19 high value drug pairs for electronic drug-drug interaction alerts to be recommended for inclusion as high value alerts in prescriber order entry software used with a pediatric patient population. We believe this list represents the most important pediatric drug interactions for practical implementation within computerized prescriber order entry systems.

Computerized clinical decision support for prescribing: provision does not guarantee uptake

PubMed Central

Moxey, Annette; Robertson, Jane; Newby, David; Hains, Isla; Williamson, Margaret; Pearson, Sallie-Anne

2010-01-01

There is wide variability in the use and adoption of recommendations generated by computerized clinical decision support systems (CDSSs) despite the benefits they may bring to clinical practice. We conducted a systematic review to explore the barriers to, and facilitators of, CDSS uptake by physicians to guide prescribing decisions. We identified 58 studies by searching electronic databases (1990–2007). Factors impacting on CDSS use included: the availability of hardware, technical support and training; integration of the system into workflows; and the relevance and timeliness of the clinical messages. Further, systems that were endorsed by colleagues, minimized perceived threats to professional autonomy, and did not compromise doctor-patient interactions were accepted by users. Despite advances in technology and CDSS sophistication, most factors were consistently reported over time and across ambulatory and institutional settings. Such factors must be addressed when deploying CDSSs so that improvements in uptake, practice and patient outcomes may be achieved. PMID:20064798

A 5-year retrospective audit of prescribing by a critical care outreach team.

PubMed

Wilson, Mark

2018-05-01

UK prescribing legislation changes made in 2006 and 2012 enabled appropriately qualified nurses to prescribe any licensed medication, and all controlled drugs in schedule 2-5 of the Misuse of Drugs Regulations 2001, for any medical condition within their clinical competence. Critical Care Outreach nurses who are independent nurse prescribers are ideally placed to ensure that acutely ill patients receive treatment without delay. The perceived challenge was how Critical Care Outreach nurses would be able to safely prescribe for a diverse patient group. This study informs this developing area of nurse prescribing in critical care practice. The aims of the audit were to: identify which medications were prescribed; develop a critical care outreach formulary; identify the frequency, timing and number of prescribing decisions being made; identify if prescribing practice changed over the years and provide information for our continuing professional development. This article reports on data collected from a 5-year retrospective audit; of prescribing activity undertaken by nine independent nurse prescribers working in a 24/7 Critical Care Outreach team of a 600-bedded district general hospital in the UK. In total, 8216 medication items were prescribed, with an average of 2·6 prescribed per shift. The most commonly prescribed items were intravenous fluids and analgesia, which were mostly prescribed at night and weekends. The audit has shown that Critical Care Outreach nurse prescribing is feasible in a whole hospital patient population. The majority of prescribing occurred after 16:00 and at night. Further research would be beneficial, particularly looking at patient outcomes following reviews from prescribing critical care outreach nurses. The audit is one of the only long-term studies that describes prescribing practice in Critical Care Outreach teams in the UK. © 2017 British Association of Critical Care Nurses.

Biomass Burning Emissions – The Importance of Reducing Uncertainties for Improved Regulatory Decision; an EPA Perspective

EPA Science Inventory

Biomass burning emissions from wildland and prescribed fires can have far reaching impacts in several of EPA’s regulatory programs under the Clean Air Act, ultimately affecting decisions on actions taken under State Implementation Plans (SIPs), and programs such as Visibility and...

A new `bio-comfort' perspective for Melbourne based on heat stress, air pollution and pollen

NASA Astrophysics Data System (ADS)

Jacobs, Stephanie J.; Pezza, Alexandre B.; Barras, Vaughan; Bye, John

2014-03-01

Humans are at risk from exposure to extremes in their environment, yet there is no consistent way to fully quantify and understand the risk when considering more than just meteorological variables. An outdoor `bio-comfort' threshold is defined for Melbourne, Australia using a combination of heat stress, air particulate concentration and grass pollen count, where comfortable conditions imply an ideal range of temperature, humidity and wind speed, acceptable levels of air particulates and a low pollen count. This is a new approach to defining the comfort of human populations. While other works have looked into the separate impacts of different variables, this is the first time that a unified bio-comfort threshold is suggested. Composite maps of surface pressure are used to illustrate the genesis and evolution of the atmospheric structures conducive to an uncomfortable day. When there is an uncomfortable day due to heat stress conditions in Melbourne, there is a high pressure anomaly to the east bringing warm air from the northern interior of Australia. This anomaly is part of a slow moving blocking high originating over the Indian Ocean. Uncomfortable days due to high particulate levels have an approaching cold front. However, for air particulate cases during the cold season there are stable atmospheric conditions enhanced by a blocking high emanating from Australia and linking with the Antarctic continent. Finally, when grass pollen levels are high, there are northerly winds carrying the pollen from rural grass lands to Melbourne, due to a stationary trough of low pressure inland. Analysis into days with multiple types of stress revealed that the atmospheric signals associated with each type of discomfort are present regardless of whether the day is uncomfortable due to one or multiple variables. Therefore, these bio-comfort results are significant because they offer a degree of predictability for future uncomfortable days in Melbourne.

A new 'bio-comfort' perspective for Melbourne based on heat stress, air pollution and pollen.

PubMed

Jacobs, Stephanie J; Pezza, Alexandre B; Barras, Vaughan; Bye, John

2014-03-01

Humans are at risk from exposure to extremes in their environment, yet there is no consistent way to fully quantify and understand the risk when considering more than just meteorological variables. An outdoor 'bio-comfort' threshold is defined for Melbourne, Australia using a combination of heat stress, air particulate concentration and grass pollen count, where comfortable conditions imply an ideal range of temperature, humidity and wind speed, acceptable levels of air particulates and a low pollen count. This is a new approach to defining the comfort of human populations. While other works have looked into the separate impacts of different variables, this is the first time that a unified bio-comfort threshold is suggested. Composite maps of surface pressure are used to illustrate the genesis and evolution of the atmospheric structures conducive to an uncomfortable day. When there is an uncomfortable day due to heat stress conditions in Melbourne, there is a high pressure anomaly to the east bringing warm air from the northern interior of Australia. This anomaly is part of a slow moving blocking high originating over the Indian Ocean. Uncomfortable days due to high particulate levels have an approaching cold front. However, for air particulate cases during the cold season there are stable atmospheric conditions enhanced by a blocking high emanating from Australia and linking with the Antarctic continent. Finally, when grass pollen levels are high, there are northerly winds carrying the pollen from rural grass lands to Melbourne, due to a stationary trough of low pressure inland. Analysis into days with multiple types of stress revealed that the atmospheric signals associated with each type of discomfort are present regardless of whether the day is uncomfortable due to one or multiple variables. Therefore, these bio-comfort results are significant because they offer a degree of predictability for future uncomfortable days in Melbourne.

The Development, Implementation, and Evaluation of a Computer-Assisted Branched Test for a Program of Individually Prescribed Instruction.

ERIC Educational Resources Information Center

Ferguson, Richard L.

The focus of this study was upon the development and evaluation of a computer-assisted branched test to be used in making instructional decisions for individuals in the program of Individually Prescribed Instruction. A Branched Test is one in which the presentation of test items is contingent upon the previous responses of the examinee. The…

PCI Choice: Cardiovascular clinicians' perceptions of shared decision making in stable coronary artery disease.

PubMed

Coylewright, Megan; O'Neill, Elizabeth S; Dick, Sara; Grande, Stuart W

2017-06-01

Describe cardiovascular clinicians' perceptions of Shared Decision Making following use of a decision aid (DA) for stable coronary artery disease (CAD) "PCI Choice", in a randomized controlled trial. We conducted a semi-structured qualitative interview study with cardiologists and physician extenders (n=13) after using PCI Choice in practice. Interviews were transcribed then coded. Codes were organized into salient themes. Final themes were determined by consensus with all authors. Most clinicians (70%) had no prior knowledge of SDM or DAs. Mixed views about the role of the DA in the visit were related to misconceptions of how patient education differed from SDM. Qualitative assessment of clinician perceptions generated three themes: 1) Gaps exist in clinician knowledge around SDM; 2) Clinicians are often uncomfortable with modifying baseline practice; and 3) Clinicians express interest in using DAs after initial exposure within a research setting. Use of DAs by clinicians during clinic visits may improve understanding of SDM. Initial use is marked by a reluctance to modify established practice patterns. As clinicians explore new approaches to benefit their patients, there is an opportunity for DAs that provide clinician instruction on core elements of SDM to lead to enhanced SDM in clinical practice. Copyright © 2017 Elsevier B.V. All rights reserved.

Characteristics of physicians who frequently see pharmaceutical sales representatives.

PubMed

Alkhateeb, Fadi M; Khanfar, Nile M; Clauson, Kevin A

2009-01-01

Pharmaceutical sales representatives (PSRs) can impact physician prescribing. The objective of this study was to test a model of physician and practice setting characteristics as influences on decisions by physicians to see PSRs. A survey was sent to a random sample of 2000 physicians. Multiple linear regression analyses were used to test models for predicting influences on decisions to see PSRs frequently, defined as at least monthly. Independent variables included: presence of restrictive policy for pharmaceutical detailing, volume of prescriptions, gender, age, type of specialty, academic affiliation, practice setting size, and urban versus rural. The dependent variable was frequency of PSRs visits to physicians. Six hundred seventy-one responses were received yielding a response rate of 34.7%. Four hundred thirty-two physicians (79.5%) reported seeing PSRs at least monthly. The decision influence model was found to be significant. Primary care physicians and high-volume prescribers showed increased likelihood to see PSRs. Physicians practicing in settings that were small, urban, without restrictive policies for pharmaceutical detailing, and not academically affiliated were more likely to see PSRs frequently. This model of physician and practice characteristics is useful in explaining the variations in physicians' characteristics who see PSRs frequently. These characteristics could be used to guide the development of future academic or counter-detailing initiatives to improve evidence-based prescribing.

Consultations between nurse prescribers and patients with diabetes in primary care: A qualitative study of patient views.

PubMed

Stenner, Karen L; Courtenay, Molly; Carey, Nicola

2011-01-01

There is a drive to improve the quality of service provision for patients with diabetes and to enable better self-management of this condition. The adoption of prescribing by nurses is increasing worldwide and can potentially enhance service provision. Evidence suggests that patients prefer services where their lifestyle factors and opinions are considered by healthcare professionals within a partnership approach. Few studies have explored patients' views about their consultations with a nurse prescriber. To explore the views patients with diabetes have about their consultations with nurse prescribers and any impact this may have on their medications management. A qualitative study involving semi-structured interviews and thematic analysis. Six primary care sites in which nurses prescribed medications for patients with diabetes in England. Data was collected in 2009. Interviews took place with 41 patients with diabetes from the case loads of 7 nurse prescribers. Findings are reported under three themes; the nurse consultation style, benefits of the nurse prescriber consultation and views on involvement and decision-making. Key aspects of the nurse consultation style were a non-hurried approach, care and rapport, approachability, continuity, and providing clear information based on specialist knowledge. Many benefits were described, including improved access to appropriate advice and medication, greater understanding and ability to self-manage, ability to address problems and improved confidence, trust and wellbeing. While patients were happy with the amount of information received and involvement they had decisions about their treatment, there was some controversy over the consistency of information provided on side-effects of treatment. The study provides new knowledge about what patients with diabetes value and benefit from in respect to care provided by nurse prescribers. Continuity of relationship, flexibility over consultation length, nurses' interpersonal skills and specialist diabetes knowledge were identified as crucial to good quality care. Patients require that nurse prescribers are skilled in providing a person-centred approach and have access to specialist training. The level of information and involvement offered to patients should reflect patients' requirements. Copyright © 2010 Elsevier Ltd. All rights reserved.

HIV care in Yangon, Myanmar; successes, challenges and implications for policy.

PubMed

Aung, Ne Myo; Hanson, Josh; Kyi, Tint Tint; Htet, Zaw Win; Cooper, David A; Boyd, Mark A; Kyi, Mar Mar; Saw, Htin Aung

2017-03-04

Approximately 0.8% of adults aged 18-49 in Myanmar are seropositive for Human Immunodeficiency Virus (HIV). Identifying the demographic, epidemiological and clinical characteristics of people living with HIV (PLHIV) is essential to inform optimal management strategies in this resource-limited country. To create a "snapshot" of the PLHIV seeking anti-retroviral therapy (ART) in Myanmar, data were collected from the registration cards of all patients who had been prescribed ART at two large referral hospitals in Yangon, prior to March 18, 2016. Anti-retroviral therapy had been prescribed to 2643 patients at the two hospitals. The patients' median [interquartile range (IQR)] age was 37 (31-44) years; 1494 (57%) were male. At registration, injecting drug use was reported in 22 (0.8%), male-to-male sexual contact in eleven (0.4%) and female sex work in eleven (0.4%), suggesting that patients under-report these risk behaviours, that health care workers are uncomfortable enquiring about them or that the two hospitals are under-servicing these populations. All three explanations appear likely. Most patients were symptomatic at registration with 2027 (77%) presenting with WHO stage 3 or 4 disease. In the 2442 patients with a CD4+ T cell count recorded at registration, the median (IQR) count was 169 (59-328) cells/mm 3 . After a median (IQR) duration of 359 (185-540) days of ART, 151 (5.7%) patients had died, 111 (4.2%) patients had been lost to follow-up, while 2381 were alive on ART. Tuberculosis (TB) co-infection was common: 1083 (41%) were already on anti-TB treatment at registration, while a further 41 (1.7%) required anti-TB treatment during follow-up. Only 21 (0.8%) patients were prescribed isoniazid prophylaxis therapy (IPT); one of these was lost to follow-up, but none of the remaining 20 patients died or required anti-TB treatment during a median (IQR) follow-up of 275 (235-293) days. People living with HIV in Yangon, Myanmar are generally presenting late in their disease course, increasing their risk of death, disease and transmitting the virus. A centralised model of ART prescription struggles to deliver care to the key affected populations. TB co-infection is very common in Myanmar, but despite the proven efficacy of IPT, it is frequently not prescribed.

Prescribing medical cannabis in Canada: Are we being too cautious?

PubMed

Lake, Stephanie; Kerr, Thomas; Montaner, Julio

2015-04-30

There has been much recent discussion and debate surrounding cannabis in Canada, including the prescribing of medical cannabis for therapeutic purposes. Certain commentators - including the Canadian Medical Association (CMA) - have denounced the prescribing of cannabis for medical purposes due to a perceived lack of evidence related to the drug's efficacy, harms, and mechanism of action. In this commentary, we present arguments in favour of prescribing medical cannabis in Canada. We believe the anti-cannabis position taken by CMA and other commentators is not entirely evidence-based. Using the example of neuropathic pain, we present and summarize the clinical evidence surrounding smoked or vapourized cannabis, including recent evidence pertaining to the effectiveness of cannabis in comparison to existing standard pharmacotherapies for neuropathy. Further, we outline how the concerns expressed regarding cannabis' mechanism of action are inconsistent with current decision-making processes related to the prescribing of many common pharmaceuticals. Finally, we discuss potential secondary public health benefits of prescribing cannabis for pain-related disorders in Canada and North America.

Patient and physician predictors of patient receipt of therapies recommended by a computerized decision support system when initially prescribed broad-spectrum antibiotics: a cohort study

PubMed Central

Lye, David C.; Arah, Onyebuchi A

2016-01-01

Objective Antibiotic computerized decision support systems (CDSSs) were developed to guide antibiotic decisions, yet prescriptions of CDSS-recommended antibiotics have remained low. Our aim was to identify predictors of patients' receipt of empiric antibiotic therapies recommended by a CDSS when the prescribing physician had an initial preference for using broad-spectrum antibiotics. Methods We conducted a prospective cohort study in a 1 500-bed tertiary-care hospital in Singapore. We included all patients admitted from October 1, 2011 through September 30, 2012, who were prescribed piperacillin-tazobactam or carbapenem for empiric therapy and auto-triggered to receive antibiotic recommendations by the in-house antibiotic CDSS. Relevant data on the patient, prescribing and attending physicians were collected via electronic linkages of medical records and administrative databases. To account for clustering, we used multilevel logistic regression models to explore factors associated with receipt of CDSS-recommended antibiotic therapy. Results One-quarter of the 1 886 patients received CDSS-recommended antibiotics. More patients treated for pneumonia (33.2%) than sepsis (12.1%) and urinary tract infections (7.1%) received CDSS-recommended antibiotic therapies. The prescribing physician – but not the attending physician or clinical specialty – accounted for some (13.3%) of the variation. Prior hospitalization (odds ratio [OR] 1.32, 95% CI, 1.01-1.71), presumed pneumonia (OR 6.77, 95% CI, 3.28-13.99), intensive care unit (ICU) admission (OR 0.38, 95% CI, 0.21-0.66), and renal impairment (OR 0.70, 95% CI, 0.52-0.93) were factors associated with patients’ receipt of CDSS-recommended antibiotic therapies. Conclusions We observed that ICU admission and renal impairment were negative predictors of patients’ receipt of CDSS-recommended antibiotic therapies. Patients admitted to ICU and those with renal impairment might have more complex clinical conditions that require a physician's assessment in addition to antibiotic CDSS. PMID:26342216

Factors influencing pharmacists’ adoption of prescribing: qualitative application of the diffusion of innovations theory

PubMed Central

2013-01-01

Background In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists’ adoption of prescribing using a model for the Diffusion of Innovations in healthcare services. Methods Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations. Results Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists’ adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists’ decisions to apply for independent prescribing privileges. Conclusions Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists’ adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists’ prescribing behaviours. PMID:24034176

Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory.

PubMed

Makowsky, Mark J; Guirguis, Lisa M; Hughes, Christine A; Sadowski, Cheryl A; Yuksel, Nese

2013-09-14

In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists' adoption of prescribing using a model for the Diffusion of Innovations in healthcare services. Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations. Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists' adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists' decisions to apply for independent prescribing privileges. Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists' adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists' prescribing behaviours.

Medication errors: definitions and classification

PubMed Central

Aronson, Jeffrey K

2009-01-01

To understand medication errors and to identify preventive strategies, we need to classify them and define the terms that describe them. The four main approaches to defining technical terms consider etymology, usage, previous definitions, and the Ramsey–Lewis method (based on an understanding of theory and practice). A medication error is ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’. Prescribing faults, a subset of medication errors, should be distinguished from prescription errors. A prescribing fault is ‘a failure in the prescribing [decision-making] process that leads to, or has the potential to lead to, harm to the patient’. The converse of this, ‘balanced prescribing’ is ‘the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm’. This excludes all forms of prescribing faults, such as irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing. A prescription error is ‘a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription’. The ‘normal features’ include the identity of the recipient, the identity of the drug, the formulation, dose, route, timing, frequency, and duration of administration. Medication errors can be classified, invoking psychological theory, as knowledge-based mistakes, rule-based mistakes, action-based slips, and memory-based lapses. This classification informs preventive strategies. PMID:19594526

43 CFR 5003.1 - Effect of decisions; general.

Code of Federal Regulations, 2013 CFR

2013-10-01

... risk of wildfire due to drought, fuels buildup, or other reasons, or at immediate risk of erosion or other damage due to wildfire, BLM may make a wildfire management decision made under this part and parts.... Wildfire management includes but is not limited to: (1) Fuel reduction or fuel treatment such as prescribed...

43 CFR 5003.1 - Effect of decisions; general.

Code of Federal Regulations, 2012 CFR

2012-10-01

... risk of wildfire due to drought, fuels buildup, or other reasons, or at immediate risk of erosion or other damage due to wildfire, BLM may make a wildfire management decision made under this part and parts.... Wildfire management includes but is not limited to: (1) Fuel reduction or fuel treatment such as prescribed...

43 CFR 5003.1 - Effect of decisions; general.

Code of Federal Regulations, 2014 CFR

2014-10-01

... risk of wildfire due to drought, fuels buildup, or other reasons, or at immediate risk of erosion or other damage due to wildfire, BLM may make a wildfire management decision made under this part and parts.... Wildfire management includes but is not limited to: (1) Fuel reduction or fuel treatment such as prescribed...

43 CFR 5003.1 - Effect of decisions; general.

Code of Federal Regulations, 2011 CFR

2011-10-01

... risk of wildfire due to drought, fuels buildup, or other reasons, or at immediate risk of erosion or other damage due to wildfire, BLM may make a wildfire management decision made under this part and parts.... Wildfire management includes but is not limited to: (1) Fuel reduction or fuel treatment such as prescribed...

Let the market help prescribe forest management practices

Treesearch

Gary W. Zinn; Edward Pepke

1989-01-01

To obtain the best economic returns from a hardwood forest, you must consider markets. Management decisions made now will affect a stand's future character and value, whether or not the decision results in immediate timber sales. Progressive forest landowners will have a management plan for their woodlots. Typically, such plans are largely land- and resource-...

Understanding the prescription of antidepressants: a Qualitative study among French GPs.

PubMed

Mercier, Alain; Auger-Aubin, Isabelle; Lebeau, Jean-Pierre; Van Royen, Paul; Peremans, Lieve

2011-09-24

One-tenth of France's population is prescribed at least one antidepressant, primarily by General Practitioners. The reasons for this high prescription rate remain unclear. One-third of these prescriptions may not comply with clinical practice guidelines, and 20% are potentially unrelated to any psychiatric condition. Our aim was to explore how GPs declare they use antidepressants in daily practice and understand their reasons for prescribing them. Six focus groups including a total of 56 rural and urban GPs, with four interviews were performed. The topic guide focused on reasons for prescribing antidepressants in various primary care situations. Phenomenological analysis was performed by four researchers. Antidepressants were seen as useful and not harmful. Personal assessment based on experience and feeling determined the GPs' decisions rather than the use of scales. Twenty-four "non-psychiatric" conditions possibly leading to prescription of antidepressants in primary care were found. The GPs reported prescribing antidepressants for a wide range of conditions other than depression. The GPs' decision making process is difficult and complex. They seemed to prefer to focus on their difficulties in diagnosing depression rather than on useless overtreatment. Instead of using the guidelines criteria to detect potential cases of useful prescription, physicians tend to use their own tools based on gut feelings, knowledge of the patient and contextual issues.

Perception of side rollover hazards in a Pennsylvania rural population while operating an all-terrain vehicle (ATV).

PubMed

Cavallo, Eugenio; Görücü, Serap; Murphy, Dennis

2015-06-05

All-terrain vehicles (ATVs) are unstable on steep and rough terrain, and thus, rollover is the most common accident which can result in a high rate of fatal outcomes, with higher rates for young and male drivers. This paper investigates the ability of rural Pennsylvania ATV drivers to correctly evaluate slopes, and the mean slope angle at which the most and least conservative drivers indicate a beginning of concern of a roll-over. The study was conducted using a simulator, a commercial ATV firmly fixed on an hydraulically-lifted platform. As the platform was being raised, participants were asked to report when they became uncomfortable and then when they would not drive across a slope at such an angle. The difference between the reported and the actual angles in both conditions were analyzed. Fifty-five individuals, mostly male and younger than 20 years, participated in riding on the simulator. Between 1/3 and 1/4 of the participants correctly estimated the angle while approximately 2/3 of participants overestimated the angles at which they felt they would be uncomfortable and they would not drive across. Participants began to feel uncomfortable at 15.9±5.7 degrees and became so uncomfortable that they felt they would not drive at 22.7±3.7 degrees. Overestimation of lateral roll angles is the most common result. This is in favor of safety when drivers are informed about a slope limit ATVs should not be operated on.

Increased prescribing of Valium, Librium, and other drugs--an example of the influence of economic and social factors on the practice of medicine.

PubMed

Waldron, I

1977-01-01

Drug prescriptions per capita in the United States have more than doubled since 1950 without a commensurate improvement in health. Drugs are often prescribed for clinical conditions in which therapeutic benefits do not outweigh the risk of adverse drug reactions. Deaths due to adverse drug reactions are roughly as frequent as deaths due to automobile accidents. Valium and Librium are the first and fourth most commonly prescribed drugs in the U.S., used by one ten adults each year. The rapid rise in use of these drugs has occurred during a period of rising social stress, as indicated by increases in alcohol consumption, suicide, and homicide, Valium and Librium are frequently prescribe for patients who go to doctors with social or other nonmedical problems, often in lieu of attempts to resolve these underlying problems. Overprescribing occurs because the decision to prescribe is influenced not only by consideration of therapeutic benefit, but also by nonmedical factors, for example the widespread expectation by both patient and doctor that the doctor will provide a drug or some other technological treatment. Prescribing decisions are also influenced by the profit-motivated activities of drug companies, including the expenditure of almost one-quarter of every sales dollar on drug promotion. The most widely used source of drug information for doctors is the industry-sponsored Physicians' Desk Reference, which overrates the therapeutic value of Valium and Librium as compared to disinterested medical sources. Drug companies also contribute to overprescribing by introducing numerous minor variants of existing drugs. The therapeutic benefits of such new drugs are often overestimated in the early years of use when adverse side effects are not well known and apparent efficacy is enhanced by placebo effects in uncontrolled observations.

Development and use of active clinical decision support for preemptive pharmacogenomics

PubMed Central

Bell, Gillian C; Crews, Kristine R; Wilkinson, Mark R; Haidar, Cyrine E; Hicks, J Kevin; Baker, Donald K; Kornegay, Nancy M; Yang, Wenjian; Cross, Shane J; Howard, Scott C; Freimuth, Robert R; Evans, William E; Broeckel, Ulrich; Relling, Mary V; Hoffman, James M

2014-01-01

Background Active clinical decision support (CDS) delivered through an electronic health record (EHR) facilitates gene-based drug prescribing and other applications of genomics to patient care. Objective We describe the development, implementation, and evaluation of active CDS for multiple pharmacogenetic test results reported preemptively. Materials and methods Clinical pharmacogenetic test results accompanied by clinical interpretations are placed into the patient's EHR, typically before a relevant drug is prescribed. Problem list entries created for high-risk phenotypes provide an unambiguous trigger for delivery of post-test alerts to clinicians when high-risk drugs are prescribed. In addition, pre-test alerts are issued if a very-high risk medication is prescribed (eg, a thiopurine), prior to the appropriate pharmacogenetic test result being entered into the EHR. Our CDS can be readily modified to incorporate new genes or high-risk drugs as they emerge. Results Through November 2012, 35 customized pharmacogenetic rules have been implemented, including rules for TPMT with azathioprine, thioguanine, and mercaptopurine, and for CYP2D6 with codeine, tramadol, amitriptyline, fluoxetine, and paroxetine. Between May 2011 and November 2012, the pre-test alerts were electronically issued 1106 times (76 for thiopurines and 1030 for drugs metabolized by CYP2D6), and the post-test alerts were issued 1552 times (1521 for TPMT and 31 for CYP2D6). Analysis of alert outcomes revealed that the interruptive CDS appropriately guided prescribing in 95% of patients for whom they were issued. Conclusions Our experience illustrates the feasibility of developing computational systems that provide clinicians with actionable alerts for gene-based drug prescribing at the point of care. PMID:23978487

Modeling of outpatient prescribing process in iran: a gateway toward electronic prescribing system.

PubMed

Ahmadi, Maryam; Samadbeik, Mahnaz; Sadoughi, Farahnaz

2014-01-01

Implementation of electronic prescribing system can overcome many problems of the paper prescribing system, and provide numerous opportunities of more effective and advantageous prescribing. Successful implementation of such a system requires complete and deep understanding of work content, human force, and workflow of paper prescribing. The current study was designed in order to model the current business process of outpatient prescribing in Iran and clarify different actions during this process. In order to describe the prescribing process and the system features in Iran, the methodology of business process modeling and analysis was used in the present study. The results of the process documentation were analyzed using a conceptual model of workflow elements and the technique of modeling "As-Is" business processes. Analysis of the current (as-is) prescribing process demonstrated that Iran stood at the first levels of sophistication in graduated levels of electronic prescribing, namely electronic prescription reference, and that there were problematic areas including bottlenecks, redundant and duplicated work, concentration of decision nodes, and communicative weaknesses among stakeholders of the process. Using information technology in some activities of medication prescription in Iran has not eliminated the dependence of the stakeholders on paper-based documents and prescriptions. Therefore, it is necessary to implement proper system programming in order to support change management and solve the problems in the existing prescribing process. To this end, a suitable basis should be provided for reorganization and improvement of the prescribing process for the future electronic systems.

Decision making and counseling around mammography screening for women aged 80 or older.

PubMed

Schonberg, Mara A; Ramanan, Radhika A; McCarthy, Ellen P; Marcantonio, Edward R

2006-09-01

Despite uncertain benefit, many women over age 80 (oldest-old) receive screening mammography. To explore decision-making and physician counseling of oldest-old women around mammography screening. Qualitative research using in-depth semi-structured interviews. Twenty-three women aged 80 or older who received care at a large academic primary care practice (13 had undergone mammography screening in the past 2 years) and 16 physicians at the same center. We asked patients and physicians to describe factors influencing mammography screening decisions of oldest-old women. We asked physicians to describe their counseling about screening to the oldest-old. Patients and/or physicians identified the importance of physician influence, patient preferences, system factors, and social influences on screening decisions. Although physicians felt that patient's health affected screening decisions, few patients felt that health mattered. Three types of elderly patients were identified: (1) women enthusiastic about screening mammography; (2) women opposed to screening mammography; and (3) women without a preference who followed their physician's recommendation. However, physician counseling about mammography screening to elderly women varies; some individualize discussions; others encourage screening; few discourage screening. Physicians report that discussions about stopping screening can be uncomfortable and time consuming. Physicians suggest that more data could facilitate these discussions. Some oldest-old women have strong opinions about screening mammography while others are influenced by physicians. Discussions about stopping screening are challenging for physicians. More data about the benefits and risks of mammography screening for women aged 80 or older could inform patients and improve provider counseling to lead to more rational use of mammography.

Using climate information for fuels management

USGS Publications Warehouse

Kolden, Crystal A.; Brown, Timothy J.

2008-01-01

Climate has come to the forefront of wildfire discussions in recent years as research contributes to the general understanding of how climate influences fuels availability to burn, the occurrence of severe fire weather conditions and other wildfire parameters. This understanding has crossed over into wildfire management applications through the creation of tools like climate forecasts for wildfire and drought indices, which are now widely used in wildfire suppression and mitigation planning. The overall question is how can climate information help fire managers meet management objectives? Climate underlies weather. For example, a number of days could be generally wet, but that may occur in the context of a two-year overall drought. Knowing the baseline climate is not only critical to preventing escaped prescribed fires, but also how it may affect fire behavior, fire effects and whether or not fire managers will meet their fuels management objectives. Thus, for fire managers to use prescribed and WFU fire safely and effectively, and to minimize the number of escaped fires and conversions to suppression, they need to understand how current climate conditions will impact the use of fire. One example is the need to use prescribed fire under set “burn windows”. Since meteorological conditions vary considerably from year to year for a given day, fire managers will be more successful in utilizing burn windows effectively if they understand those climate thresholds conducive to an increased number of safe burn windows, and are able to predict and take advantage of those burn windows. While climate and wildfire has been studied extensively, climate and fire use has not. The initial goal of this project was to assess how climate impacts prescribed fire use in a more general sense. After a preliminary informal survey in the spring of 2003, we determined that 1) there is insufficient data (less than 10 years) to conduct empirical correlative studies similar to those of the relationships between climate and wildfire (e.g., Swetnam and Betancourt 1990), and 2) prescribed fire policy has many regulations that potentially inhibited the use of climate information for decision-making. It was also determined that because fire use is a human decision, it would be more informative to ask fire managers themselves how climate impacts fire use through their decision-making processes, and whether or not they use climate information for prescribed fire. The first task for this project was to complete a regional survey of prescribed fire managers in California and Nevada. During the second phase of the project, additional prescribed fire managers were surveyed across the country. During the third year a second survey of WFU managers was completed. The goals of these inquiries were to determine: 1) If fire managers use climate information for fuels management; 2) The perspective fire managers have towards climate affecting fuels management; 3) Determine any obstacles that make it difficult to use climate information for fuels management; and 4) Determine climate information managers need to help them make better decisions for fire use.

Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals.

PubMed

Chaves, N J; Cheng, A C; Runnegar, N; Kirschner, J; Lee, T; Buising, K

2014-06-01

Antimicrobial stewardship programmes aim to optimise use of antibiotics and are now mandatory in all Australian hospitals. We aimed to identify barriers to and enablers of appropriate antimicrobial prescribing among hospital doctors. Two paper-based and one web-based surveys were administered at three Australian university teaching hospitals from March 2010 to May 2011. The 18-item questionnaire recorded doctors’ level of experience, their knowledge regarding the use of common antimicrobials and their attitudes regarding antimicrobial prescribing. Local survey modifications allowed inclusion of specific questions on: infections in intensive care unit patients, clinical microbiology and use of local guidelines. The respondents (n = 272) were comprised of 96 (35%) registrars, 67 (25%)residents, 57 (21%) interns and 47 (17%) consultant hospital doctors. Forty-one per cent were working in a medical specialty. Identified barriers included: gaps in antimicrobial prescribing knowledge (especially among interns), a lack of awareness about which antimicrobials were restricted and a reliance on senior colleagues to make antimicrobial prescribing decisions. Enablers of optimal prescribing included: an acknowledgement of the need for assistance in prescribing and reported readiness to consult national prescribing guidelines. These results were used to help guide and prioritise interventions to improve prescribing practices. A transferable knowledge and attitudes survey tool can be used to highlight barriers and facilitators to optimal hospital antimicrobial prescribing in order to inform tailored antimicrobial stewardship interventions.

A Novel Design for Drug-Drug Interaction Alerts Improves Prescribing Efficiency.

PubMed

Russ, Alissa L; Chen, Siying; Melton, Brittany L; Johnson, Elizabette G; Spina, Jeffrey R; Weiner, Michael; Zillich, Alan J

2015-09-01

Drug-drug interactions (DDIs) are common in clinical care and pose serious risks for patients. Electronic health records display DDI alerts that can influence prescribers, but the interface design of DDI alerts has largely been unstudied. In this study, the objective was to apply human factors engineering principles to alert design. It was hypothesized that redesigned DDI alerts would significantly improve prescribers' efficiency and reduce prescribing errors. In a counterbalanced, crossover study with prescribers, two DDI alert designs were evaluated. Department of Veterans Affairs (VA) prescribers were video recorded as they completed fictitious patient scenarios, which included DDI alerts of varying severity. Efficiency was measured from time-stamped recordings. Prescribing errors were evaluated against predefined criteria. Efficiency and prescribing errors were analyzed with the Wilcoxon signed-rank test. Other usability data were collected on the adequacy of alert content, prescribers' use of the DDI monograph, and alert navigation. Twenty prescribers completed patient scenarios for both designs. Prescribers resolved redesigned alerts in about half the time (redesign: 52 seconds versus original design: 97 seconds; p<.001). Prescribing errors were not significantly different between the two designs. Usability results indicate that DDI alerts might be enhanced by facilitating easier access to laboratory data and dosing information and by allowing prescribers to cancel either interacting medication directly from the alert. Results also suggest that neither design provided adequate information for decision making via the primary interface. Applying human factors principles to DDI alerts improved overall efficiency. Aspects of DDI alert design that could be further enhanced prior to implementation were also identified.

Opioid Prescribing After Curative-Intent Surgery: A Qualitative Study Using the Theoretical Domains Framework.

PubMed

Lee, Jay S; Parashar, Vartika; Miller, Jacquelyn B; Bremmer, Samantha M; Vu, Joceline V; Waljee, Jennifer F; Dossett, Lesly A

2018-07-01

Excessive opioid prescribing is common after curative-intent surgery, but little is known about what factors influence prescribing behaviors among surgeons. To identify targets for intervention, we performed a qualitative study of opioid prescribing after curative-intent surgery using the Theoretical Domains Framework, a well-established implementation science method for identifying factors influencing healthcare provider behavior. Prior to data collection, we constructed a semi-structured interview guide to explore decision making for opioid prescribing. We then conducted interviews with surgical oncology providers at a single comprehensive cancer center. Interviews were recorded, transcribed verbatim, then independently coded by two investigators using the Theoretical Domains Framework to identify theoretical domains relevant to opioid prescribing. Relevant domains were then linked to behavior models to select targeted interventions likely to improve opioid prescribing. Twenty-one subjects were interviewed from November 2016 to May 2017, including attending surgeons, resident surgeons, physician assistants, and nurses. Five theoretical domains emerged as relevant to opioid prescribing: environmental context and resources; social influences; beliefs about consequences; social/professional role and identity; and goals. Using these domains, three interventions were identified as likely to change opioid prescribing behavior: (1) enablement (deploy nurses during preoperative visits to counsel patients on opioid use); (2) environmental restructuring (provide on-screen prompts with normative data on the quantity of opioid prescribed); and (3) education (provide prescribing guidelines). Key determinants of opioid prescribing behavior after curative-intent surgery include environmental and social factors. Interventions targeting these factors are likely to improve opioid prescribing in surgical oncology.

Development of a Decision Support System to Predict Physicians' Rehabilitation Protocols for Patients with Knee Osteoarthritis

ERIC Educational Resources Information Center

Hawamdeh, Ziad M.; Alshraideh, Mohammad A.; Al-Ajlouni, Jihad M.; Salah, Imad K.; Holm, Margo B.; Otom, Ali H.

2012-01-01

To design a medical decision support system (MDSS) that would accurately predict the rehabilitation protocols prescribed by the physicians for patients with knee osteoarthritis (OA) using only their demographic and clinical characteristics. The demographic and clinical variables for 170 patients receiving one of three treatment protocols for knee…

Optimizing medicines management: From compliance to concordance

PubMed Central

Cushing, Annie; Metcalfe, Richard

2007-01-01

Medication prescribed but not consumed represents a huge loss in drug and prescribing costs and an enormous waste of expensive medical time. In this article we discuss what is known about compliance and adherence, explore the concept of concordance and demonstrate its fundamental difference from both. Not all patients are ready or suitable for shared decision making in management of their condition, some still preferring a doctor-led decision but an increasing number want a partnership approach. By opening up and rebalancing the discussion about medication, we can expect a consultation which is more satisfying for both parties and flowing from this, more effective, focused prescribing of medication which is more likely to be adhered to by the patient. We examine the extent to which doctor and patient behaviors are currently compatible with this change of concept and practice, look at available consultation models which might be useful to the reflective practitioner and consider what actions on the part of the doctor and the healthcare system could promote medicine prescription and utilization in line with this new approach based on partnership. PMID:18516274

A Five- Year CMAQ Model Performance for Wildfires and ...

EPA Pesticide Factsheets

Biomass burning has been identified as an important contributor to the degradation of air quality because of its impact on ozone and particulate matter. Two components of the biomass burning inventory, wildfires and prescribed fires are routinely estimated in the national emissions inventory. However, there is a large amount of uncertainty in the development of these emission inventory sectors. We have completed a 5 year set of CMAQ model simulations (2008-2012) in which we have simulated regional air quality with and without the wildfire and prescribed fire inventory. We will examine CMAQ model performance over regions with significant PM2.5 and Ozone contribution from prescribed fires and wildfires. The National Exposure Research Laboratory (NERL) Computational Exposure Division (CED) develops and evaluates data, decision-support tools, and models to be applied to media-specific or receptor-specific problem areas. CED uses modeling-based approaches to characterize exposures, evaluate fate and transport, and support environmental diagnostics/forensics with input from multiple data sources. It also develops media- and receptor-specific models, process models, and decision support tools for use both within and outside of EPA.

Prescribing tamoxifen in primary care for the prevention of breast cancer: a national online survey of GPs' attitudes.

PubMed

Smith, Samuel G; Foy, Robbie; McGowan, Jennifer A; Kobayashi, Lindsay C; DeCensi, Andrea; Brown, Karen; Side, Lucy; Cuzick, Jack

2017-06-01

The cancer strategy for England (2015-2020) recommends GPs prescribe tamoxifen for breast cancer primary prevention among women at increased risk. To investigate GPs' attitudes towards prescribing tamoxifen. In an online survey, GPs in England, Northern Ireland, and Wales ( n = 928) were randomised using a 2 × 2 between-subjects design to read one of four vignettes describing a healthy patient seeking a tamoxifen prescription. In the vignette, the hypothetical patient's breast cancer risk (moderate versus high) and the clinician initiating the prescription (GP prescriber versus secondary care clinician [SCC] prescriber) were manipulated in a 1:1:1:1 ratio. Outcomes were willingness to prescribe, comfort discussing harms and benefits, comfort managing the patient, factors affecting the prescribing decision, and awareness of tamoxifen and the National Institute for Health and Care Excellence (NICE) guideline CG164. Half (51.7%) of the GPs knew tamoxifen can reduce breast cancer risk, and one-quarter (24.1%) were aware of NICE guideline CG164. Responders asked to initiate prescribing (GP prescriber) were less willing to prescribe tamoxifen than those continuing a prescription initiated in secondary care (SCC prescriber) (68.9% versus 84.6%, P <0.001). The GP prescribers reported less comfort discussing tamoxifen (53.4% versus 62.5%, P = 0.01). GPs willing to prescribe were more likely to be aware of the NICE guideline ( P = 0.039) and to have acknowledged the benefits of tamoxifen ( P <0.001), and were less likely to have considered its off-licence status ( P <0.001). Initiating tamoxifen prescriptions for preventive therapy in secondary care before asking GPs to continue the patient's care may overcome some prescribing barriers. © British Journal of General Practice 2017.

Choice of modality with the use of high-performance membrane and evaluation for clinical effects.

PubMed

Masakane, Ikuto

2011-01-01

The golden target for dialysis therapy should be to guarantee longer survival and to give a higher quality of life without dialysis-related complications. In order to achieve this target, the choice of dialysis modality and membrane is essential but we have not yet established what the best choice for a dialysis modality and membrane are. Generally, we choose a dialysis modality for better solute removal and better biocompatibility. In this issue we would like to propose that the patients' preference for dialysis therapy is a useful parameter in prescribing the dialysis modality. In our recent experience, chronic dialysis patients have had preferences on a dialysis modality and membrane, those being PMMA, EVAL, AN-69 and pre-dilution online HDF. These modalities could relieve them of uncomfortable dialysis-related symptoms such as insomnia, itchiness, irritability, and so on. Other characteristics of these modalities are of a nutritional advantage, a broad removal pattern of uremic toxins including low-molecular-weight protein and protein-bound uremic toxins, and good biocompatibility free from chemical components of dialysis membrane. In conclusion, patients' symptoms could be a useful parameter to choose a dialysis modality and membrane. Copyright © 2011 S. Karger AG, Basel.

Why do general practitioners prescribe antibiotics for upper respiratory tract infections to meet patient expectations: a mixed methods study

PubMed Central

Fletcher-Lartey, Stephanie; Yee, Melissa; Gaarslev, Christina; Khan, Rabia

2016-01-01

Objectives To describe the role patient expectations play in general practitioners (GPs) antibiotic prescribing for upper respiratory tract infections (URTI). Methods Concurrent explanatory mixed methods approach using a cross-sectional survey and semistructured interviews. Settings Primary care GPs in Australia. Participants 584 GPs (response rate of 23.6%) completed the cross-sectional survey. 32 GPs were interviewed individually. Outcome measure Prescribing of antibiotics for URTI. Results More than half the GP respondents to the survey in Australia self-reported that they would prescribe antibiotics for an URTI to meet patient expectations. Our qualitative findings suggest that ‘patient expectations’ may be the main reason given for inappropriate prescribing, but it is an all-encompassing phrase that includes other reasons. These include limited time, poor doctor–patient communication and diagnostic uncertainty. We have identified three role archetypes to explain the behaviour of GPs in reference to antibiotic prescribing for URTIs. The main themes emerging from the qualitative component was that many GPs did not think that antibiotic prescribing in primary care was responsible for the development of antibiotic resistance nor that their individual prescribing would make any difference in light of other bigger issues like hospital prescribing or veterinary use. For them, there were negligible negative consequences from their inappropriate prescribing. Conclusions There is a need to increase awareness of the scope and magnitude of antibiotic resistance and the role primary care prescribing plays, and of the contribution of individual prescribing decisions to the problem of antibiotic resistance. PMID:27798010

Reducing antibiotic prescribing in Australian general practice: time for a national strategy.

PubMed

Del Mar, Christopher B; Scott, Anna Mae; Glasziou, Paul P; Hoffmann, Tammy; van Driel, Mieke L; Beller, Elaine; Phillips, Susan M; Dartnell, Jonathan

2017-11-06

In Australia, the antibiotic resistance crisis may be partly alleviated by reducing antibiotic use in general practice, which has relatively high prescribing rates - antibiotics are mostly prescribed for acute respiratory infections, for which they provide only minor benefits. Current surveillance is inadequate for monitoring community antibiotic resistance rates, prescribing rates by indication, and serious complications of acute respiratory infections (which antibiotic use earlier in the infection may have averted), making target setting difficult. Categories of interventions that may support general practitioners to reduce prescribing antibiotics are: regulatory (eg, changing the default to "no repeats" in electronic prescribing, changing the packaging of antibiotics to facilitate tailored amounts of antibiotics for the right indication and restricting access to prescribing selected antibiotics to conserve them), externally administered (eg, academic detailing and audit and feedback on total antibiotic use for individual GPs), interventions that GPs can individually implement (eg, delayed prescribing, shared decision making, public declarations in the practice about conserving antibiotics, and self-administered audit), supporting GPs' access to near-patient diagnostic testing, and public awareness campaigns. Many unanswered clinical research questions remain, including research into optimal implementation methods. Reducing antibiotic use in Australian general practice will require a range of approaches (with various intervention categories), a sustained effort over many years and a commitment of appropriate resources and support.

Statin initiation by GPs in WA--a structured vignette study.

PubMed

Stafford, Leanne; Harmer, Nichola; Dhaliwal, Satvinder; Jiwa, Moyez

2009-09-01

Statins are recommended for all patients with known coronary heart disease. This pilot study investigated statin initiation by a Western Australian general practitioner cohort and the influence of prescriber and patient characteristics on prescribing. A structured vignette questionnaire was posted to members of the Fremantle GP Network. Respondents indicated their prescribing decisions for nine hypothetical patients who had recently suffered a myocardial infarction. Data analysis utilised logistic regression analyses and a generalised linear model with a logit link function. Fifty-five GPs responded (16.0% response rate). In over 20% of cases a statin was not prescribed. Male (OR 4.71; 95% CI: 1.24-17.87) and GPs with fewer years in practice (4.50; 1.21-16.77) were more likely to prescribe appropriately. Younger patients (2.21; 1.38-3.53), and those with diabetes (1.74; 1.09-2.76) or hypercholesterolaemia (4.81; 2.88-8.03) were more likely to receive therapy. Prescribing practices failed to comply with current guidelines in a significant number of cases. Further research to confirm these findings is warranted.

Factors associated with physicians' reliance on pharmaceutical sales representatives.

PubMed

Anderson, Britta L; Silverman, Gabriel K; Loewenstein, George F; Zinberg, Stanley; Schulkin, Jay

2009-08-01

To examine relationships between pharmaceutical representatives and obstetrician-gynecologists and identify factors associated with self-reported reliance on representatives when making prescribing decisions. In 2006-2007, questionnaires were mailed to 515 randomly selected physicians in the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network. Participants were asked about the information sources used when deciding to prescribe a new drug, interactions with sales representatives, views of representatives' value, and guidelines they had read on appropriate industry interactions. Two hundred fifty-one completed questionnaires (49%) were returned. Seventy-six percent of participants see sales representatives' information as at least somewhat valuable. Twenty-nine percent use representatives often or almost always when deciding whether to prescribe a new drug; 44% use them sometimes. Physicians in private practice are more likely than those in university hospitals to interact with, value, and rely on representatives; community hospital physicians tend to fall in the middle. Gender and age are not associated with industry interaction. Dispensing samples is associated with increased reliance on representatives when making prescribing decisions, beyond what is predicted by a physician's own beliefs about the value of representatives' information. Reading guidelines on physician-industry interaction is not associated with less reliance on representatives after controlling for practice setting. Physicians' interactions with industry and their familiarity with guidelines vary by practice setting, perhaps because of more restrictive policies in university settings, professional isolation of private practice, or differences in social norms. Prescribing samples may be associated with physicians' use of information from sales representatives more than is merited by the physicians' own beliefs about the value of pharmaceutical representatives.

Identifying fallacious arguments in a qualitative study of antipsychotic prescribing in dementia.

PubMed

Donyai, Parastou

2017-10-01

Dementia can result in cognitive, noncognitive and behavioural symptoms which are difficult to manage. Formal guidelines for the care and management of dementia in the UK state that antipsychotics should only be prescribed where fully justified. This is because inappropriate use, particularly problematic in care-home settings, can produce severe side effects including death. The aim of this study was to explore the use of fallacious arguments in professionals' deliberations about antipsychotic prescribing in dementia in care-home settings. Fallacious arguments have the potential to become unremarkable discourses that construct and validate practices which are counter to guidelines. This qualitative study involved interviews with 28 care-home managers and health professionals involved in caring for patients with dementia. Potentially fallacious arguments were identified using qualitative content analysis and a coding framework constructed from existing explanatory models of fallacious reasoning. Fallacious arguments were identified in a range of explanations and reasons that participants gave for in answer to questions about initiating, reducing doses of and stopping antipsychotics in dementia. The dominant fallacy was false dichotomy. Appeal to popularity, tradition, consequence, emotion, or fear, and the slippery slope argument was also identified. Fallacious arguments were often formulated to present convincing cases whereby prescribing antipsychotics or maintaining existing doses (versus not starting medication or reducing the dose, for example) appeared as the only acceptable decision but this is not always the case. The findings could help health professionals to recognise and mitigate the effect of logic-based errors in decisions about the prescribing of antipsychotics in dementia. © 2016 Royal Pharmaceutical Society.

Family Physician attitudes about prescribing using a drug formulary

PubMed Central

Suggs, L Suzanne; Raina, Parminder; Gafni, Amiram; Grant, Susan; Skilton, Kevin; Fan, Aimei; Szala-Meneok, Karen

2009-01-01

Background Drug formularies have been created by third party payers to control prescription drug usage and manage costs. Physicians try to provide the best care for their patients. This research examines family physicians' attitudes regarding prescription reimbursement criteria, prescribing and advocacy for patients experiencing reimbursement barriers. Methods Focus groups were used to collect qualitative data on family physicians' prescribing decisions related to drug reimbursement guidelines. Forty-eight family physicians from four Ontario cities participated. Ethics approval for this study was received from the Hamilton Health Sciences/Faculty of Health Sciences Research Ethics Board at McMaster University. Four clinical scenarios were used to situate and initiate focus group discussions about prescribing decisions. Open-ended questions were used to probe physicians' experiences and attitudes and responses were audio recorded. NVivo software was used to assist in data analysis. Results Most physicians reported that drug reimbursement guidelines complicated their prescribing process and can require lengthy interpretation and advocacy for patients who require medication that is subject to reimbursement restrictions. Conclusion Physicians do not generally see their role as being cost-containment monitors and observed that cumbersome reimbursement guidelines influence medication choice beyond the clinical needs of the patient, and produce unequal access to medication. They observed that frustration, discouragement, fatigue, and lack of appreciation can often contribute to family physicians' failure to advocate more for patients. Physicians argue cumbersome reimbursement regulations contribute to lower quality care and misuse of physicians' time increasing overall health care costs by adding unnecessary visits to family physicians, specialists, and emergency rooms. PMID:19835601

Negotiating the dynamics of uncomfortable knowledge: The case of dual use and synthetic biology

PubMed Central

Marris, Claire; Jefferson, Catherine; Lentzos, Filippa

2014-01-01

Institutions need to ignore some knowledge in order to function. This is “uncomfortable knowledge” because it undermines the ability of those institutions to pursue their goals (Rayner, 2012). We identify three bodies of knowledge that are relevant to understandings of the dual use threat posed by synthetic biology but are excluded from related policy discussions. We demonstrate how these “unknown knowns” constitute uncomfortable knowledge because they disrupt the simplified worldview that underpins contemporary discourse on the potential misuse of synthetic biology by malign actors. We describe how these inconvenient truths have been systematically ignored and argue that this is because they are perceived as a threat by organisations involved in the promotion of synthetic biology as well as by those involved in managing biosecurity risks. This has led to a situation where concerns about the biosecurity threat posed by synthetic biology are not only exaggerated, but are, more importantly, misplaced. This, in turn, means that related policies are misdirected and unlikely to have much impact. We focus on the dynamics of discussions about synthetic biology and dual use to demonstrate how the same “knowns” that are denied or dismissed as “unknown knowns” in certain circumstances are sometimes mobilised as “known knowns” by the same category of actors in a different context, when this serves to sustain the goals of the individuals and institutions involved. Based on our own experience, we argue that negotiating the dynamics of uncomfortable knowledge is a difficult, but necessary, component of meaningful transdisciplinary collaborations. PMID:25484910

Minimising impairment: Protocol for a multicentre randomised controlled trial of upper limb orthoses for children with cerebral palsy.

PubMed

Imms, Christine; Wallen, Margaret; Elliott, Catherine; Hoare, Brian; Randall, Melinda; Greaves, Susan; Adair, Brooke; Bradshaw, Elizabeth; Carter, Rob; Orsini, Francesca; Shih, Sophy T F; Reddihough, Dinah

2016-05-27

Upper limb orthoses are frequently prescribed for children with cerebral palsy (CP) who have muscle overactivity predominantly due to spasticity, with little evidence of long-term effectiveness. Clinical consensus is that orthoses help to preserve range of movement: nevertheless, they can be complex to construct, expensive, uncomfortable and require commitment from parents and children to wear. This protocol paper describes a randomised controlled trial to evaluate whether long-term use of rigid wrist/hand orthoses (WHO) in children with CP, combined with usual multidisciplinary care, can prevent or reduce musculoskeletal impairments, including muscle stiffness/tone and loss of movement range, compared to usual multidisciplinary care alone. This pragmatic, multicentre, assessor-blinded randomised controlled trial with economic analysis will recruit 194 children with CP, aged 5-15 years, who present with flexor muscle stiffness of the wrist and/or fingers/thumb (Modified Ashworth Scale score ≥1). Children, recruited from treatment centres in Victoria, New South Wales and Western Australia, will be randomised to groups (1:1 allocation) using concealed procedures. All children will receive care typically provided by their treating organisation. The treatment group will receive a custom-made serially adjustable rigid WHO, prescribed for 6 h nightly (or daily) to wear for 3 years. An application developed for mobile devices will monitor WHO wearing time and adverse events. The control group will not receive a WHO, and will cease wearing one if previously prescribed. Outcomes will be measured 6 monthly over a period of 3 years. The primary outcome is passive range of wrist extension, measured with fingers extended using a goniometer at 3 years. Secondary outcomes include muscle stiffness, spasticity, pain, grip strength and hand deformity. Activity, participation, quality of life, cost and cost-effectiveness will also be assessed. This study will provide evidence to inform clinicians, services, funding agencies and parents/carers of children with CP whether the provision of a rigid WHO to reduce upper limb impairment, in combination with usual multidisciplinary care, is worth the effort and costs. ANZ Clinical Trials Registry: U1111-1164-0572 .

Co-prescribing naloxone does not increase liability risk.

PubMed

Davis, Corey S; Burris, Scott; Beletsky, Leo; Binswanger, Ingrid

2016-01-01

The opioid overdose epidemic claims the lives of tens of thousands of Americans every year. Opioid overdose is reversible by the administration of naloxone, a pure antagonist now available in formulations specifically designed and labeled for layperson use. Despite broad support for layperson access to naloxone from professional organizations, health officials, and clinical experts, qualitative studies suggest that some providers have concerns about legal risks associated with naloxone prescribing, particularly co-prescribing naloxone to pain patients. Such concerns are unfounded. The legal risk associated with prescribing naloxone is no higher than that associated with any other medication and is lower than many. Additionally, laws in a majority of states provide explicit legal protections for providers who prescribe or dispense naloxone, in many cases extending this protection to prescriptions issued to friends, family members, and others. In this large and increasing number of states, the liability risk of prescribing or dispensing naloxone in good faith to a patient at risk of overdose (or, in states where such prescribing is permitted, to an associate of such a patient) is either extremely low or absent entirely. Where a prescriber determines, in his or her clinical judgment, that a patient is at risk of overdose, co-prescribing naloxone is a reasonable and prudent clinical and legal decision. No clinician should fail or refuse to issue such a prescription based on liability concerns.

Antibiotics for coughing in general practice: a qualitative decision analysis.

PubMed

Coenen, S; Van Royen, P; Vermeire, E; Hermann, I; Denekens, J

2000-10-01

In family practice, medical decisions are prompted most often by complaints about coughing. There is no single yardstick for the differential diagnosis of respiratory tract infections (RTIs). In 80% of cases, the excessive use of antibiotics in the treatment of RTIs is caused by the prescription behaviour of GPs. Our aim was to explicate GPs' diagnostic (and therapeutic) decisions regarding adult patients who consult them with complaints about coughing, and to investigate what determines decision making. Exploratory, descriptive focus groups were held with GPs. Hypotheses were generated on the basis of 'qualitative content analysis'. Results. Twenty-four GPs participated in four semi-structured group discussions. In order to differentiate RTIs from other possible diagnoses, less likely diagnoses were not ruled out explicitly. In the case of suspected RTI, there was a low degree of certainty in the differentiation between RTIs (e.g. between bronchitis and pneumonia). Clinical signs and symptoms, which determine the probability of disease, often left GPs with reasonable diagnostic doubt. In the end, the decision whether or not to prescribe antibiotics was taken. GPs' prescription behaviour was also determined by doctor- and patient-related factors (e.g. having missed pneumonia once, patient expectations). The 'chagrin factor' explains why these factors lead to a shift in the action threshold, in favour of antibiotics. This inductive research method enabled the generation of meaningful hypotheses regarding the complex decision processes pursued by GPs. The authors are developing an educational intervention that builds on these findings, focusing on the prescribing decision.

Patient, Physician and Organizational Influences on Variation in Antipsychotic Prescribing Behavior.

PubMed

Tang, Yan; Chang, Chung-Chou H; Lave, Judith R; Gellad, Walid F; Huskamp, Haiden A; Donohue, Julie M

2016-03-01

Physicians face the choice of multiple ingredients when prescribing drugs in many therapeutic categories. For conditions with considerable patient heterogeneity in treatment response, customizing treatment to individual patient needs and preferences may improve outcomes. To assess variation in the diversity of antipsychotic prescribing for mental health conditions, a necessary although not sufficient condition for personalizing treatment. To identify patient caseload, physician, and organizational factors associated with the diversity of antipsychotic prescribing. Using 2011 data from Pennsylvania's Medicaid program, IMS Health's HCOSTM database, and the AMA Masterfile, we identified 764 psychiatrists who prescribed antipsychotics to 10 patients. We constructed three physician-level measures of diversity/concentration of antipsychotic prescribing: number of ingredients prescribed, share of prescriptions for most preferred ingredient, and Herfindahl-Hirschman index (HHI). We used multiple membership linear mixed models to examine patient caseload, physician, and healthcare organizational predictors of physician concentration of antipsychotic prescribing. There was substantial variability in antipsychotic prescribing concentration among psychiatrists, with number of ingredients ranging from 2-17, share for most preferred ingredient from 16%-85%, and HHI from 1,088-7,270. On average, psychiatrist prescribing behavior was relatively diversified; however, 11% of psychiatrists wrote an average of 55% of their prescriptions for their most preferred ingredient. Female prescribers and those with smaller shares of disabled or serious mental illness patients had more concentrated prescribing behavior on average. Antipsychotic prescribing by individual psychiatrists in a large state Medicaid program varied substantially across psychiatrists. Our findings illustrate the importance of understanding physicians' prescribing behavior and indicate that even among specialties regularly prescribing a therapeutic category, some physicians rely heavily on a small number of agents. Health systems may need to offer educational interventions to clinicians in order to improve their ability to tailor treatment decisions to the needs of individual patients. Future studies should examine the impact of the diversity of antipsychotic prescribing to determine whether more diversified prescribing improves patient adherence and outcomes.

Uncomfortable images in art and nature.

PubMed

Fernandez, Dominic; Wilkins, Arnold J

2008-01-01

The ratings of discomfort from a wide variety of images can be predicted from the energy at different spatial scales in the image, as measured by the Fourier amplitude spectrum of the luminance. Whereas comfortable images show the regression of Fourier amplitude against spatial frequency common in natural scenes, uncomfortable images show a regression with disproportionately greater amplitude at spatial frequencies within two octaves of 3 cycles deg(-1). In six studies, the amplitude in this spatial frequency range relative to that elsewhere in the spectrum explains variance in judgments of discomfort from art, from images constructed from filtered noise, and from art in which the phase or amplitude spectra have been altered. Striped patterns with spatial frequency within the above range are known to be uncomfortable and capable of provoking headaches and seizures in susceptible persons. The present findings show for the first time that, even in more complex images, the energy in this spatial-frequency range is associated with aversion. We propose a simple measurement that can predict aversion to those works of art that have reached the national media because of negative public reaction.

Uncomfortable images in art and nature

PubMed Central

Fernandez, Dominic; Wilkins, Arnold J.

2008-01-01

We find that the ratings of discomfort from a wide variety of images can be predicted from the energy at different spatial scales in the image, as measured by the Fourier amplitude spectrum of the luminance. Whereas comfortable images show the regression of Fourier amplitude against spatial frequency common in natural scenes, uncomfortable images show a regression with disproportionately greater amplitude at spatial frequencies within two octaves of 3 cycles per degree. In six studies, the amplitude at this spatial frequency relative to that 3 octaves below explains variance in judgments of discomfort from art, from images constructed from filtered noise and from art in which the phase or amplitude spectra have been altered. Striped patterns with spatial frequency within the above range are known to be uncomfortable and capable of provoking headaches and seizures in susceptible persons. The present findings show for the first time that even in more complex images the energy in this spatial frequency range is associated with aversion. We propose a simple measurement that can predict aversion to those works of art that have reached the national media because of negative public reaction. PMID:18773732

Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation

PubMed Central

Russ, Alissa L; Zillich, Alan J; Melton, Brittany L; Russell, Scott A; Chen, Siying; Spina, Jeffrey R; Weiner, Michael; Johnson, Elizabette G; Daggy, Joanne K; McManus, M Sue; Hawsey, Jason M; Puleo, Anthony G; Doebbeling, Bradley N; Saleem, Jason J

2014-01-01

Objective To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. Materials and methods We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug–allergy, drug–drug interaction, and drug–disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. Results Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1–5) compared to original alerts: 4 (1–7); p=0.024). Discussion Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. Conclusions This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes. PMID:24668841

Effects of an e-Prescribing interface redesign on rates of generic drug prescribing: exploiting default options.

PubMed

Malhotra, Sameer; Cheriff, Adam D; Gossey, J Travis; Cole, Curtis L; Kaushal, Rainu; Ancker, Jessica S

2016-09-01

Increasing the use of generic medications could help control medical costs. However, educational interventions have limited impact on prescriber behavior, and e-prescribing alerts are associated with high override rates and alert fatigue. Our objective was to evaluate the effect of a less intrusive intervention, a redesign of an e-prescribing interface that provides default options intended to "nudge" prescribers towards prescribing generic drugs. This retrospective cohort study in an academic ambulatory multispecialty practice assessed the effects of customizing an e-prescribing interface to substitute generic equivalents for brand-name medications during order entry and allow a one-click override to order the brand-name medication. Among drugs with generic equivalents, the proportion of generic drugs prescribed more than doubled after the interface redesign, rising abruptly from 39.7% to 95.9% (a 56.2% increase; 95% confidence interval, 56.0-56.4%; P < .001). Before the redesign, generic drug prescribing rates varied by therapeutic class, with rates as low as 8.6% for genitourinary products and 15.7% for neuromuscular drugs. After the redesign, generic drug prescribing rates for all but four therapeutic classes were above 90%: endocrine drugs, neuromuscular drugs, nutritional products, and miscellaneous products. Changing the default option in an e-prescribing interface in an ambulatory care setting was followed by large and sustained increases in the proportion of generic drugs prescribed at the practice. Default options in health information technology exert a powerful effect on user behavior, an effect that can be leveraged to optimize decision making. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation.

PubMed

Russ, Alissa L; Zillich, Alan J; Melton, Brittany L; Russell, Scott A; Chen, Siying; Spina, Jeffrey R; Weiner, Michael; Johnson, Elizabette G; Daggy, Joanne K; McManus, M Sue; Hawsey, Jason M; Puleo, Anthony G; Doebbeling, Bradley N; Saleem, Jason J

2014-10-01

To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Nurse and Medical Provider Perspectives on Antibiotic Stewardship in Nursing Homes.

PubMed

Scales, Kezia; Zimmerman, Sheryl; Reed, David; Beeber, Anna Song; Kistler, Christine E; Preisser, John S; Weiner, Bryan J; Ward, Kimberly; Fann, Amy; Sloane, Philip D

2017-01-01

To examine perspectives on antibiotic use and antibiotic stewardship of nurses and medical providers in nursing homes (NHs). Cross-sectional survey. NHs in North Carolina (N = 31). Nursing staff (n = 182) and medical providers (n = 50). Respondents completed a self-administered questionnaire about their perspectives on antibiotic use in their NH, the influence of residents and families on antibiotic prescribing decisions, and readiness to improve antibiotic stewardship. Open-ended questions on barriers to antibiotic stewardship were also asked. Linear mixed modeling was used to analyze differences between respondent groups and to test for associations with individual and organizational characteristics. All respondents supported reducing antibiotic use, although medical providers' support was significantly stronger (P = .005). When asked about their perception of residents' and family members' preference for antibiotic use in the case of suspected infection and the influence of that preference on antibiotic-prescribing decisions, respondents indicated that residents and families favor antibiotic use and influence prescribing decisions. Nurses reported a stronger perception than medical providers that families prefer antibiotics (P = .04) and influence prescribing decisions (P = .02). All respondents reported commitment and efficacy to change practices (mean 4.0-4.1 for nurses and 3.6-3.9 for medical providers on a 5-point scale). Four significant associations related to organizational and individual characteristics were found: directors of nursing and specialist nurses reported greater self-efficacy for changing practice than other nurses (P = .003), medical providers with a subspecialty (e.g., geriatrics) reported greater self-efficacy (P = .007) and commitment to change (P = .001) than those without a subspecialty, and medical providers specializing in hospice and palliative care rated family influence (P = .006) higher than those with other subspecialties. Nursing staff and medical providers share a commitment to reducing unnecessary antibiotic use. Antibiotic stewardship interventions should foster cooperation and build competency to implement alternative management approaches and to educate residents and families. Nurse leaders and medical providers with long-term care training may be especially effective champions for antibiotic stewardship. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

Decision tree analyses of key patient characteristics in Middle Eastern/North African and Latin American men treated with long-acting and short-acting PDE5 inhibitors for erectile dysfunction.

PubMed

Rubio-Aurioles, Eusebio; El-Meliegy, Amr; Abdulwahed, Samer; Henneges, Carsten; Sorsaburu, Sebastian; Gurbuz, Sirel

2015-02-01

Phosphodiesterase type 5 (PDE5) inhibitors have discontinuation rates as high as 60% in men with erectile dysfunction. Treatment satisfaction has been significantly associated with treatment continuation. Understanding key characteristics in terms of treatment preference, relationship, and lifestyle issues could provide direction on how to improve compliance with PDE5 inhibitor treatment globally. The objective was to identify subgroups of interest in the pooled database of two observational studies conducted in Latin America (LA) and Middle East/North Africa (MENA) exploring patient characteristics and prescription of either a long- or short-acting PDE5 inhibitor at baseline. Two identical prospective, non-interventional, observational, studies in MENA (N = 493) and LA (N = 511) treated men with an 'on demand' (pro re nata, PRN) PDE5 inhibitor (sildenafil, tadalafil, vardenafil, or lodenafil) during 6 months. In this post-hoc meta-analysis of two observational studies with equal design, pooled data were analyzed to determine patient characteristics and PDE5 inhibitor prescribed/used most likely to be associated with patient expectations, satisfaction, self-esteem, and patient-partner relationships. Decision tree analyses, with and without weighting, were used to identify and describe key features. In each analysis of patient expectations, patient-partner relationship, and self-esteem, we describe the two major subgroups at baseline for each decision tree. Analyses of patient expectations and sexual self-esteem revealed that patients prescribed long-acting PDE5 inhibitors (59%) highlighted the importance of treatment effect duration, second to partner satisfaction with treatment, while patients prescribed short-acting PDE5 inhibitors (32%) placed less importance on treatment effect duration but considerable importance on treatment effect lasting until intercourse completion. Further insights regarding patients, partner relationship characteristics, and treatment expectations were identified. Our analyses have described key characteristics, such as self- and partner perceptions, sexual attitudes, and treatment expectations in relation to the patients' country and prescribed treatment, which might guide treatment decisions in MENA and LA men with ED.

Psychosocial determinants of physicians' acceptance of recommendations by antibiotic computerised decision support systems: A mixed methods study.

PubMed

Chow, Angela; Lye, David C B; Arah, Onyebuchi A

2015-03-01

Antibiotic computerised decision support systems (CDSSs) were developed to facilitate optimal prescribing, but acceptance of their recommendations has remained low. We aimed to evaluate physicians' perceptions and attitudes toward antibiotic CDSSs and determine psychosocial factors associated with acceptance of CDSS recommendations for empirical therapy. A mixed methods study was conducted in an adult tertiary-care hospital in Singapore, with its in-house antibiotic CDSS that integrates antimicrobial stewardship with electronic prescribing. Focus group discussions were conducted among purposively sampled physicians and data were analysed using the framework approach. Emerging themes were included in the questionnaire with newly developed scales for the subsequent cross-sectional survey involving all physicians. Principal components analysis was performed to derive the latent factor structure that was later applied in multivariate analyses. Physicians expressed confidence in the credibility of CDSS recommendations. Junior physicians accepted CDSS recommendations most of the time, whilst senior physicians acknowledged overriding recommendations in complex patients with multiple infections or allergies. Willingness to consult the CDSS for common and complex infections (OR=1.68, 95% CI 1.16-2.44) and preference for personal or team decision (OR=0.61, 95% CI 0.43-0.85) were associated with acceptance of CDSS recommendations. Cronbach's α for scales measuring physicians' attitudes and perceptions towards acceptance of CDSS recommendations ranged from 0.64 to 0.88. Physicians' willingness to consult an antibiotic CDSS determined acceptance of its recommendations. Physicians would choose to exercise their own or clinical team's decision over CDSS recommendations in complex patient situations when the antibiotic prescribing needs were not met. Copyright © 2014 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.

Physician consideration of patients' out-of-pocket costs in making common clinical decisions.

PubMed

Pham, Hoangmai H; Alexander, G Caleb; O'Malley, Ann S

2007-04-09

Patients face growing cost-sharing through higher deductibles and other out-of-pocket (OP) expenses, with uncertain effects on clinical decision making. We analyzed data on 6628 respondents to the nationally representative 2004-2005 Community Tracking Study Physician Survey to examine how frequently physicians report considering their insured patients' OP expenses when prescribing drugs, selecting diagnostic tests, and choosing inpatient vs outpatient care settings. Responses were dichotomized as always/usually vs sometimes/rarely/never. In separate multivariate logistic regressions, we examined associations between physicians' reported frequency of considering OP costs for each type of decision and characteristics of individual physicians and their practices. Seventy-eight percent of physicians reported routinely considering OP costs when prescribing drugs, while 51.2% reported doing so when selecting care settings, and 40.2% when selecting diagnostic tests. In adjusted analyses, primary care physicians were more likely than medical specialists to consider patients' OP costs in choosing prescription drugs (85.3% vs 74.5%) (P<.001), care settings (53.9% vs 43.1%) (P<.001), and diagnostic tests (46.3% vs 29.9%) (P<.001). Physicians working in large groups or health maintenance organizations were more likely to consider OP costs in prescribing generic drugs (P<.001 for comparisons with solo and 2-person practices), but those in solo or 2-person practices were more likely to do so in choosing tests and care settings (P<.05 for all comparisons with other practice types). Physicians providing at least 10 hours of charity care a month were more likely than those not providing any to consider OP costs in both diagnostic testing (40.7% vs 35.8%) (P<.001) and care setting decisions (51.4% vs 47.6%) (P<.005). Cost-sharing arrangements targeting patients are likely to have limited effects in safely reducing health care spending because physicians do not routinely consider patients' OP costs when making decisions regarding more expensive medical services.

The power of apology.

PubMed

Bismark, Marie M

2009-10-09

In the aftermath of an adverse event, an apology can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust to their relationship. According to the Health and Disability Commissioner: "The way a practitioner handles the situation at the outset can influence a patient's decision about what further action to take, and an appropriate apology may prevent the problem escalating into a complaint to HDC". Yet, for many health practitioners saying "I'm sorry" remains a difficult and uncomfortable thing to do. We can help to bring down this wall of silence by developing a clear understanding of the importance of apologies to patients and health practitioners; appreciating the difference between expressing empathy and accepting legal responsibility for an adverse outcome; knowing the key elements of a full apology and when they should be used; and supporting those who have the honesty and courage to say "I'm sorry" to patients who have been harmed while receiving healthcare.

Proctalgia fugax: caused by pudendal neuropathy?

PubMed

Takano, Masahiro

2005-01-01

There is a strange disease called proctalgia fugax in which rather uncomfortable pain appears suddenly mostly at night without any particular warning and disappears completely without any objective traces. It also is categorized as a functional anorectal pain under the Rome II (diagnostic criteria for the functional gastrointestinal disorders). For the causes, many theories have been advocated but not decisive and therefore were not linked to the definite treatment. The author experienced 68 patients with proctalgia fugax, among which 55 patients had tenderness along the pudendal nerve. The location, character, and degree of pain caused by digital examination were confirmed by all of them to be similar to that which they experience at times of paroxysm. After administration of a nerve block, symptoms disappeared completely in 65 percent of the patients and decreased in 25 percent. These data suggest that the pathogenesis of proctalgia fugax is neuralgia of the pudendal nerves.

The influence of evidence-based medicine training on decision-making in relation to over-the-counter medicines: a qualitative study.

PubMed

Hanna, Lezley-Anne; Hughes, Carmel

2012-12-01

To explore the role of evidence of effectiveness when making decisions about over-the-counter (OTC) medication and to ascertain whether evidence-based medicine training raised awareness in decision-making. Additionally, this work aimed to complement the findings of a previous study because all participants in this current study had received training in evidence-based medicine (unlike the previous participants). Following ethical approval and an e-mailed invitation, face-to-face, semi-structured interviews were conducted with newly registered pharmacists (who had received training in evidence-based medicine as part of their MPharm degree) to discuss the role of evidence of effectiveness with OTC medicines. Interviews were recorded and transcribed verbatim. Following transcription, all data were entered into the NVivo software package (version 8). Data were coded and analysed using a constant comparison approach. Twenty-five pharmacists (7 males and 18 females; registered for less than 4 months) were recruited and all participated in the study. Their primary focus with OTC medicines was safety; sales of products (including those that lack evidence of effectiveness) were justified provided they did no harm. Meeting patient expectation was also an important consideration and often superseded evidence. Despite knowledge of the concept, and an awareness of ethical requirements, an evidence-based approach was not routinely implemented by these pharmacists. Pharmacists did not routinely utilize evidence-based resources when making decisions about OTC medicines and some felt uncomfortable discussing the evidence-base for OTC products with patients. The evidence-based medicine training that these pharmacists received appeared to have limited influence on OTC decision-making. More work could be conducted to ensure that an evidence-based approach is routinely implemented in practice. © 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society.

Involvement of Rabbinic and communal authorities in decision-making by haredi Jews in the UK with breast cancer: an interpretative phenomenological analysis.

PubMed

Coleman-Brueckheimer, Kate; Spitzer, Joseph; Koffman, Jonathan

2009-01-01

This paper examines how Rabbinic and communal authorities participated in treatment decisions made by a group of strictly orthodox haredi Jews with breast cancer living in London. Semi-structured interviews were conducted with five haredi breast cancer patients. The transcripts were analysed using interpretative phenomenological analysis. Demographic and personal data were collected using structured questionnaires. All participants sought Rabbinic involvement, with four seeking rulings concerning religious rituals and treatment options. Participants' motivations were to ensure their actions accorded with Jewish law and hence God's will. By delegating treatment decisions, decision-making became easier and participants could avoid guilt and blame. They could actively participate in the process by choosing which Rabbi to approach, by providing personal information and by stating their preferences. Attitudes towards Rabbinic involvement were occasionally conflicted. This was related to the understanding that Rabbinic rulings were binding, and occasional doubts that their situation would be correctly interpreted. Three participants consulted the community's 'culture broker' for medical referrals and non-binding advice concerning treatment. Those who consulted the culture broker had to transcend social norms restricting unnecessary contact between men and women. Hence, some participants described talking to him as uncomfortable. Other concerns related to confidentiality. By consulting Rabbinic authorities, haredi cancer patients participated in a socially sanctioned method of decision-making continuous with their religious values. Imposing meaning on their illness in this way may be associated with positive psychological adjustment. Rabbinic and communal figures may endorse therapeutic recommendations and make religious and cultural issues comprehensible to clinicians, and as such healthcare practitioners may benefit from this involvement.

Opioid vs nonopioid prescribers: Variations in care for a standardized acute back pain case.

PubMed

Hanley, Kathleen; Zabar, Sondra; Altshuler, Lisa; Lee, Hillary; Ross, Jasmine; Rivera, Nicomedes; Marvilli, Christian; Gillespie, Colleen

2017-01-01

Opioid analgesics are effective and appropriate therapy for many types of acute pain. Epidemiologic evidence supports a direct relationship between increased opioid prescribing and increases in opioid use disorders and overdoses. To tailor our residency curriculum, we designed and fielded an unannounced standardized patient (USP) case involving a patient with acute back pain who is requesting Vicodin (5/325 mg). We describe residents' case management and examine whether their management decisions, including opioid prescribing, were related to their core clinical skills. Results are based on 50 (USP) visits with residents in 2 urban primary care clinics. Highly trained USPs portrayed a patient with acute lower back pain who was taking leftover Vicodin with effective pain relief but was running out. We describe how residents managed this case, using both USP report and chart review data, and compare summary clinical skills scores between those who prescribed Vicodin and those who did not. Of the 50 residents, 18 prescribed Vicodin (10-60 pills). Among those who did not prescribe (32/50), most (50%) prescribed ibuprofen. Eighty-three percent of the prescribers and 72% of nonprescribers ordered physical therapy (nonsignificant). Of the 18 prescribers, 13 documented checking the prescription monitoring database. Prescribers had significantly better communication scores than nonprescribers (relationship development: 80% vs. 58% well done, P = .029; patient education: 59% vs. 31% well done, P = .018). Assessment summary scores were also higher (60% vs. 46%) but not significantly (P = .060). Patient satisfaction and activation scores were higher in the prescribers than nonprescribers (71% vs. 39%, P = .004 and 48% vs. 26%, P = .034, respectively). Most Vicodin prescribers did not follow prescribing guidelines, and they demonstrated better communication and assessment skills than the nonprescribers. Results suggest the need to guide residents in using a systematic approach to prescribing opioids safely and to develop an acceptable alternative pain management plan when they decide against prescribing.

Regional Brain Responses Are Biased Toward Infant Facial Expressions Compared to Adult Facial Expressions in Nulliparous Women.

PubMed

Li, Bingbing; Cheng, Gang; Zhang, Dajun; Wei, Dongtao; Qiao, Lei; Wang, Xiangpeng; Che, Xianwei

2016-01-01

Recent neuroimaging studies suggest that neutral infant faces compared to neutral adult faces elicit greater activity in brain areas associated with face processing, attention, empathic response, reward, and movement. However, whether infant facial expressions evoke larger brain responses than adult facial expressions remains unclear. Here, we performed event-related functional magnetic resonance imaging in nulliparous women while they were presented with images of matched unfamiliar infant and adult facial expressions (happy, neutral, and uncomfortable/sad) in a pseudo-randomized order. We found that the bilateral fusiform and right lingual gyrus were overall more activated during the presentation of infant facial expressions compared to adult facial expressions. Uncomfortable infant faces compared to sad adult faces evoked greater activation in the bilateral fusiform gyrus, precentral gyrus, postcentral gyrus, posterior cingulate cortex-thalamus, and precuneus. Neutral infant faces activated larger brain responses in the left fusiform gyrus compared to neutral adult faces. Happy infant faces compared to happy adult faces elicited larger responses in areas of the brain associated with emotion and reward processing using a more liberal threshold of p < 0.005 uncorrected. Furthermore, the level of the test subjects' Interest-In-Infants was positively associated with the intensity of right fusiform gyrus response to infant faces and uncomfortable infant faces compared to sad adult faces. In addition, the Perspective Taking subscale score on the Interpersonal Reactivity Index-Chinese was significantly correlated with precuneus activity during uncomfortable infant faces compared to sad adult faces. Our findings suggest that regional brain areas may bias cognitive and emotional responses to infant facial expressions compared to adult facial expressions among nulliparous women, and this bias may be modulated by individual differences in Interest-In-Infants and perspective taking ability.

Regional Brain Responses Are Biased Toward Infant Facial Expressions Compared to Adult Facial Expressions in Nulliparous Women

PubMed Central

Zhang, Dajun; Wei, Dongtao; Qiao, Lei; Wang, Xiangpeng; Che, Xianwei

2016-01-01

Recent neuroimaging studies suggest that neutral infant faces compared to neutral adult faces elicit greater activity in brain areas associated with face processing, attention, empathic response, reward, and movement. However, whether infant facial expressions evoke larger brain responses than adult facial expressions remains unclear. Here, we performed event-related functional magnetic resonance imaging in nulliparous women while they were presented with images of matched unfamiliar infant and adult facial expressions (happy, neutral, and uncomfortable/sad) in a pseudo-randomized order. We found that the bilateral fusiform and right lingual gyrus were overall more activated during the presentation of infant facial expressions compared to adult facial expressions. Uncomfortable infant faces compared to sad adult faces evoked greater activation in the bilateral fusiform gyrus, precentral gyrus, postcentral gyrus, posterior cingulate cortex-thalamus, and precuneus. Neutral infant faces activated larger brain responses in the left fusiform gyrus compared to neutral adult faces. Happy infant faces compared to happy adult faces elicited larger responses in areas of the brain associated with emotion and reward processing using a more liberal threshold of p < 0.005 uncorrected. Furthermore, the level of the test subjects’ Interest-In-Infants was positively associated with the intensity of right fusiform gyrus response to infant faces and uncomfortable infant faces compared to sad adult faces. In addition, the Perspective Taking subscale score on the Interpersonal Reactivity Index-Chinese was significantly correlated with precuneus activity during uncomfortable infant faces compared to sad adult faces. Our findings suggest that regional brain areas may bias cognitive and emotional responses to infant facial expressions compared to adult facial expressions among nulliparous women, and this bias may be modulated by individual differences in Interest-In-Infants and perspective taking ability. PMID:27977692

Prevalence of ocular surface symptoms, signs, and uncomfortable hours of wear in contact lens wearers: the effect of refitting with daily-wear silicone hydrogel lenses (senofilcon a).

PubMed

Riley, Colleen; Young, Graeme; Chalmers, Robin

2006-12-01

Many soft contact lens wearers have symptoms or signs that compromise successful lens wear. This study estimated the prevalence of problems in current wearers of soft contact lenses and tested the effect of refitting patients with senofilcon A silicone hydrogel lenses (ACUVUE Oasys). Prevalence was estimated from 1,092 current lens wearers for frequent or constant discomfort or dryness, at least 2 hours of uncomfortable wear, at least grade 2 limbal or bulbar hyperemia (0-4), or at least grade 3 corneal staining (0-15). In the second part of the study, 112 of the 564 wearers classified as problem patients were refitted with senofilcon A lenses and reassessed 2 weeks later. Fifty-two percent (564 of 1,092) had some qualifying criteria, with dryness reported by 23%, discomfort by 13%, and at least 2 hours of uncomfortable wear by 27%. Six percent of subjects had qualifying limbal hyperemia; 10% had bulbar hyperemia; and 12% had corneal staining. After refitting 112 problem patients, 75% had less dryness; 88% had better comfort (P<0.0001 each); and 76% had fewer uncomfortable hours of wear (P=0.004). Although the average wearing time was unchanged, comfortable wearing time increased significantly (10.4 to 11.6 hours) (P=0.004). All (35 of 35) eyes with qualifying limbal hyperemia before the refit also improved (P<0.0001), as did 80% (40 of 50) of those with bulbar hyperemia (P<0.0001) and 76% (26 of 34) of those with corneal staining (P=0.005). Most soft lens wearers encounter clinically significant signs or symptoms with their current contact lenses. Refitting with new-generation silicone hydrogel lenses (senofilcon A) can alleviate some of these common problems.

[Uncertain analgetic efficacy of intraurethral instillation of anesthetic jelly in rigid cystoscopy for men].

PubMed

Matsuda, Daisuke; Irie, Akira; Shimura, Satoru; Hirayama, Takahiro; Kurosaka, Shinji; Tsumura, Hideyasu; Maru, Norio; Baba, Shiro

2005-09-01

The analgetic efficacy of intraurethral instillation of anesthetic jelly in rigid cystoscopic examination for men is not clearly confirmed. This study evaluated the usefulness of intraurethral instillation of anesthetic jelly by questionnaires regarding the pain and uncomfortable feelings during and after the cystoscopic examination. A total of 62 men were enrolled in the study. Sixteen patients had not received cystoscopy previously (first cases), and 46 had prior experiences of cystoscopy more than twice (repeat cases). These patients were sequentially divided into two groups; one group (jelly-group) received intraurethral instillation of oxybuprocaine hydrochroride jelly (Benoxil jelly) prior to cystoscopic examination, and the other group (no-jelly-group) did not receive the jelly instillation. Pain during the jelly instillation to examination, and uncomfortable feelings at micturition after the examination was evaluated by questionnaires. Instillation of the jelly itself caused considerable pain, which almost similar to that of scope insertion. There was no significant difference in pain score between jelly-group and no-jelly-group during the insertion of the scope to examination. The miction pain after examination was significantly severer in the jelly-group than in the no-jelly-group in repeat cases. In addition, 75% of repeat cases felt better comfortableness when jelly was not instilled, and 96% of repeat cases did not want jelly instillation for their future examination. Intraurethral instillation of anesthetic jelly had no efficacy for reducing the pain during cystoscopy. Instillation of the jelly itself caused considerable pain, and it made pain and uncomfortable feelings after the examination worse. These results suggested that the instillation of anesthetic jelly before rigid cystoscopy in men might not be useful enough for reducing the uncomfortable feeling during the examination.

Computational prediction of multidisciplinary team decision-making for adjuvant breast cancer drug therapies: a machine learning approach.

PubMed

Lin, Frank P Y; Pokorny, Adrian; Teng, Christina; Dear, Rachel; Epstein, Richard J

2016-12-01

Multidisciplinary team (MDT) meetings are used to optimise expert decision-making about treatment options, but such expertise is not digitally transferable between centres. To help standardise medical decision-making, we developed a machine learning model designed to predict MDT decisions about adjuvant breast cancer treatments. We analysed MDT decisions regarding adjuvant systemic therapy for 1065 breast cancer cases over eight years. Machine learning classifiers with and without bootstrap aggregation were correlated with MDT decisions (recommended, not recommended, or discussable) regarding adjuvant cytotoxic, endocrine and biologic/targeted therapies, then tested for predictability using stratified ten-fold cross-validations. The predictions so derived were duly compared with those based on published (ESMO and NCCN) cancer guidelines. Machine learning more accurately predicted adjuvant chemotherapy MDT decisions than did simple application of guidelines. No differences were found between MDT- vs. ESMO/NCCN- based decisions to prescribe either adjuvant endocrine (97%, p = 0.44/0.74) or biologic/targeted therapies (98%, p = 0.82/0.59). In contrast, significant discrepancies were evident between MDT- and guideline-based decisions to prescribe chemotherapy (87%, p < 0.01, representing 43% and 53% variations from ESMO/NCCN guidelines, respectively). Using ten-fold cross-validation, the best classifiers achieved areas under the receiver operating characteristic curve (AUC) of 0.940 for chemotherapy (95% C.I., 0.922-0.958), 0.899 for the endocrine therapy (95% C.I., 0.880-0.918), and 0.977 for trastuzumab therapy (95% C.I., 0.955-0.999) respectively. Overall, bootstrap aggregated classifiers performed better among all evaluated machine learning models. A machine learning approach based on clinicopathologic characteristics can predict MDT decisions about adjuvant breast cancer drug therapies. The discrepancy between MDT- and guideline-based decisions regarding adjuvant chemotherapy implies that certain non-clincopathologic criteria, such as patient preference and resource availability, are factored into clinical decision-making by local experts but not captured by guidelines.

A ranking system for prescribed burn prioritization in Table Mountain National Park, South Africa.

PubMed

Cowell, Carly Ruth; Cheney, Chad

2017-04-01

To aid prescribed burn decision making in Table Mountain National Park, in South Africa a priority ranking system was tested. Historically a wildfire suppression strategy was adopted due to wildfires threatening urban areas close to the park, with few prescribed burns conducted. A large percentage of vegetation across the park exceeded the ecological threshold of 15 years. We held a multidisciplinary workshop, to prioritize areas for prescribed burning. Fire Management Blocks were mapped and assessed using the following seven categories: (1) ecological, (2) management, (3) tourism, (4) infrastructure, (5) invasive alien vegetation, (6) wildland-urban interface and (7) heritage. A priority ranking system was used to score each block. The oldest or most threatened vegetation types were not necessarily the top priority blocks. Selected blocks were burnt and burning fewer large blocks proved more effective economically, ecologically and practically due to the limited burning days permitted. The prioritization process was efficient as it could be updated annually following prescribed burns and wildfire incidents. Integration of prescribed burn planning and wildfire suppression strategies resulted in a reduction in operational costs. We recommend protected areas make use of a priority ranking system developed with expert knowledge and stakeholder engagement to determine objective prescribed burn plans. Copyright © 2017 Elsevier Ltd. All rights reserved.

Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan

PubMed Central

Teich, Jonathan M.; Osheroff, Jerome A.; Pifer, Eric A.; Sittig, Dean F.; Jenders, Robert A.

2005-01-01

Clinical decision support (CDS) in electronic prescribing (eRx) systems can improve the safety, quality, efficiency, and cost-effectiveness of care. However, at present, these potential benefits have not been fully realized. In this consensus white paper, we set forth recommendations and action plans in three critical domains: (1) advances in system capabilities, including basic and advanced sets of CDS interventions and knowledge, supporting database elements, operational features to improve usability and measure performance, and management and governance structures; (2) uniform standards, vocabularies, and centralized knowledge structures and services that could reduce rework by vendors and care providers, improve dissemination of well-constructed CDS interventions, promote generally applicable research in CDS methods, and accelerate the movement of new medical knowledge from research to practice; and (3) appropriate financial and legal incentives to promote adoption. PMID:15802474

Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use.

PubMed

Vandenberg, Ann E; Vaughan, Camille P; Stevens, Melissa; Hastings, Susan N; Powers, James; Markland, Alayne; Hwang, Ula; Hung, William; Echt, Katharina V

2017-02-01

Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers. Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns. Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed. Geriatric order sets were implemented at two sites as part of the multicomponent 'Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department' quality improvement initiative. Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups (n = 20), those 'EQUiPPED' with the interventions (n = 10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record (n = 10, 5 at each site). All providers were asked about order set 'use' and 'usefulness'. Users (n = 11) were asked about 'usability'. Order set adopters described 'usefulness' in terms of 'safety' and 'efficiency', whereas order set consultants and order set non-users described 'usefulness' in terms of 'information' or 'training'. Provider 'autonomy', 'comfort' level with existing tools, and 'learning curve' were stated as barriers to use. Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

A thematic analysis for how patients, prescribers, experts, and patient advocates view the prescription choice process.

PubMed

Schommer, Jon C; Worley, Marcia M; Kjos, Andrea L; Pakhomov, Serguei V S; Schondelmeyer, Stephen W

2009-06-01

Typically, patients are unaware of the cost consequences regarding prescribing decisions during their clinical encounter and rarely talk with their physicians about costs of prescription drugs. Prescription medications that are deemed by patients to be too costly when the costs become known after purchase are discontinued or used at suboptimal doses compared to prescription medications that are deemed to be worth the cost. To learn more about the prescription choice process from several viewpoints, the purpose of this study was to uncover and describe how patients, prescribers, experts, and patient advocates view the prescription choice process. Data were collected via 9 focus group interviews held between April 24 and July 31, 2007 (3 with patients, 3 with prescribers, 2 with experts, and 1 with patient advocates). The interviews were audiotaped and transcribed. The resulting text was analyzed in a descriptive and interpretive manner. Theme extraction was based on convergence and external divergence; that is, identified themes were internally consistent but distinct from one and another. To ensure quality and credibility of analysis, multiple analysts and multiple methods were used to provide a quality check on selective perception and blind interpretive bias that could occur through a single person doing all of the analysis or through employment of a single method. The findings revealed 5 overall themes related to the prescription choice process: (1) information, (2) relationship, (3) patient variation, (4) practitioner variation, and (5) role expectations. The results showed that patients, prescribers, experts, and patient advocates viewed the themes within differing contexts. It appears that the prescription choice process entails an interplay among information, relationship, patient variation, practitioner variation, and role expectations, with each viewed within different contexts by individuals engaged in such decision making.

Oncology providers' perspectives on endocrine therapy prescribing and management.

PubMed

Wheeler, Stephanie B; Roberts, Megan C; Bloom, Diane; Reeder-Hayes, Katherine E; Espada, Maya; Peppercorn, Jeffrey; Golin, Carol E; Earp, Jo Anne

2016-01-01

Adjuvant endocrine therapy (ET) can reduce the risk of recurrence among females with hormone receptor-positive breast cancer. Overall, initiation and adherence to ET are suboptimal, though reasons are not well described. The study's objective was to better understand ET decision making, prescribing, and patient management from oncology providers' perspectives. Using purposive sampling, we recruited oncology providers who saw five or more breast cancer patients per week (n=20). We conducted 30-45-minute telephone interviews, using a semistructured guide to elicit perspectives on ET use. We used thematic content analysis to systematically identify categories of meaning and double-coded transcripts using Atlas.ti. Providers recommend ET to all eligible patients except those with contraindications or other risk factors. Providers base their ET prescribing decisions on the patient's menopausal status, side effects, and comorbidities. ET is typically discussed multiple times: at the onset of breast cancer treatment and in more detail after other treatment completion. Providers felt that the associated recurrence risk reduction is the most compelling argument for patients during ET decision making. While providers rarely perceived noninitiation as a problem, nonadherence was prevalent, often due to unresolvable side effects. From the clinicians' perspectives, side effects from ET are the dominant factor in nonadherence. Efforts to improve adherence should focus on strategies to minimize side effects and ensure clinicians and patients are well informed regarding optimal side effect management. This finding has important implications for novel endocrine regimens that offer improved outcomes through longer duration or more intensive therapy.

A qualitative study of GPs' and PCO stakeholders' views on the importance and influence of cost on prescribing.

PubMed

Prosser, Helen; Walley, Tom

2005-03-01

With prescribing expenditure rising and evidence of prescribing costs variation, general practitioners (GPs) in the UK are under increasing pressure to contain spending. The introduction of cash-limited, unified budgets and increased monitoring of prescribing within Primary Care Organizations (PCO) are intended to increase efficiency and enhance GPs financial responsibility. Whilst GPs regularly receive data on the costs of their prescribing and also performance against a set prescribing budget, little is known about the extent to which GPs take cost into account in their prescribing decisions. This study undertook a qualitative exploration of the attitudes of various stakeholders on the relative importance and influence of cost on general practice prescribing. In order to explore a plurality of perspectives, data were obtained from focus groups and a series of individual semi-structured interviews with GPs and key PCO stakeholders. The data suggest that although almost all GPs believed costs should be taken into account when prescribing, there was great variation in the extent to which this was applied and to how sensitive GPs were to costs. Cost was secondary to clinical effectiveness and safety, whilst individual patient need was emphasized above other forms of rationality or notions of opportunity costs. Conflict was apparent between a PCO policy of cost-containment and GPs' resistance to cost-cutting. GPs largely applied simple cost-minimization while cost-consideration was undermined by contextual factors. Implications for research and policy are discussed.

Prescribed fire applications: Restoring ecological structure and process in ponderosa pine forests

Treesearch

Michael G. Harrington

1996-01-01

The decision to include the fire process as part of a restoration treatment for a particular forest site is most logically made in conjunction with the decision for a silvicultural treatment. In other words, forest managers do not typically wait to visually or quantitatively evaluate the post harvest site before deciding whether or not to apply fire. Each phase of the...

The views of patients with severe chronic obstructive pulmonary disease on advance care planning: a qualitative study.

PubMed

MacPherson, Anna; Walshe, Catherine; O'Donnell, Valerie; Vyas, Aashish

2013-03-01

Chronic obstructive pulmonary disease (COPD) is a major cause of death worldwide and there are concerns that end-of-life care for these patients is inadequate. Advance care planning is encouraged, with the hope that it will improve communication and avoid unwanted interventions, which have been particular concerns; in practice, these discussions rarely occur. We have little knowledge of the views of patients with COPD on advance care planning. Understanding this could help integrate advance care planning into the routine management of patients with COPD. To explore the views of people with severe COPD about advance care planning. Qualitative design, with data collection incorporating audio recorded semi-structured interviews. Analysis followed a grounded theory approach. Patients with severe COPD (n =10, Gold Standards Framework criteria) were recruited from primary and secondary care settings. Participants felt they had not been given enough information about their diagnosis and prognosis, and were keen for more discussion with healthcare professionals. They wanted more involvement in decisions about their treatment when those decisions were required. Participants were happy to discuss their general views about future care, but felt uncomfortable with the traditional model of binding 'advance directives'. Considering advance care planning as a repeated process of discussion of prognosis, concerns and probable preferences for care would be more useful than encouraging binding advance decisions. Further research should assess the effectiveness of this approach. Local coordination of who is responsible for information provision is needed, and greater involvement of patients with COPD in management decisions as they arise.

Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts.

PubMed

Zetts, Rachel M; Stoesz, Andrea; Smith, Brian A; Hyun, David Y

2018-06-01

Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance. Copyright © 2018 by the American Academy of Pediatrics.

Involved, inputting or informing: "Shared" decision making in adult mental health care.

PubMed

Bradley, Eleanor; Green, Debra

2018-02-01

A diagnosis of serious mental illness can impact on the whole family. Families informally provide significant amounts of care but are disproportionately at risk of carer burden when compared to those supporting people with other long-term conditions. Shared decision making (SDM) is an ethical model of health communication associated with positive health outcomes; however, there has been little research to evaluate how routinely family is invited to participate in SDM, or what this looks like in practice. This UK study aimed to better understand how the family caregivers of those diagnosed with SMI are currently involved in decision making, particularly decisions about treatment options including prescribed medication. Objectives were to Explore the extent to which family members wish to be involved in decisions about prescribed medication Determine how and when professionals engage family in these decisions Identify barriers and facilitators associated with the engagement of family in decisions about treatment. Open-ended questions were sent to professionals and family members to elicit written responses. Qualitative responses were analysed thematically. Themes included the definition of involvement and "rules of engagement." Staff members are gatekeepers for family involvement, and the process is not democratic. Family and staff ascribe practical, rather than recovery-oriented roles to family, with pre-occupation around notions of adherence. Staff members need support, training and education to apply SDM. Time to exchange information is vital but practically difficult. Negotiated teams, comprising of staff, service users, family, peers as applicable, with ascribed roles and responsibilities could support SDM. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Eliciting general practitioners' salient beliefs towards prescribing: a qualitative study based on the Theory of Planned Behaviour in Greece.

PubMed

Tsiantou, V; Shea, S; Martinez, L; Agius, D; Basak, O; Faresjö, T; Moschandreas, J; Samoutis, G; Symvoulakis, E K; Lionis, C

2013-04-01

Prescribing represents an important medical action especially in primary care. However, irrational prescribing is common and has an impact on clinical and economic outcomes. Therefore, there is a growing need to rationalize prescribing. Knowledge of influential factors is crucial for achieving this. The aim of the present study was to identify the behavioural, normative and control beliefs of GPs regarding prescribing in Greece. Focus group sessions were conducted in three geographically defined areas in Greece. GPs working in the private and public sector in primary care settings were invited to participate. Transcripts from focus groups were content analysed using the Theory of Planned Behaviour (TPB) as the theoretical framework. GPs acknowledged prescribing as the most important method for treating diseases in primary health care, with significant impact on patient's health and quality of life. The expectations of patients and their families were extremely influential during prescribing. Pharmaceutical sales representatives, other GPs and specialists, as well as public health authorities influenced prescribing. GPs admitted that factors such as the income of the patient, the limited time available and special situations such as prescribing through a third person or prescribing following patients' prescription requests for medicines that they have previously purchased over the counter through pharmacies may facilitate or hinder their prescribing decision. This elicitation study shed light into GPs' beliefs regarding prescribing. Factors that are not common in the usual European setting were revealed, such as the influence of the patients' family and special situations during prescribing. Thus, various issues were highlighted that should inform the development of items for inclusion in a forthcoming TPB-based questionnaire. The results of this study revealed also certain issues that can affect the design of policies aiming at the rationalization of prescribing. © 2013 Blackwell Publishing Ltd.

Patient perspectives on choosing buprenorphine over methadone in an urban, equal-access system.

PubMed

Gryczynski, Jan; Jaffe, Jerome H; Schwartz, Robert P; Dušek, Kristi A; Gugsa, Nishan; Monroe, Cristin L; O'Grady, Kevin E; Olsen, Yngvild K; Mitchell, Shannon Gwin

2013-01-01

Recent policy initiatives in Baltimore City, MD significantly reduced access disparities between methadone and buprenorphine in the publicly funded treatment sector. This study examines reasons for choosing buprenorphine over methadone among patients with access to both medications. This study was embedded within a larger clinical trial conducted at two outpatient substance abuse treatment programs offering buprenorphine. Qualitative and quantitative data on treatment choice were collected for new patients starting buprenorphine treatment (n = 80). The sample consisted of predominantly urban African American (94%) heroin users who had prior experience with non-prescribed street buprenorphine (85%), and opioid agonist treatment (68%). Qualitative data were transcribed and coded for themes, while quantitative data were analyzed using descriptive and bivariate statistics. Participants typically conveyed their choice of buprenorphine treatment as a decision against methadone. Buprenorphine was perceived as a helpful medication while methadone was perceived as a harmful narcotic with multiple unwanted physical effects. Positive experiences with non-prescribed "street buprenorphine" were a central factor in participants' decisions to seek buprenorphine treatment. Differences in service structure between methadone and buprenorphine did not strongly influence treatment-seeking decisions in this sample. Personal experiences with medications and the street narrative surrounding them play an important role in treatment selection decisions. This study characterizes important decision factors that underlie patients' selection of buprenorphine over methadone treatment. Copyright © American Academy of Addiction Psychiatry.

Patient Perspectives on Choosing Buprenorphine over Methadone in an Urban Equal Access System

PubMed Central

Gryczynski, Jan; Jaffe, Jerome H.; Schwartz, Robert P.; Dušek, Kristi A.; Gugsa, Nishan; Monroe, Cristin L.; O'Grady, Kevin E.; Olsen, Yngvild K.; Mitchell, Shannon Gwin

2014-01-01

Background Recent policy initiatives in Baltimore City, MD significantly reduced access disparities between methadone and buprenorphine in the publicly-funded treatment sector. Objectives This study examines reasons for choosing buprenorphine over methadone among patients with access to both medications. Methods This study was embedded within a larger clinical trial conducted at two outpatient substance abuse treatment programs offering buprenorphine. Qualitative and quantitative data on treatment choice were collected for new patients starting buprenorphine treatment (n=80). The sample consisted of predominantly urban African American (94%) heroin users who had prior experience with non-prescribed street buprenorphine (85%) and opioid agonist treatment (68%). Qualitative data were transcribed and coded for themes, while quantitative data were analyzed using descriptive and bivariate statistics. Results Participants typically conveyed their choice of buprenorphine treatment as a decision against methadone. Buprenorphine was perceived as a helpful medication while methadone was perceived as a harmful narcotic with multiple unwanted physical effects. Positive experiences with non-prescribed “street buprenorphine” were a central factor in participants’ decisions to seek buprenorphine treatment. Conclusions Differences in service structure between methadone and buprenorphine did not strongly influence treatment-seeking decisions in this sample. Personal experiences with medications and the street narrative surrounding them play an important role in treatment selection decisions. Scientific Significance This study characterizes important decision factors that underlie patients’ selection of buprenorphine over methadone treatment. PMID:23617873

Attitudes and behaviour of general practitioners and their prescribing costs: a national cross sectional survey.

PubMed

Watkins, C; Harvey, I; Carthy, P; Moore, L; Robinson, E; Brawn, R

2003-02-01

General practitioner (GP) prescribing accounts for about 10% of NHS expenditure. GPs at the top of the range have annual prescribing costs that are almost twice as much as those at the bottom of the range. This variation cannot be accounted for purely in terms of differences in underlying need for health care. To describe the relationship between GPs' prescribing costs and their attitudes towards prescribing decisions and prescribing information sources, and to identify potentially modifiable attitudinal and behavioural factors associated with high cost prescribing. A postal questionnaire was designed on the basis of hypotheses developed from a literature search and an earlier qualitative survey. This questionnaire was sent to a national sample of GPs with equal numbers of practices in the upper, middle, and lowest quintile of prescribing costs. GP practices in England. 1714 GPs in NHS practice. GPs' self-reported practices, attitudes and personal characteristics. There was a 64% response rate. Responders were more likely to be from larger practices, in less deprived areas, and with lower prescribing costs than were non-responders. Multivariable analysis showed that GPs with high prescribing costs were significantly more likely to work in dispensing practices, in practices with low income populations, in single handed practices, and in practices without a GP trainer. They were also significantly more likely to see drug company representatives more frequently, to prescribe newly available drugs more freely, to prescribe more readily to patients who expect a prescription, to report high levels of frustration from lack of time in the consultation, to find unsatisfactory those consultations which ended in advice only, and to express dissatisfaction with their review methods for repeat prescribing. They were significantly less likely to find useful criticism of prescribing habits by colleagues, and to check the BNF rather than other sources when uncertain about an aspect of drug treatment. While they cannot be held to have a causal relationship, the pattern of attitudes towards prescribing of GPs in the highest quintile of prescribing costs provide the basis for developing an educational intervention which may be an acceptable method of modifying the attitudes of GPs and consequently reducing their prescribing costs.

Patient, Physician and Organizational Influences on Variation in Antipsychotic Prescribing Behavior

PubMed Central

Tang, Yan; Chang, Chung-Chou H.; Lave, Judith R.; Gellad, Walid F.; Huskamp, Haiden A.; Donohue, Julie M.

2016-01-01

Background Physicians face the choice of multiple ingredients when prescribing drugs in many therapeutic categories. For conditions with considerable patient heterogeneity in treatment response, customizing treatment to individual patient needs and preferences may improve outcomes. Aims of the Study To assess variation in the diversity of antipsychotic prescribing for mental health conditions, a necessary although not sufficient condition for personalizing treatment. To identify patient caseload, physician, and organizational factors associated with the diversity of antipsychotic prescribing. Methods Using 2011 data from Pennsylvania’s Medicaid program, IMS Health’s HCOS™ database, and the AMA Masterfile, we identified 764 psychiatrists who prescribed antipsychotics to ≥10 patients. We constructed three physician-level measures of diversity/concentration of antipsychotic prescribing: number of ingredients prescribed, share of prescriptions for most preferred ingredient, and Herfindahl-Hirschman index (HHI). We used multiple membership linear mixed models to examine patient caseload, physician, and healthcare organizational predictors of physician concentration of antipsychotic prescribing. Results There was substantial variability in antipsychotic prescribing concentration among psychiatrists, with number of ingredients ranging from 2-17, share for most preferred ingredient from 16%-85%, and HHI from 1,088-7,270. On average, psychiatrist prescribing behavior was relatively diversified; however, 11% of psychiatrists wrote an average of 55% of their prescriptions for their most preferred ingredient. Female prescribers and those with smaller shares of disabled or serious mental illness patients had more concentrated prescribing behavior on average. Discussion Antipsychotic prescribing by individual psychiatrists in a large state Medicaid program varied substantially across psychiatrists. Our findings illustrate the importance of understanding physicians’ prescribing behavior and indicate that even among specialties regularly prescribing a therapeutic category, some physicians rely heavily on a small number of agents. Implications for Health Policies, Health Care Provision and Use Health systems may need to offer educational interventions to clinicians in order to improve their ability to tailor treatment decisions to the needs of individual patients. Implications for Future Research Future studies should examine the impact of the diversity of antipsychotic prescribing to determine whether more diversified prescribing improves patient adherence and outcomes. PMID:27084793

The prescriber as moralist: values in the antidepressant debate.

PubMed

Scheurich, Neil

2006-01-01

The past decade has seen a growing debate about the expanding use of psychotropic medications. Of particular concern are current antidepressants, as well as hypothetical "mood brighteners" that could modify affect and behavior in people heretofore classified as being within the normal range. This paper argues that objections to such pharmacologic applications are based on appeals to cultural values--authenticity, diversity, inwardness, and stoicism among others--that are viewed as being under increasing threat in contemporary American culture. Critiques of mood brighteners, like critiques of technological, consumer-driven culture, repudiate the ideals of shallow satisfaction and of the self as commodity. The decision to prescribe or not to prescribe a psychotropic medication in any given case is based on cultural values as well as clinical judgment.

Cost-effectiveness of point-of-care C-reactive protein testing to inform antibiotic prescribing decisions

PubMed Central

Oppong, Raymond; Jit, Mark; Smith, Richard D; Butler, Christopher C; Melbye, Hasse; Mölstad, Sigvard; Coast, Joanna

2013-01-01

Background Point-of-care C-reactive protein (POCCRP) is a biomarker of inflammation that offers clinicians a rapid POC test to guide antibiotic prescribing decisions for acute cough and lower respiratory tract infections (LRTI). However, evidence that POCCRP is cost-effective is limited, particularly outside experimental settings. Aim To assess the cost-effectiveness of POCCRP as a diagnostic tool for acute cough and LRTI from the perspective of the health service. Design and setting Observational study of the presentation, management, and outcomes of patients with acute cough and LRTI in primary care settings in Norway and Sweden. Method Using hierarchical regression, data were analysed in terms of the effect on antibiotic use, cost, and patient outcomes (symptom severity after 7 and 14 days, time to recovery, and EQ-5D), while controlling for patient characteristics (self-reported symptom severity, comorbidities, and health-related quality of life) at first attendance. Results POCCRP testing is associated with non-significant positive reductions in antibiotic prescribing (P = 0.078) and increased cost (P = 0.092). Despite the uncertainty, POCCRP testing is also associated with a cost per quality-adjusted life year (QALY) gain of €9391. At a willingness-to-pay threshold of €30 000 per QALY gained, there is a 70% probability of CRP being cost-effective. Conclusion POCCRP testing is likely to provide a cost-effective diagnostic intervention both in terms of reducing antibiotic prescribing and in terms of QALYs gained. PMID:23834883

Best practice strategies to safeguard drug prescribing and drug administration: an anthology of expert views and opinions.

PubMed

Seidling, Hanna M; Stützle, Marion; Hoppe-Tichy, Torsten; Allenet, Benoît; Bedouch, Pierrick; Bonnabry, Pascal; Coleman, Jamie J; Fernandez-Llimos, Fernando; Lovis, Christian; Rei, Maria Jose; Störzinger, Dominic; Taylor, Lenka A; Pontefract, Sarah K; van den Bemt, Patricia M L A; van der Sijs, Heleen; Haefeli, Walter E

2016-04-01

While evidence on implementation of medication safety strategies is increasing, reasons for selecting and relinquishing distinct strategies and details on implementation are typically not shared in published literature. We aimed to collect and structure expert information resulting from implementing medication safety strategies to provide advice for decision-makers. Medication safety experts with clinical expertise from thirteen hospitals throughout twelve European and North American countries shared their experience in workshop meetings, on-site-visits and remote structured interviews. We performed an expert-based, in-depth assessment of implementation of best-practice strategies to improve drug prescribing and drug administration. Workflow, variability and recommended medication safety strategies in drug prescribing and drug administration processes. According to the experts, institutions chose strategies that targeted process steps known to be particularly error-prone in the respective setting. Often, the selection was channeled by local constraints such as the e-health equipment and critically modulated by national context factors. In our study, the experts favored electronic prescribing with clinical decision support and medication reconciliation as most promising interventions. They agreed that self-assessment and introduction of medication safety boards were crucial to satisfy the setting-specific differences and foster successful implementation. While general evidence for implementation of strategies to improve medication safety exists, successful selection and adaptation of a distinct strategy requires a thorough knowledge of the institute-specific constraints and an ongoing monitoring and adjustment of the implemented measures.

Understanding the culture of antimicrobial prescribing in agriculture: a qualitative study of UK pig veterinary surgeons

PubMed Central

Coyne, L. A.; Latham, S. M.; Williams, N. J.; Dawson, S.; Donald, I. J.; Pearson, R. B.; Smith, R. F.; Pinchbeck, G. L.

2016-01-01

Objectives The use of antimicrobials in food-producing animals has been linked with the emergence of antimicrobial resistance in bacterial populations, with consequences for animal and public health. This study explored the underpinning drivers, motivators and reasoning behind prescribing decisions made by veterinary surgeons working in the UK pig industry. Methods A qualitative interview study was conducted with 21 veterinary surgeons purposively selected from all UK pig veterinary surgeons. Thematic analysis was used to analyse transcripts. Results Ensuring optimum pig health and welfare was described as a driver for antimicrobial use by many veterinary surgeons and was considered a professional and moral obligation. Veterinary surgeons also exhibited a strong sense of social responsibility over the need to ensure that antimicrobial use was responsible. A close relationship between management practices, health and economics was evident, with improvements in management commonly identified as being potential routes to reduce antimicrobial usage; however, these were not always considered economically viable. The relationship with clients was identified as being a source of professional stress for practitioners due to pressure from farmers requesting antimicrobial prescriptions, and concern over poor compliance of antimicrobial administration by some farmers. Conclusions The drivers behind prescribing decisions by veterinary surgeons were complex and diverse. A combination of education, improving communication between veterinary surgeons and farmers, and changes in regulations, in farm management and in consumer/retailer demands may all be needed to ensure that antimicrobial prescribing is optimal and to achieve significant reductions in use. PMID:27516473

Clinical, social and relational determinants of paediatric ambulatory drug prescriptions due to respiratory tract infections in Italy.

PubMed

Ciofi degli Atti, Marta Luisa; Massari, Marco; Bella, Antonino; Boccia, Delia; Filia, Antonietta; Salmaso, Stefania

2006-12-01

Collecting information on patterns of drug prescriptions and on factors influencing prescribing decisions is fundamental for supporting the rational use of drugs. This study was aimed at investigating patterns of drug prescription in paediatric outpatients and at evaluating determinants of prescriptions for respiratory tract infections (RTIs). We conducted a national cross-sectional survey involving primary care paediatricians and parents. Diagnoses and prescriptions made at each consultation were described. Poisson regression models were used to analyse determinants of drug and antibiotic prescriptions for visits due to RTIs. A total of 4,302 physician and parent questionnaires were analysed. These corresponded to 2,151 visits, 792 of which were due to RTIs. Drugs were prescribed in 83.4% of RTI visits, while antibiotics were prescribed in 40.4%. According to paediatricians' perceptions, 84.2% of parents of children with a RTI expected to receive a drug prescription. Paediatricians' perception of parental expectations was the strongest determinant for prescription of drugs and specifically of antibiotics [adjusted relative risk (RR): 1.7 and 3.6, respectively; P < 0.001]. However, in 77.1% of RTI visits, paediatricians judged themselves as not being influenced at all by parents' expectations in their decision to prescribe. This study underscores that relational factors, in particular perceived parental expectations, are one of the leading factors of drug prescriptions in paediatric ambulatory care settings, reinforcing the opinion that communication between physicians and parents can affect prescription patterns.

Efficacy of prokinetic agents in improving bowel preparation for colonoscopy.

PubMed

Mishima, Yuko; Amano, Yuji; Okita, Koichi; Takahashi, Yoshiko; Moriyama, Nobuyuki; Ishimura, Norihisa; Furuta, Kenji; Ishihara, Shunji; Adachi, Kyoichi; Kinoshita, Yoshikazu

2008-01-01

Colonoscopy plays an important role in the diagnosis and treatment of gastrointestinal illness in both Western countries and Japan. However, preparative bowel cleansing for colonoscopy is frequently troublesome for elderly and/or constipated patients, since they must drink larger volumes of lavage solution for adequate cleansing. We investigated the use of prokinetic agents for improving the efficacy and tolerability of bowel cleansing prior to colonoscopy. 613 patients were divided into two groups according to oral lavage solution used (polyethylene glycol or magnesium citrate), and were further randomized to receive either vehicle (100 ml water) alone, vehicle with 5 mg mosapride citrate, or vehicle with 50 mg itopride hydrochloride 30 min before administration of lavage solution. Experimental parameters included bowel cleansing quality, times to first defecation and completion of bowel cleansing, and incidence of uncomfortable abdominal symptoms during colonoscopy preparation. Administration of mosapride citrate or itopride hydrochloride prior to oral lavage solution did not significantly improve bowel cleansing quality. However, statistically significantly fewer uncomfortable abdominal symptoms were found in patients who received mosapride citrate or itopride hydrochloride versus vehicle alone. Prokinetic agents effectively decreased the incidence of uncomfortable abdominal symptoms experienced during colonoscopy preparation. Copyright 2008 S. Karger AG, Basel.

A comparative study on the effects of systemic manual acupuncture, periauricular electroacupuncture, and digital electroacupuncture to treat tinnitus: A randomized, paralleled, open-labeled exploratory trial.

PubMed

Kim, Bong Hyun; Kim, Kyuseok; Nam, Hae Jeong

2017-01-31

Many previous studies of electroacupuncture used combined therapy of electroacupuncture and systemic manual acupuncture, so it was uncertain which treatment was effective. This study evaluated and compared the effects of systemic manual acupuncture, periauricular electroacupuncture and distal electroacupuncture for treating patients with tinnitus. A randomized, parallel, open-labeled exploratory trial was conducted. Subjects aged 20-75 years who had suffered from idiopathic tinnitus for > 2 weeks were recruited from May 2013 to April 2014. The subjects were divided into three groups by systemic manual acupuncture group (MA), periauricular electroacupuncture group (PE), and distal electroacupuncture group (DE). The groups were selected by random drawing. Nine acupoints (TE 17, TE21, SI19, GB2, GB8, ST36, ST37, TE3 and TE9), two periauricular acupoints (TE17 and TE21), and four distal acupoints (TE3, TE9, ST36, and ST37) were selected. The treatment sessions were performed twice weekly for a total of eight sessions over 4 weeks. Outcomes were the tinnitus handicap inventory (THI) score and the loud and uncomfortable visual analogue scales (VAS). Demographic and clinical characteristics of all participants were compared between the groups upon admission using one-way analysis of variance (ANOVA). One-way ANOVA was used to evaluate the THI, VAS loud , and VAS uncomfortable scores. The least significant difference test was used as a post-hoc test. Thirty-nine subjects were eligible and their data were analyzed. No difference in THI and VAS loudness scores was observed in between groups. The VAS uncomfortable scores decreased significantly in MA and DE compared with those in PE. Within the group, all three treatments showed some effect on THI, VAS loudness scores and VAS uncomfortable scores after treatment except DE in THI. There was no statistically significant difference between systemic manual acupuncture, periauricular electroacupuncture and distal electroacupuncture in tinnitus. However, all three treatments had some effect on tinnitus within the group before and after treatment. Systemic manual acupuncture and distal electroacupuncture have some effect on VAS uncomfortable . KCT0001991 by CRIS (Clinical Research Information Service), 2016-8-1, retrospectively registered.

Risk perceptions and behavioral context: U.S. Forest Service fire management professionals

USGS Publications Warehouse

Taylor, Jonathan G.; Carpenter, Edwin H.; Cortner, Hanna J.; Cleaves, David A.

1989-01-01

Fire managers from the U.S. Forest Service were surveyed to determine which decision factors most strongly influenced their fire‐risk decisions. Safety, the resources at risk, public opinion, and the reliability of information were important influences on these decisions. This research allowed direct comparison between fire managers’ perceptions of factor importance and how their fire‐risk decisions changed in response to those factors. These risk decisions were highly responsive to changes in context (an escaped wildfire decision versus a prescribed burning decision) as well as to changing factors. The results demonstrate the utility of using scenarios in risk research and the vital importance of context in studying risk‐taking behavior. Research which attempts to remove risk decisions from their real‐world context may well distort the nature of risk‐taking behavior.

Decision making in venous thromboembolism prophylaxis: Is LWMH being inappropriately withheld from patients admitted with chronic liver disease?

PubMed

Lau, Clement; Burd, Christian; Abeles, Daniel; Sherman, David

2015-02-01

Although chronic liver disease (CLD) constitutes a significant proportion of acute medical admissions, it is not known how CLD influences venous thromboembolism (VTE) prophylaxis decision making and low molecular weight heparin (LMWH) prescription. Furthermore, recent evidence suggests that VTE risk has been underestimated in CLD and that prophylactic LMWH is safe and may improve outcome in this patient group. We therefore evaluated VTE prophylaxis in patients with CLD and aimed to determine the factors contributing to decisions to prescribe LMWH. Prescription of LMWH was significantly less likely in CLD patients than in general medical patients (29% vs 55%; p < 0.01). Patients with CLD who were prescribed LMWH were more likely to have been admitted for a 'non-liver' reason than those that did not receive LMWH (19% vs 52%; p < 0.01). These preliminary results show that many patients admitted with CLD, who may benefit from LMWH prophylaxis, do not receive this therapy, because of perceived contraindications for which there may be little evidence. Decision making appears to be affected by whether an admission is 'liver' or 'non-liver' related. Prophylactic LMWH was safe in this small cohort. Further studies are warranted to further inform LMWH prescription in CLD. © 2015 Royal College of Physicians.

Personalized Approaches to Clopidogrel Therapy: Are We There Yet?

PubMed Central

Anderson, Christopher D.; Biffi, Alessandro; Greenberg, Steven M.; Rosand, Jonathan

2010-01-01

Clopidogrel is one of the most commonly prescribed medications world-wide. Recent advisories from the US Food and Drug Administration (FDA) have drawn attention to the possibility of personalized decision-making for individuals who are candidates for clopidogrel. As is the case with antihypertensives, statins and warfarin, common genetic sequence variants can influence clopidogrel metabolism and its effect on platelet activity. These genetic variants have, in multiple studies, been associated with adverse clinical outcomes. Concurrent medication use also influences the body's handling of clopidogrel. Proton pump inhibitors, widely prescribed in conjunction with clopidogrel, may blunt its effectiveness. We address implications for bedside decision-making in light of accumulated data and current FDA advisories, and conclude that genetic testing for CYP2C19 genotype and limitation of PPI interactions do not yet appear to offer an opportunity to optimize treatment given the current state of knowledge. PMID:21030701

Barriers and facilitators to implementing electronic prescription: a systematic review of user groups' perceptions.

PubMed

Gagnon, Marie-Pierre; Nsangou, Édith-Romy; Payne-Gagnon, Julie; Grenier, Sonya; Sicotte, Claude

2014-01-01

We conducted a systematic review identifying users groups' perceptions of barriers and facilitators to implementing electronic prescription (e-prescribing) in primary care. We included studies following these criteria: presence of an empirical design, focus on the users' experience of e-prescribing implementation, conducted in primary care, and providing data on barriers and facilitators to e-prescribing implementation. We used the Donabedian logical model of healthcare quality (adapted by Barber et al) to analyze our findings. We found 34 publications (related to 28 individual studies) eligible to be included in this review. These studies identified a total of 594 elements as barriers or facilitators to e-prescribing implementation. Most user groups perceived that e-prescribing was facilitated by design and technical concerns, interoperability, content appropriate for the users, attitude towards e-prescribing, productivity, and available resources. This review highlights the importance of technical and organizational support for the successful implementation of e-prescribing systems. It also shows that the same factor can be seen as a barrier or a facilitator depending on the project's own circumstances. Moreover, a factor can change in nature, from a barrier to a facilitator and vice versa, in the process of e-prescribing implementation. This review summarizes current knowledge on factors related to e-prescribing implementation in primary care that could support decision makers in their design of effective implementation strategies. Finally, future studies should emphasize on the perceptions of other user groups, such as pharmacists, managers, vendors, and patients, who remain neglected in the literature.

Changes in antimicrobial prescribing behavior after the introduction of the antimicrobial stewardship program: A pre- and post-intervention survey.

PubMed

Chavada, Ruchir; Walker, Harry N; Tong, Deborah; Murray, Amy

2017-10-02

The introduction of an antimicrobial stewardship (AMS) program is associated with a change in antimicrobial prescribing behavior. A proposed mechanism for this change is by impacting the prescribing etiquette described in qualitative studies. This study sought to detect a change in prescribing attitudes 12 months after the introduction of AMS and gauge utility of various AMS interventions. Surveys were distributed to doctors in two regional Australian hospitals on a convenience basis 6 months before, and 12 months after, the introduction of AMS. Agreement with 20 statements describing attitudes (cultural, behavioral and knowledge) towards antimicrobial prescribing was assessed on a 4-point Likert scale. Mean response scores were compared using the Wilcoxon Rank sum test. 155 responses were collected before the introduction of AMS, and 144 afterwards. After the introduction of AMS, an increase was observed in knowledge about available resources such as electronic decision support systems (EDSS) and therapeutic guidelines, with raised awareness about the support available through AMS rounds and the process to be followed when prescribing restricted antimicrobials. Additionally, doctors were less likely to rely on pharmacy to ascertain when an antimicrobial was restricted, depend on infectious diseases consultant advice and use past experience to guide antimicrobial prescribing. Responses to this survey indicate that positive changes to the antimicrobial prescribing etiquette may be achieved with the introduction of an AMS program. Use of EDSS and other resources such as evidence-based guidelines are perceived to be important to drive rational antimicrobial prescribing within AMS programs.

Hospitalization and pharmacotherapy for borderline personality disorder in a psychiatric emergency service.

PubMed

Pascual, Juan C; Córcoles, David; Castaño, Juan; Ginés, Jose M; Gurrea, Alfredo; Martín-Santos, Rocio; Garcia-Ribera, Carlos; Pérez, Victor; Bulbena, Antonio

2007-09-01

This study aimed to determine factors associated with hospitalization and decisions to prescribe psychotropic medication for patients with borderline personality disorder seeking care at psychiatric emergency units. A total of 11,578 consecutive visits were reviewed over a four-year period at a psychiatric emergency service in a tertiary hospital in Spain. Some patients were repeat visitors. Data collected included sociodemographic, clinical, social, and therapeutic information and the Severity of Psychiatric Illness (SPI) score. Borderline personality disorder was the diagnosis in 1,032 of the visits (9%) to the emergency department, which corresponded to 540 individuals. Of these visits, 11% required hospitalization. Multivariate statistical logistic regression analysis showed that the decision to hospitalize was associated with risk of suicide, danger to others, severity of symptoms, difficulty with self-care, and noncompliance with treatment. The decision to prescribe benzodiazepines was related to male sex, anxiety as the reason for seeking care, little difficulty with self-care, few medical or drug problems, and housing instability. Factors related to the prescription of antipsychotics were male sex, risk of endangering others, and psychosis as the reason for the visit. Factors associated with the prescription of antidepressants were depression as the reason for seeking help and little premorbid dysfunction. Patients with borderline personality disorder had greater clinical severity, but the percentage of hospitalizations was lower than for patients without the disorder. Although a psychiatric emergency service is not the ideal setting to initiate pharmacotherapy, in practice, psychiatrists often prescribe medications in this setting. The SPI was a good tool to assess the severity of illness of these patients.

Development of a Web-Based Clinical Decision Support System for Drug Prescription: Non-Interventional Naturalistic Description of the Antipsychotic Prescription Patterns in 4345 Outpatients and Future Applications.

PubMed

Berrouiguet, Sofian; Barrigón, Maria Luisa; Brandt, Sara A; Ovejero-García, Santiago; Álvarez-García, Raquel; Carballo, Juan Jose; Lenca, Philippe; Courtet, Philippe; Baca-García, Enrique

2016-01-01

The emergence of electronic prescribing devices with clinical decision support systems (CDSS) is able to significantly improve management pharmacological treatments. We developed a web application available on smartphones in order to help clinicians monitor prescription and further propose CDSS. A web application (www.MEmind.net) was developed to assess patients and collect data regarding gender, age, diagnosis and treatment. We analyzed antipsychotic prescriptions in 4345 patients attended in five Psychiatric Community Mental Health Centers from June 2014 to October 2014. The web-application reported average daily dose prescribed for antipsychotics, prescribed daily dose (PDD), and the PDD to defined daily dose (DDD) ratio. The MEmind web-application reported that antipsychotics were used in 1116 patients out of the total sample, mostly in 486 (44%) patients with schizophrenia related disorders but also in other diagnoses. Second generation antipsychotics (quetiapine, aripiprazole and long-acting paliperidone) were preferably employed. Low doses were more frequently used than high doses. Long acting paliperidone and ziprasidone however, were the only two antipsychotics used at excessive dosing. Antipsychotic polypharmacy was used in 287 (26%) patients with classic depot drugs, clotiapine, amisulpride and clozapine. In this study we describe the first step of the development of a web application that is able to make polypharmacy, high dose usage and off label usage of antipsychotics visible to clinicians. Current development of the MEmind web application may help to improve prescription security via momentary feedback of prescription and clinical decision support system.

Development of a Web-Based Clinical Decision Support System for Drug Prescription: Non-Interventional Naturalistic Description of the Antipsychotic Prescription Patterns in 4345 Outpatients and Future Applications

PubMed Central

Berrouiguet, Sofian; Barrigón, Maria Luisa; Brandt, Sara A.; Ovejero-García, Santiago; Álvarez-García, Raquel; Carballo, Juan Jose; Lenca, Philippe; Courtet, Philippe; Baca-García, Enrique

2016-01-01

Purpose The emergence of electronic prescribing devices with clinical decision support systems (CDSS) is able to significantly improve management pharmacological treatments. We developed a web application available on smartphones in order to help clinicians monitor prescription and further propose CDSS. Method A web application (www.MEmind.net) was developed to assess patients and collect data regarding gender, age, diagnosis and treatment. We analyzed antipsychotic prescriptions in 4345 patients attended in five Psychiatric Community Mental Health Centers from June 2014 to October 2014. The web-application reported average daily dose prescribed for antipsychotics, prescribed daily dose (PDD), and the PDD to defined daily dose (DDD) ratio. Results The MEmind web-application reported that antipsychotics were used in 1116 patients out of the total sample, mostly in 486 (44%) patients with schizophrenia related disorders but also in other diagnoses. Second generation antipsychotics (quetiapine, aripiprazole and long-acting paliperidone) were preferably employed. Low doses were more frequently used than high doses. Long acting paliperidone and ziprasidone however, were the only two antipsychotics used at excessive dosing. Antipsychotic polypharmacy was used in 287 (26%) patients with classic depot drugs, clotiapine, amisulpride and clozapine. Conclusions In this study we describe the first step of the development of a web application that is able to make polypharmacy, high dose usage and off label usage of antipsychotics visible to clinicians. Current development of the MEmind web application may help to improve prescription security via momentary feedback of prescription and clinical decision support system. PMID:27764107

Decisions without blinders.

PubMed

Bazerman, Max H; Chugh, Dolly

2006-01-01

By the time Merck withdrew its pain relief drug Vioxx from the market in 2004, more than 100 million prescriptions had been filled in the United States alone. Yet researchers now estimate that Vioxx may have been associated with as many as 25,000 heart attacks and strokes. Evidence of the drug's risks was available as early as 2000, so why did so many doctors keep prescribing it? The answer, say the authors, involves the phenomenon of bounded awareness--when cognitive blinders prevent a person from seeing, seeking, using, or sharing highly relevant, easily accessible, and readily perceivable information during the decision-making process. Doctors prescribing Vioxx, for instance, more often than not received positive feedback from patients. So, despite having access to information about the risks, physicians may have been blinded to the actual extent of the risks. Bounded awareness can occur at three points in the decision-making process. First, executives may fail to see or seek out the important information needed to make a sound decision. Second, they may fail to use the information that they do see because they aren't aware of its relevance. Third, executives may fail to share information with others, thereby bounding the organization's awareness. Drawing on examples such as the Challenger disaster and Citibank's failures in Japan, this article examines what prevents executives from seeing what's right in front of them and offers advice on how to increase awareness. Of course, not every decision requires executives to consciously broaden their focus. Collecting too much information for every decision would waste time and other valuable resources. The key is being mindful. If executives think an error could generate almost irrecoverable damage, then they should insist on getting all the information they need to make a wise decision.

76 FR 60889 - Stephen L. Reitman, M.D.; Decision and Order

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-30

... abated until the late 1990s when he was suffering from cervical stenosis and neck pain. [Tr. 78]. 33. The... with chronic pain. He prescribes Vicodin, codeine, and Darvocet, as well as anti- anxiety medications...

Prescribing Oxygen for Cluster Headache: A Guide for the Provider.

PubMed

Tepper, Stewart J; Duplin, Jessica; Nye, Barbara; Tepper, Deborah E

2017-10-01

Oxygen is the standard of care for acute treatment of cluster headache. CMS, the US Centers for Medicaid and Medicare Services, has made the indefensible decision to not cover oxygen for cluster headache for patients with Medicaid and Medicare insurance, despite the evidence and professional guidelines. Commercial insurance generally covers oxygen for cluster headache. This is a "how-to" guide for successfully prescribing oxygen in the US. Prescription information is provided that can be incorporated as dot phrases, smart sets, or other standard templates for prescribing oxygen for cluster patients. In many states, oxygen is affordable and can be prescribed for Medicaid and Medicare patients who wish to pay cash. Welding or nonmedical grade industrial oxygen is almost the same cost as medical oxygen. However, it is less pure, lacks the same inspection of tanks, and is delivered without regulators to provide appropriate flow rates. Patients who pay cash should be strongly encouraged to buy medical oxygen. © 2017 American Headache Society.

Process versus outcome in hypertension: a positive result.

PubMed

Haynes, R B; Gibson, E S; Taylor, D W; Bernholz, C D; Sackett, D L

1982-01-01

We studied the association between the outcome of antihypertensive care and three items of that care among 230 hypertensive steelworkers who were referred to 83 physicians. The first item was the decision to treat some patients but not others: 63% of the patients were prescribed antihypertensive drugs and the mean decrease in their diastolic blood pressure (DBP) was greater than that among untreated patients (12.2 +/- 0.84 vs 7.8 +/- 0.83 mm Hg [+/- SEM], p less than 0.001). The second item was the vigor of prescribed medication: Patients prescribed more vigorous treatments had lower DBP (p less than 0.005). Third, patient compliance was related to achieving a goal DBP of less than 90 mm Hg (p less than 0.05) and the product of prescribed vigor and compliance was highly associated with DBP response (p less than 0.0001). These results stand in contrast to those of previous studies that failed to detect associations between various other items of the care process and the outcome of antihypertensive care.

Performing the Union: the Prüm Decision and the European dream.

PubMed

Prainsack, Barbara; Toom, Victor

2013-03-01

In 2005, seven European countries signed the so-called Prüm Treaty to increase transnational collaboration in combating international crime, terrorism and illegal immigration. Three years later, the Treaty was adopted into EU law. EU member countries were now obliged to have systems in place to allow authorities of other member states access to nationally held data on DNA, fingerprints, and vehicles by August 2011. In this paper, we discuss the conditions of possibility for the Prüm network to emerge, and argue that rather than a linear ascent towards technological and political convergence and harmonisation, the (hi)story of Prüm is heterogeneous and halting. This is reflected also in the early stages of implementing the Prüm Decision which has proven to be more challenging than it was hoped by the drivers of the Prüm process. In this sense, the Prüm network sits uncomfortably with success stories of forensic science (many of which served the goal of justifying the expansion of technological and surveillance systems). Instead of telling a story of heroic science, the story of Prüm articulates the European dream: one in which goods, services, and people live and travel freely and securely. Copyright © 2012. Published by Elsevier Ltd.

Understanding complex clinical reasoning in infectious diseases for improving clinical decision support design.

PubMed

Islam, Roosan; Weir, Charlene R; Jones, Makoto; Del Fiol, Guilherme; Samore, Matthew H

2015-11-30

Clinical experts' cognitive mechanisms for managing complexity have implications for the design of future innovative healthcare systems. The purpose of the study is to examine the constituents of decision complexity and explore the cognitive strategies clinicians use to control and adapt to their information environment. We used Cognitive Task Analysis (CTA) methods to interview 10 Infectious Disease (ID) experts at the University of Utah and Salt Lake City Veterans Administration Medical Center. Participants were asked to recall a complex, critical and vivid antibiotic-prescribing incident using the Critical Decision Method (CDM), a type of Cognitive Task Analysis (CTA). Using the four iterations of the Critical Decision Method, questions were posed to fully explore the incident, focusing in depth on the clinical components underlying the complexity. Probes were included to assess cognitive and decision strategies used by participants. The following three themes emerged as the constituents of decision complexity experienced by the Infectious Diseases experts: 1) the overall clinical picture does not match the pattern, 2) a lack of comprehension of the situation and 3) dealing with social and emotional pressures such as fear and anxiety. All these factors contribute to decision complexity. These factors almost always occurred together, creating unexpected events and uncertainty in clinical reasoning. Five themes emerged in the analyses of how experts deal with the complexity. Expert clinicians frequently used 1) watchful waiting instead of over- prescribing antibiotics, engaged in 2) theory of mind to project and simulate other practitioners' perspectives, reduced very complex cases into simple 3) heuristics, employed 4) anticipatory thinking to plan and re-plan events and consulted with peers to share knowledge, solicit opinions and 5) seek help on patient cases. The cognitive strategies to deal with decision complexity found in this study have important implications for design future decision support systems for the management of complex patients.

Improving drug-therapy decisions through educational outreach. A randomized controlled trial of academically based "detailing".

PubMed

Avorn, J; Soumerai, S B

1983-06-16

Improving precision and economy in the prescribing of drugs is a goal whose importance has increased with the proliferation of new and potent agents and with growing economic pressures to contain health-care costs. We implemented an office-based physician education program to reduce the excessive use of three drug groups: cerebral and peripheral vasodilators, an oral cephalosporin, and propoxyphene. A four-state sample of 435 prescribers of these drugs was identified through Medicaid records and randomly assigned to one of three groups. Physicians who were offered personal educational visits by clinical pharmacists along with a series of mailed "unadvertisements" reduced their prescribing of the target drugs by 14 per cent as compared with controls (P = 0.0001). A comparable reduction in the number of dollars reimbursed for these drugs was also seen between the two groups, resulting in substantial cost savings. No such change was seen in physicians who received mailed print materials only. The effect persisted for at least nine months after the start of the intervention, and no significant increase in the use of expensive substitute drugs was found. Academically based "detailing" may represent a useful and cost-effective way to improve the quality of drug-therapy decisions and reduce unnecessary expenditures.

Evaluation of Electronic Prescribing Decision Support System at a Tertiary Care Pediatric Hospital: The User Acceptance Perspective.

PubMed

Omar, Abdurahman; Ellenius, Johan; Lindemalm, Synnöve

2017-01-01

This study aims to evaluate pediatrician's acceptance, perception and use of Electronic Prescribing Decision Support Systems (EPDSS) at a tertiary care using Extended Technology Acceptance Model (TAM2). Qualitative research methodology was applied. Semi-structured questions were developed according to TAM2 model. Pediatricians perceived that the EPDSS is useful and they showed a favorable attitude. However, perceived ease of use and output quality appeared to affect use of EPDSS. Concerns were expressed about complicated screens, difficulty to read and view medication overview of the patient, the navigation requires many clicks and medication system don't meet their need. End users have difficulty of ordering drugs for ploy-clinical patients and they were unable to cancel or stop medications. Junior pediatricians were influenced by senior colleague since they can get better advice about medication order than the system. Applying TAM2 framework has revealed that pediatrician's attitude and acceptance of electronic prescribing system. This study has identified factors that are important for end user acceptance as well as suggestions for system improvement. Although pediatricians are positive to the usefulness of EPDSS, it appears there are some acceptance problems due to ease of use concern and usability issues of the system.

Understanding the culture of antimicrobial prescribing in agriculture: a qualitative study of UK pig veterinary surgeons.

PubMed

Coyne, L A; Latham, S M; Williams, N J; Dawson, S; Donald, I J; Pearson, R B; Smith, R F; Pinchbeck, G L

2016-11-01

The use of antimicrobials in food-producing animals has been linked with the emergence of antimicrobial resistance in bacterial populations, with consequences for animal and public health. This study explored the underpinning drivers, motivators and reasoning behind prescribing decisions made by veterinary surgeons working in the UK pig industry. A qualitative interview study was conducted with 21 veterinary surgeons purposively selected from all UK pig veterinary surgeons. Thematic analysis was used to analyse transcripts. Ensuring optimum pig health and welfare was described as a driver for antimicrobial use by many veterinary surgeons and was considered a professional and moral obligation. Veterinary surgeons also exhibited a strong sense of social responsibility over the need to ensure that antimicrobial use was responsible. A close relationship between management practices, health and economics was evident, with improvements in management commonly identified as being potential routes to reduce antimicrobial usage; however, these were not always considered economically viable. The relationship with clients was identified as being a source of professional stress for practitioners due to pressure from farmers requesting antimicrobial prescriptions, and concern over poor compliance of antimicrobial administration by some farmers. The drivers behind prescribing decisions by veterinary surgeons were complex and diverse. A combination of education, improving communication between veterinary surgeons and farmers, and changes in regulations, in farm management and in consumer/retailer demands may all be needed to ensure that antimicrobial prescribing is optimal and to achieve significant reductions in use. © The Author 2016. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.

Electronic information and clinical decision support for prescribing: state of play in Australian general practice

PubMed Central

Robertson, Jane; Moxey, Annette J; Newby, David A; Gillies, Malcolm B; Williamson, Margaret; Pearson, Sallie-Anne

2011-01-01

Background. Investments in eHealth worldwide have been mirrored in Australia, with >90% of general practices computerized. Recent eHealth incentives promote the use of up to date electronic information sources relevant to general practice with flexibility in mode of access. Objective. To determine GPs’ access to and use of electronic information sources and computerized clinical decision support systems (CDSSs) for prescribing. Methods. Semi-structured interviews were conducted with 18 experienced GPs and nine GP trainees in New South Wales, Australia in 2008. A thematic analysis of interview transcripts was undertaken. Results. Information needs varied with clinical experience, and people resources (specialists, GP peers and supervisors for trainees) were often preferred over written formats. Experienced GPs used a small number of electronic resources and accessed them infrequently. Familiarity from training and early clinical practice and easy access were dominant influences on resource use. Practice time constraints meant relevant information needed to be readily accessible during consultations, requiring integration or direct access from prescribing software. Quality of electronic resource content was assumed and cost a barrier for some GPs. Conclusions. The current Australian practice incentives do not prescribe which information resources GPs should use. Without integration into practice computing systems, uptake and routine use seem unlikely. CDSS developments must recognize the time pressures of practice, preference for integration and cost concerns. Minimum standards are required to ensure that high-quality information resources are integrated and regularly updated. Without standards, the anticipated benefits of computerization on patient safety and health outcomes will be uncertain. PMID:21109619

Socket Interface Pressure and Amputee Reported Outcomes for Comfortable and Uncomfortable Conditions of Patellar Tendon Bearing Socket: A Pilot Study.

PubMed

Safari, Mohammad Reza; Tafti, Nahid; Aminian, Gholamreza

2015-01-01

The objectives of the current study were to compare intra-socket pressure differences between comfortable and uncomfortable socket conditions, and the usefulness of subject perception of satisfaction, activity limitations, and socket comfort in distinguishing between these two socket conditions. Five unilateral trans-tibial amputees took part in the study. They answered the Socket Comfort Score (SCS) and Trinity Amputation and Prosthetic Experience Scale (TAPES) questionnaires before the interface pressure (in standing and walking) was measured for the uncomfortable socket condition at five regions of the residual limb. Participants were then provided with a comfortable socket and wore it for two weeks. Participants who were satisfied with the socket fit after two weeks repeated the SCS and TAPES questionnaires and interface pressure measurements. The differences between the test results of the two conditions were not statistically significant, except for the interface pressure at the popliteal region during the early stance phase, TAPES socket fit subscale, and the SCS. Due to large variability of the data and the lack of statistical significance, no firm conclusion can be made on the possible relationship between the interface pressure values and the patient-reported outcomes of the two socket conditions. A larger sample size and longer acclimation period are required to locate significant differences.

Usability evaluation of pharmacogenomics clinical decision support aids and clinical knowledge resources in a computerized provider order entry system: a mixed methods approach.

PubMed

Devine, Emily Beth; Lee, Chia-Ju; Overby, Casey L; Abernethy, Neil; McCune, Jeannine; Smith, Joe W; Tarczy-Hornoch, Peter

2014-07-01

Pharmacogenomics (PGx) is positioned to have a widespread impact on the practice of medicine, yet physician acceptance is low. The presentation of context-specific PGx information, in the form of clinical decision support (CDS) alerts embedded in a computerized provider order entry (CPOE) system, can aid uptake. Usability evaluations can inform optimal design, which, in turn, can spur adoption. The study objectives were to: (1) evaluate an early prototype, commercial CPOE system with PGx-CDS alerts in a simulated environment, (2) identify potential improvements to the system user interface, and (3) understand the contexts under which PGx knowledge embedded in an electronic health record is useful to prescribers. Using a mixed methods approach, we presented seven cardiologists and three oncologists with five hypothetical clinical case scenarios. Each scenario featured a drug for which a gene encoding drug metabolizing enzyme required consideration of dosage adjustment. We used Morae(®) to capture comments and on-screen movements as participants prescribed each drug. In addition to PGx-CDS alerts, 'Infobutton(®)' and 'Evidence' icons provided participants with clinical knowledge resources to aid decision-making. Nine themes emerged. Five suggested minor improvements to the CPOE user interface; two suggested presenting PGx information through PGx-CDS alerts using an 'Infobutton' or 'Evidence' icon. The remaining themes were strong recommendations to provide succinct, relevant guidelines and dosing recommendations of phenotypic information from credible and trustworthy sources; any more information was overwhelming. Participants' median rating of PGx-CDS system usability was 2 on a Likert scale ranging from 1 (strongly agree) to 7 (strongly disagree). Usability evaluation results suggest that participants considered PGx information important for improving prescribing decisions; and that they would incorporate PGx-CDS when information is presented in relevant and useful ways. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Barriers and facilitators of evidence-based management of patients with bacterial infections among general dental practitioners: a theory-informed interview study.

PubMed

Newlands, Rumana; Duncan, Eilidh M; Prior, Maria; Elouafkaoui, Paula; Elders, Andrew; Young, Linda; Clarkson, Jan E; Ramsay, Craig R

2016-01-29

General dental practitioners (GDPs) regularly prescribe antibiotics to manage dental infections although most infections can be treated successfully by local measures. Published guidance to support GDPs to make appropriate prescribing decisions exists but there continues to be wide variation in dental antibiotic prescribing. An interview study was conducted as part of the Reducing Antibiotic Prescribing in Dentistry (RAPiD) trial to understand the barriers and facilitators of using local measures instead of prescribing antibiotics to manage bacterial infections. Thirty semi-structured one-to-one telephone interviews were conducted using the Theoretical Domains Framework (TDF). Responses were coded into domains of the TDF and sub-themes. Priority domains (high frequency: ≥50 % interviewees discussed) relevant to behaviour change were identified as targets for future intervention efforts and mapped onto 'intervention functions' of the Behaviour Change Wheel system. Five domains (behavioural regulation, social influences, reinforcement, environmental context and resources, and beliefs about consequences) with seven sub-themes were identified as targets for future intervention. All participants had knowledge about the evidence-based management of bacterial infections, but they reported difficulties in following this due to patient factors and time management. Lack of time was found to significantly influence their decision processes with regard to performing local measures. Beliefs about their capabilities to overcome patient influence, beliefs that performing local measures would impact on subsequent appointment times as well as there being no incentives for performing local measures were also featured. Though no knowledge or basic skills issues were identified, the participants suggested some continuous professional development programmes (e.g. time management, an overview of published guidance) to address some of the barriers. The domain results suggest a number of intervention functions through which future interventions could change GDPs' antibiotic prescribing for bacterial infections: imparting skills through training, providing an example for GDPs to imitate (i.e. modelling) or creating the expectation of a reward (i.e. incentivisation). This is the first theoretically informed study to identify barriers and facilitators of evidence-based management of patients with bacterial infections among GDPs. A pragmatic approach is needed to address the modifiable barriers in future interventions intended to change dentists' inappropriate prescribing behaviour.

A systematic review of the effectiveness of interruptive medication prescribing alerts in hospital CPOE systems to change prescriber behavior and improve patient safety.

PubMed

Page, N; Baysari, M T; Westbrook, J I

2017-09-01

To assess the evidence of the effectiveness of different categories of interruptive medication prescribing alerts to change prescriber behavior and/or improve patient outcomes in hospital computerized provider order entry (CPOE) systems. PubMed, Embase, CINAHL and the Cochrane Library were searched for relevant articles published between January 2000 and February 2016. Studies were included if they compared the outcomes of automatic, interruptive medication prescribing alert/s to a control/comparison group to determine alert effectiveness. Twenty-three studies describing 32 alerts classified into 11 alert categories were identified. The most common alert categories studied were drug-condition interaction (n=6), drug-drug interaction alerts (n=6) and corollary order alerts (n=6). All 23 papers investigated the effect of the intervention alert on at least one outcome measure of prescriber behavior. Just over half of the studies (53%, n=17) reported a statistically significant beneficial effect from the intervention alert; 34% (n=11) reported no statistically significant effect, and 6% (n=2) reported a significant detrimental effect. Two studies also evaluated the effect of alerts on patient outcome measures; neither finding that patient outcomes significantly improved following alert implementation (6%, n=2). The greatest volume of evidence relates to three alert categories: drug-condition, drug-drug and corollary order alerts. Of these, drug-condition alerts had the greatest number of studies reporting positive effects (five out of six studies). Only two of six studies of drug-drug interaction and one of six of corollary alerts reported positive benefits. The current evidence-base does not show a clear indication that particular categories of alerts are more effective than others. While the majority of alert categories were shown to improve outcomes in some studies, there were also many cases where outcomes did not improve. This lack of evidence hinders decisions about the amount and type of decision support that should be integrated into CPOE systems to increase safety while reducing the risk of alert fatigue. Virtually no studies have sought to investigate the impact on changes to prescriber behavior and outcomes overall when alerts from multiple categories are incorporated within the same system. Copyright © 2017 Elsevier B.V. All rights reserved.

[Knowledge of the disease and the advance directives in patients with HIV infection].

PubMed

Miró, Glòria; Pedrol, Enric; Soler, Anna; Serra-Prat, Mateu; Yébenes, Joan Carles; Martínez, Rafael; Capdevila, Josep Antón

2006-04-22

Advanced directives documents (ADD), allow respect and know patient's intentions in health matters, when they are not able by themselves, for decision making. The aim of this study is making a valoration of the knowledgment of this documents in human immunodeficiency virus (HIV) infected patients, as well as their own knowledgment about this patology and possible complications. HIV infected patients controlled in 2 centers (Hospital de Mataró and Hospital de Granollers). Plained interview as a questinonary, that permits evaluate: own knowledge of the patology, received medical information level of satisfaction, patient s medical decision making involving desire, aptitudes in front of different hypothetical health status, and ADD knowledge. Factors associated to both knowledges (patology and ADD) are also evaluated. 74.3% of the interviewed patients, showed a good patology knowledge. This result was associated with: youth, less functional level according to Karnofsky's scale, subjective perception on severity, previous admission at an intensive care unit, chronic hepatopathy, and previous parenteral drugs addiction. In the same way was associated with the negative to depend of mechanical ventilation or another people, and not being uncomfortable talking about this subjects. ADD's knowledge was relationated with the fact of being female (42.0% vs 26.8%; p = 0.024), higher academic formation (55.1% vs 25.5%; p < 0.001) and belief that medical decision making must be done by themselves (78.3% vs 53.6%; p = 0.002). Patology understanding and its complications, may be considered optimal in HIV population. One third of this group, has a good knowledge of ADDs, and is directly relationated with female sex, academic level, and clinical decisions making implication by the patients.

FY 1998 Proposed Rail Improvement Program Supplement Update - Bloomington II

DOT National Transportation Integrated Search

1997-07-01

The purpose of this amendment to the FY 1998 Rail Improvement Program Supplement : is to present an analysis which has been formulated, using prescribed methodology, to assist in an investment decision concerning track rehabilitation and new track co...

ACHIEVING SUSTAINABILITY - FINAL STEPS IN A DYNAMIC DANCE

EPA Science Inventory

Achieving sustainability relies upon adequate metrics to evaluate the environment and guide decisions. Although adequate assessment is important to prescribing remedies, achieving a sustainable environment cannot be delayed. It must be achieved today as well as tomorrow so that t...

77 FR 57133 - T.J. Mcnichol, M.D.; Decision and Order

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-17

... medication as prescribed, and that there is ``no such thing in this clinic * * * of running out of medication. Id. at 14-16. Respondent further explained that ``one of the reasons why we don't run out here'' is...

FY 1998 Proposed Rail Improvement Program Supplement Update - Pontiac

DOT National Transportation Integrated Search

1997-07-01

The purpose of this amendment to the FY 1998 Rail Improvement Program Supplement is to present an analysis which has been formulated, using prescribed methodology, to assist in an investment decision concerning new track construction at the Prairie C...

Associations between statewide prescription drug monitoring program (PDMP) requirement and physician patterns of prescribing opioid analgesics for patients with non-cancer chronic pain.

PubMed

Lin, Hsien-Chang; Wang, Zhi; Boyd, Carol; Simoni-Wastila, Linda; Buu, Anne

2018-01-01

State-level prescription drug monitoring programs (PDMPs) have been implemented in most states. PDMPs enable registered prescribers to obtain real-time information on patients' prescription history to reduce non-medical use of controlled drugs. This study examined whether PDMP implementation and different levels of PDMP requirements were associated with physicians' patterns of prescribing opioid analgesics for patients with non-cancer chronic pain. This is a secondary analysis study using cross-sectional national data. Patients with non-cancer chronic pain from the 2012 National Ambulatory Medical Care Survey were included (weighted N=81,018,131; unweighted N=3295). Heckman two-step selection procedure employing two logistic regressions was used to explore the associations between PDMP requirements and physicians' prescribing behaviors, controlling for physician characteristics, patient characteristics, physician-healthcare system interaction, and physician-patient relationship, guided by the Eisenberg's model of physician decision making. State PDMP implementation status and requirement levels were not associated with physician opioid prescribing for non-cancer chronic pain treatment (p's ranged 0.30-0.32). Patients with Medicare coverage were more likely to be prescribed opioid analgesics than those with private health insurance (OR=1.55, p<0.01). Hispanic patients were less likely to be prescribed opioid analgesics than non-Hispanic white patients (OR=0.61, p<0.05). Findings indicated that the effectiveness of PDMPs on physicians' opioid prescribing tendency for non-cancer chronic pain treatment could not be supported. Policy makers should be aware of the need for redesigning PDMPs regarding requirements and enforcement for prescribers and related stakeholders. Future studies also are needed to identify characteristics contributing to PDMP effectiveness in reducing non-medical use of prescription opioids. Copyright © 2017 Elsevier Ltd. All rights reserved.

Antibiotics in urinary-tract infections. Sustained change in prescribing habits by practice test and self-reflection: a mixed methods before-after study.

PubMed

Kuehlein, T; Goetz, K; Laux, G; Gutscher, A; Szecsenyi, J; Joos, S

2011-06-01

BACKGROUND The German guideline recommends trimethoprim (TMP) for the treatment of uncomplicated lower-urinary-tract infections (uLUTI) in primary care. In the authors' research network, the participating general practitioners (GPs) were asked why they prescribe mostly quinolones instead. The GPs stated the perception of a high rate of therapy failure of TMP and strongly rejected the guideline. OBJECTIVE To examine prescribing behaviour for uLUTI and whether a practice test of TMP might effect a change in prescribing habits. METHODS The study was conducted using observational and qualitative elements. A first focus-group (n=6) assessed reasons for current prescribing behaviour. In a 3-month practice test, patients with uLUTI were prescribed TMP (150 mg twice for 3 days). In a second focus group, the GPs (n=12) were presented with the results of the practice test. RESULTS The first focus group revealed that prescribing was mainly driven by former hospital training and what was perceived as common therapy. GPs felt no need to change a successful regimen. In the practice test, TMP had a success rate of 94% (84 episodes of uLUTI). The second focus group revealed that the practice test had strongly changed opinions in favour of TMP. Self-reflection and ownership of data acquisition were seen as major contributions for change in prescribing. After the test period, TMP remained the antibiotic most often prescribed. CONCLUSION Internal evidence and peer-group opinion are strong determinants for clinical decisions. A self-conducted practice test, together with self-reflection in a peer group, strongly supports the process of change.

Application of prescribing recommendations in older people with reduced kidney function: a cross-sectional study in general practice.

PubMed

Wood, Su; Petty, Duncan; Glidewell, Liz; Raynor, Dk Theo

2018-05-01

Kidney function reduces with age, increasing the risk of harm from increased blood levels of many medicines. Although estimated glomerular filtration rate (eGFR) is reported for prescribing decisions in those aged ≥65 years, creatinine clearance (Cockcroft-Gault) gives a more accurate estimate of kidney function. To explore the extent of prescribing outside recommendations for people aged ≥65 years with reduced kidney function in primary care and to assess the impact of using eGFR instead of creatinine clearance to calculate kidney function. A cross-sectional survey of anonymised prescribing data in people aged ≥65 years from all 80 general practices (70 900 patients) in a north of England former primary care trust. The prevalence of prescribing outside recommendations was analysed for eight exemplar drugs. Data were collected for age, sex, actual weight, serum creatinine, and eGFR. Kidney function as creatinine clearance (Cockcroft-Gault) was calculated using actual body weight and estimated ideal body weight. Kidney function was too low for recommended prescribing in 4-40% of people aged ≥65 years, and in 24-80% of people aged ≥85 years despite more than 90% of patients having recent recorded kidney function results. Using eGFR overestimated kidney function for 3-28% of those aged ≥65 years, and for 13-58% of those aged ≥85 years. Increased age predicted higher odds of having a kidney function estimate too low for recommended prescribing of the study drugs. Prescribing recommendations when kidney function is reduced are not applied for many people aged ≥65 years in primary care. Using eGFR considerably overestimates kidney function for prescribing and, therefore, creatinine clearance (Cockcroft-Gault) should be assessed when prescribing for these people. Interventions are needed to aid prescribers when kidney function is reduced. © British Journal of General Practice 2018.

Brand Name Statin Prescribing in a Resident Ambulatory Practice: Implications for Teaching Cost-Conscious Medicine.

PubMed

Ryskina, Kira L; Pesko, Michael F; Gossey, J Travis; Caesar, Erica Phillips; Bishop, Tara F

2014-09-01

Several national initiatives aim to teach high-value care to residents. While there is a growing body of literature on cost impact of physicians' therapeutic decisions, few studies have assessed factors that influence residents' prescribing practices. We studied factors associated with intensive health care utilization among internal medicine residents, using brand name statin prescribing as a proxy for higher-cost care. We conducted a retrospective, cross-sectional analysis of statin prescriptions by residents at an urban academic internal medicine program, using electronic health record data between July 1, 2010, and June 30, 2011. For 319 encounters by 90 residents, patients were given a brand name statin in 50% of cases. When categorized into quintiles, the bottom quintile of residents prescribed brand name statins in 2% of encounters, while the top quintile prescribed brand name statins in 98% of encounters. After adjusting for potential confounders, including patient characteristics and supervising attending, being in the primary care track was associated with lower odds (odds ratio [OR], 0.38; P  =  .02; 95% confidence interval [CI], 0.16-0.86), and graduating from a medical school with an above-average hospital care intensity index was associated with higher odds of prescribing brand name statins (OR, 1.70; P  =  .049; 95% CI, 1.003-2.88). We found considerable variation in brand name statin prescribing by residents. Medical school attended and residency program type were associated with resident prescribing behavior. Future interventions should raise awareness of these patterns in an effort to teach high-value, cost-conscious care to all residents.

Expectations for antibiotics increase their prescribing: Causal evidence about localized impact.

PubMed

Sirota, Miroslav; Round, Thomas; Samaranayaka, Shyamalee; Kostopoulou, Olga

2017-04-01

Clinically irrelevant but psychologically important factors such as patients' expectations for antibiotics encourage overprescribing. We aimed to (a) provide missing causal evidence of this effect, (b) identify whether the expectations distort the perceived probability of a bacterial infection either in a pre- or postdecisional distortions pathway, and (c) detect possible moderators of this effect. Family physicians expressed their willingness to prescribe antibiotics (Experiment 1, n₁ = 305) or their decision to prescribe (Experiment 2, n₂ = 131) and assessed the probability of a bacterial infection in hypothetical patients with infections either with low or high expectations for antibiotics. Response order of prescribing/probability was manipulated in Experiment 1. Overall, the expectations for antibiotics increased intention to prescribe (Experiment 1, F(1, 301) = 25.32, p < .001, η p ² = .08, regardless of the response order; Experiment 2, odds ratio [OR] = 2.31, and OR = 0.75, Vignettes 1 and 2, respectively). Expectations for antibiotics did not change the perceived probability of a bacterial infection (Experiment 1, F(1, 301) = 1.86, p = .173, η p ² = .01, regardless of the response order; Experiment 2, d = -0.03, and d = +0.25, Vignettes 1 and 2, respectively). Physicians' experience was positively associated with prescribing, but it did not moderate the expectations effect on prescribing. Patients' and their parents' expectations increase antibiotics prescribing, but their effect is localized-it does not leak into the perceived probability of a bacterial infection. Interventions reducing the overprescribing of antibiotics should target also psychological factors. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Legal barriers to effective ecosystem management: exploring linkages between liability, regulations, and prescribed fire.

PubMed

Wonkka, Carissa L; Rogers, William E; Kreuter, Urs P

2015-12-01

Resistance to the use of prescribed fire is strong among many private land managers despite the advantages it offers for maintaining fire-adapted ecosystems. Even managers who are aware of the benefits of using prescribed fire as a management tool avoid using it, citing potential liability as a major reason for their aversion. Recognizing the importance of prescribed fire for ecosystem management and the constraints current statutory schemes impose on its use, several states in the United States have undertaken prescribed burn statutory reform. The stated purpose of these statutory reforms, often called "right to burn" or "prescribed burning" acts, is to encourage prescribed burning for resource protection, public safety, and land management. Our research assessed the consequences of prescribed burn statutory reform by identifying legal incentives and impediments to prescribed fire application for ecosystem restoration and management, as well as fuel reduction. Specifically, we explored the relationship between prescribed burning laws and decisions made by land managers by exploiting a geographic-based natural experiment to compare landowner-prescribed fire use in contiguous counties with different regulations and legal liability standards. Controlling for potentially confounding variables, we found that private landowners in counties with gross negligence liability standards burn significantly more hectares than those in counties with simple negligence standards (F6,72 = 4.16, P = 0.046). There was no difference in hectares burned on private land between counties with additional statutorily mandated regulatory requirements and those requiring only a permit to complete a prescribed burn (F6,72 = 1.42, P = 0.24) or between counties with burn ban exemptions for certified prescribed burn managers and those with no exemptions during burn bans (F6,72 = 1.39, P = 0.24). Lawmakers attempting to develop prescribed burning statutes to promote the safe use of prescribed fire should consider the benefits of lower legal liability standards in conjunction with regulatory requirements that promote safety for those managing forests and rangelands with fire. Moreover, ecologists and land managers might be better prepared and motivated to educate stakeholder groups who influence prescribed fire policies if they are cognizant of the manner in which policy regulations and liability concerns create legal barriers that inhibit the implementation of effective ecosystem management strategies.

Maintenance inhaler preference, attribute importance, and satisfaction in prescribing physicians and patients with asthma, COPD, or asthma–COPD overlap syndrome consulting for routine care

PubMed Central

Ding, Bo; Small, Mark; Scheffel, Gina; Holmgren, Ulf

2018-01-01

Background In respiratory disorders, patient- and physician-perceived satisfaction with the maintenance inhaler device is an important factor driving treatment compliance and outcomes. We examine inhaler preferences in asthma and COPD from patient and physician perspectives, particularly focusing on the relative importance of individual device attributes and patient characteristics guiding inhaler choice. Materials and methods Real-world data from >7,300 patients with asthma, COPD, or asthma–COPD overlap syndrome (ACOS) consulting for routine care were derived from respiratory Disease Specific Programs conducted in Europe, USA, Japan, and China. Outcome variables included current pattern of inhaled maintenance therapy and device type, physician preference, patient-reported device attribute importance, and satisfaction. Results The most commonly prescribed inhalers for maintenance therapy of asthma, COPD, and ACOS were dry powder inhalers (62.8%–88.5% of patients) and pressurized metered dose inhalers (18.9%–35.3% of patients). One-third of physicians stated no preference for maintenance device when prescribing treatment, and less than one-third of patients reported being “extremely satisfied” with any attribute of their device. Instructions being “simple and easy to follow” was the inhaler attribute most commonly selected as important. For approximately one-third of patients across all groups, “ease of use/suitability of inhaler device” was a reason for the prescribing decision, as stated by the physician. Device characteristics were more likely to impact the prescribing decision in older patients (in asthma and COPD; P<0.01) and those with worse disease severity (in COPD; P<0.001). Conclusion A relatively high proportion of physicians had no preference for inhaler type across asthma, COPD, and ACOS. Simplicity of use was the most important inhaler attribute from a patient’s perspective. Physicians appeared to place most importance on ease of use and device suitability when selecting inhalers for older patients and those with more severe disease, particularly in COPD. PMID:29588581

Physicians' perceptions of medical representative visits in Yemen: a qualitative study.

PubMed

Al-Areefi, Mahmoud Abdullah; Hassali, Mohamed Azmi; Ibrahim, Mohamed Izham b Mohamed

2013-08-20

The pharmaceutical industry invests heavily in promotion, and it uses a variety of promotional strategies to influence physicians' prescribing decisions. Within this context, medical representatives (MRs) are the key personnel employed in promoting their products. One significant consequence of the interactions between physicians and medical representatives is a conflict of interests which may contribute to the over prescribing of medications and thus negative effects on patients' health and economics. There is limited detailed information published on the reasons why physicians interact with pharmaceutical representatives. This study aims to qualitatively explore physicians' attitudes about interactions with medical representatives and their reasons for accepting the medical representatives' visits. In-depth interviews were used to gain a better understanding of physicians' perceptions of medical representative visits. A total of 32 physicians from both private and public hospitals were interviewed. The recordings of the interviews were transcribed verbatim and subject to thematic analysis using a framework analysis approach. The present qualitative study found that the majority of the physicians had positive interactions with medical representatives. The physicians' main reasons stated for allowing medical representatives' visits are the social contacts and mutual benefits they will gain from these representatives. They also emphasized that the meeting with representatives provides educational and scientific benefits. A few physicians stated that the main reasons behind refusing the meeting with medical representatives were lack of conviction about the product and obligation to prescribe medicine from the representative company. Most of the physicians believed that they were under marketing pressure to prescribe certain medicines. Although physicians are aware that the medical representatives could influence their prescribing decision, they welcome representatives to visit them and consider receiving free samples, gifts and various kinds of support as a normal practice. The findings provided insight into possible target areas for educational interventions concerning pharmaceutical marketing. Such a finding will provide the basis for policymakers in the public and private health sector in Yemen to develop a suitable policy and regulations in terms of drug promotion.

Investigating and Learning Lessons from Early Experiences of Implementing ePrescribing Systems into NHS Hospitals: A Questionnaire Study

PubMed Central

Cresswell, Kathrin; Coleman, Jamie; Slee, Ann; Williams, Robin; Sheikh, Aziz

2013-01-01

Background ePrescribing systems have significant potential to improve the safety and efficiency of healthcare, but they need to be carefully selected and implemented to maximise benefits. Implementations in English hospitals are in the early stages and there is a lack of standards guiding the procurement, functional specifications, and expected benefits. We sought to provide an updated overview of the current picture in relation to implementation of ePrescribing systems, explore existing strategies, and identify early lessons learned. Methods A descriptive questionnaire-based study, which included closed and free text questions and involved both quantitative and qualitative analysis of the data generated. Results We obtained responses from 85 of 108 NHS staff (78.7% response rate). At least 6% (n = 10) of the 168 English NHS Trusts have already implemented ePrescribing systems, 2% (n = 4) have no plans of implementing, and 34% (n = 55) are planning to implement with intended rapid implementation timelines driven by high expectations surrounding improved safety and efficiency of care. The majority are unclear as to which system to choose, but integration with existing systems and sophisticated decision support functionality are important decisive factors. Participants highlighted the need for increased guidance in relation to implementation strategy, system choice and standards, as well as the need for top-level management support to adequately resource the project. Although some early benefits were reported by hospitals that had already implemented, the hoped for benefits relating to improved efficiency and cost-savings remain elusive due to a lack of system maturity. Conclusions Whilst few have begun implementation, there is considerable interest in ePrescribing systems with ambitious timelines amongst those hospitals that are planning implementations. In order to ensure maximum chances of realising benefits, there is a need for increased guidance in relation to implementation strategy, system choice and standards, as well as increased financial resources to fund local activities. PMID:23335961

Which non-technical skills do junior doctors require to prescribe safely? A systematic review.

PubMed

Dearden, Effie; Mellanby, Edward; Cameron, Helen; Harden, Jeni

2015-12-01

Prescribing errors are a major source of avoidable morbidity and mortality. Junior doctors write most in-hospital prescriptions and are the least experienced members of the healthcare team. This puts them at high risk of error and makes them attractive targets for interventions to improve prescription safety. Error analysis has shown a background of complex environments with multiple contributory conditions. Similar conditions in other high risk industries, such as aviation, have led to an increased understanding of so-called human factors and the use of non-technical skills (NTS) training to try to reduce error. To date no research has examined the NTS required for safe prescribing. The aim of this review was to develop a prototype NTS taxonomy for safe prescribing, by junior doctors, in hospital settings. A systematic search identified 14 studies analyzing prescribing behaviours and errors by junior doctors. Framework analysis was used to extract data from the studies and identify behaviours related to categories of NTS that might be relevant to safe and effective prescribing performance by junior doctors. Categories were derived from existing literature and inductively from the data. A prototype taxonomy of relevant categories (situational awareness, decision making, communication and team working, and task management) and elements was constructed. This prototype will form the basis of future work to create a tool that can be used for training and assessment of medical students and junior doctors to reduce prescribing error in the future. © 2015 The British Pharmacological Society.

A questionnaire-based audit to assess overall experience and convenience among patients using vaginal progesterone tablets (Lutigest®) for luteal phase support during IVF treatment.

PubMed

Heine, Polly; Sellar, Laura; Whitten, Sue; Bajaj, Priti

2017-01-01

The aim of this audit was to assess the overall experience and patient convenience of vaginal progesterone tablets (Lutigest ® , marketed as Endometrin ® in the USA) used for luteal phase support (LPS) during in vitro fertilization (IVF) treatment. This questionnaire-based audit included responses from 100 patients undergoing IVF treatment at six IVF clinics in the UK from September 2015 to November 2016. Fourteen days after starting progesterone supplementation for LPS during their IVF treatment, patients rated overall experience and perceived convenience of the prescribed progesterone by completing a questionnaire. Of the 100 patients included, 96 received vaginal progesterone tablets for LPS. Overall, 53.1% (51/96) indicated that the progesterone tablets were "very easy" to use; 42.7% (41/96) and 44.8% (43/96) found it "very convenient" or "neither convenient or inconvenient" to administer the tablet, respectively. Overall experience with using progesterone tablets was rated as "very comfortable" by 34.4% (33/96) and "neither comfortable or uncomfortable" by 56.3% (54/96) of patients. The applicator was used by 93.8% (90/96) of patients to administer the tablet, and 86.5% (83/96) indicated that the applicator was easy to clean for repeated use. A total of 33 patients had a previous IVF cycle during which they were prescribed vaginal progesterone pessaries for LPS. Compared with progesterone pessaries, the majority found treatment with progesterone tablets to be more comfortable (60.6%; 20/33) and more convenient (57.6%; 19/33) and indicated that the progesterone tablet was their preferred progesterone formulation for LPS (60.6%; 20/33). These findings offer insights into real-world patient experiences with the progesterone vaginal tablet formulation. The results suggest overall patient convenience, ease, and comfort with using progesterone vaginal tablets for LPS. The majority of patients found progesterone vaginal tablets more convenient and comfortable to use compared with progesterone pessaries.

Consultant psychiatrists’ experiences of and attitudes towards shared decision making in antipsychotic prescribing, a qualitative study

PubMed Central

2014-01-01

Background Shared decision making represents a clinical consultation model where both clinician and service user are conceptualised as experts; information is shared bilaterally and joint treatment decisions are reached. Little previous research has been conducted to assess experience of this model in psychiatric practice. The current project therefore sought to explore the attitudes and experiences of consultant psychiatrists relating to shared decision making in the prescribing of antipsychotic medications. Methods A qualitative research design allowed the experiences and beliefs of participants in relation to shared decision making to be elicited. Purposive sampling was used to recruit participants from a range of clinical backgrounds and with varying length of clinical experience. A semi-structured interview schedule was utilised and was adapted in subsequent interviews to reflect emergent themes. Data analysis was completed in parallel with interviews in order to guide interview topics and to inform recruitment. A directed analysis method was utilised for interview analysis with themes identified being fitted to a framework identified from the research literature as applicable to the practice of shared decision making. Examples of themes contradictory to, or not adequately explained by, the framework were sought. Results A total of 26 consultant psychiatrists were interviewed. Participants expressed support for the shared decision making model, but also acknowledged that it was necessary to be flexible as the clinical situation dictated. A number of potential barriers to the process were perceived however: The commonest barrier was the clinician’s beliefs regarding the service users’ insight into their mental disorder, presented in some cases as an absolute barrier to shared decision making. In addition factors external to the clinician - service user relationship were identified as impacting on the decision making process, including; environmental factors, financial constraints as well as societal perceptions of mental disorder in general and antipsychotic medication in particular. Conclusions This project has allowed identification of potential barriers to shared decision making in psychiatric practice. Further work is necessary to observe the decision making process in clinical practice and also to identify means in which the identified barriers, in particular ‘lack of insight’, may be more effectively managed. PMID:24886121

Consultant psychiatrists' experiences of and attitudes towards shared decision making in antipsychotic prescribing, a qualitative study.

PubMed

Shepherd, Andrew; Shorthouse, Oliver; Gask, Linda

2014-05-01

Shared decision making represents a clinical consultation model where both clinician and service user are conceptualised as experts; information is shared bilaterally and joint treatment decisions are reached. Little previous research has been conducted to assess experience of this model in psychiatric practice. The current project therefore sought to explore the attitudes and experiences of consultant psychiatrists relating to shared decision making in the prescribing of antipsychotic medications. A qualitative research design allowed the experiences and beliefs of participants in relation to shared decision making to be elicited. Purposive sampling was used to recruit participants from a range of clinical backgrounds and with varying length of clinical experience. A semi-structured interview schedule was utilised and was adapted in subsequent interviews to reflect emergent themes.Data analysis was completed in parallel with interviews in order to guide interview topics and to inform recruitment. A directed analysis method was utilised for interview analysis with themes identified being fitted to a framework identified from the research literature as applicable to the practice of shared decision making. Examples of themes contradictory to, or not adequately explained by, the framework were sought. A total of 26 consultant psychiatrists were interviewed. Participants expressed support for the shared decision making model, but also acknowledged that it was necessary to be flexible as the clinical situation dictated. A number of potential barriers to the process were perceived however: The commonest barrier was the clinician's beliefs regarding the service users' insight into their mental disorder, presented in some cases as an absolute barrier to shared decision making. In addition factors external to the clinician - service user relationship were identified as impacting on the decision making process, including; environmental factors, financial constraints as well as societal perceptions of mental disorder in general and antipsychotic medication in particular. This project has allowed identification of potential barriers to shared decision making in psychiatric practice. Further work is necessary to observe the decision making process in clinical practice and also to identify means in which the identified barriers, in particular 'lack of insight', may be more effectively managed.

Practical and Constitutional Implications of Legal Advertising.

ERIC Educational Resources Information Center

Gibson, Dirk C.

Recent Supreme Court decisions have fundamentally altered the attorney's right to advertise. This potentially revolutionary revision in prescribed professional communications has paradoxically had ambiguous results. Despite the freedom to advertise, most attorneys forego this opportunity to maximize profits, expand clientele, or merely enhance…

15 CFR 904.200 - Scope and applicability.

Code of Federal Regulations, 2010 CFR

2010-01-01

... administrative decisions of NOAA involving alleged violations of the laws cited in § 904.1(c) and regulations... basis for claiming the right to a hearing but, instead, prescribes procedures for the conduct of hearings, the right to which is provided by other authority. ...

Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.

PubMed

Terrell, Kevin M; Perkins, Anthony J; Hui, Siu L; Callahan, Christopher M; Dexter, Paul R; Miller, Douglas K

2010-12-01

Emergency physicians prescribe several discharge medications that require dosage adjustment for patients with renal disease. The hypothesis for this research was that decision support in a computerized physician order entry system would reduce the rate of excessive medication dosing for patients with renal impairment. This was a randomized, controlled trial in an academic emergency department (ED), in which computerized physician order entry was used to write all prescriptions for patients being discharged from the ED. The sample included 42 physicians who were randomized to the intervention (21 physicians) or control (21 physicians) group. The intervention was decision support that provided dosing recommendations for targeted medications for patients aged 18 years and older when the patient's estimated creatinine clearance level was below the threshold for dosage adjustment. The primary outcome was the proportion of targeted medications that were excessively dosed. For 2,783 (46%) of the 6,015 patient visits, the decision support had sufficient information to estimate the patient's creatinine clearance level. The average age of these patients was 46 years, 1,768 (64%) were women, and 1,523 (55%) were black. Decision support was provided 73 times to physicians in the intervention group, who excessively dosed 31 (43%) prescriptions. In comparison, control physicians excessively dosed a significantly larger proportion of medications: 34 of 46, 74% (effect size=31%; 95% confidence interval 14% to 49%; P=.001). Emergency physicians often prescribed excessive doses of medications that require dosage adjustment for renal impairment. Computerized physician order entry with decision support significantly reduced excessive dosing of targeted medications. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Shared decision making for psychiatric medication management: beyond the micro-social.

PubMed

Morant, Nicola; Kaminskiy, Emma; Ramon, Shulamit

2016-10-01

Mental health care has lagged behind other health-care domains in developing and applying shared decision making (SDM) for treatment decisions. This is despite compatibilities with ideals of modern mental health care such as self-management and recovery-oriented practice, and growing policy-level interest. Psychiatric medication is a mainstay of mental health treatment, but there are known problems with prescribing practices, and service users report feeling uninvolved in medication decisions and concerned about adverse effects. SDM has potential to produce better tailoring of psychiatric medication to individuals' needs. This conceptual review argues that several aspects of mental health care that differ from other health-care contexts (e.g. forms of coercion, questions about service users' insight and disempowerment) may impact on processes and possibilities for SDM. It is therefore problematic to uncritically import models of SDM developed in other health-care contexts. We argue that decision making for psychiatric medication is better understood in a broader way that moves beyond the micro-social focus of a medical consultation. Contextualizing specific medication-related consultations within longer term relationships, and broader service systems enables recognition of the multiple processes, actors and agendas that shape how psychiatric medication is prescribed, managed and used, and which may facilitate or impede SDM. A broad conceptualization of decision making for psychiatric medication that moves beyond the micro-social can account for why SDM in this domain remains a rarity. It has both conceptual and practical utility for evaluating research evidence, identifying future research priorities and highlighting fruitful ways of developing and implementing SDM in mental health care. © 2015 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Patterns of communication in high-fidelity simulation.

PubMed

Anderson, Judy K; Nelson, Kimberly

2015-01-01

High-fidelity simulation is commonplace in nursing education. However, critical thinking, decision making, and psychomotor skills scenarios are emphasized. Scenarios involving communication occur in interprofessional or intraprofessional settings. The importance of effective nurse-patient communication is reflected in statements from the American Nurses Association and Quality and Safety Education for Nurses, and in the graduate outcomes of most nursing programs. This qualitative study examined the patterns of communication observed in video recordings of a medical-surgical scenario with 71 senior students in a baccalaureate program. Thematic analysis revealed patterns of (a) focusing on tasks, (b) communicating-in-action, and (c) being therapeutic. Additional categories under the patterns included missing opportunities, viewing the "small picture," relying on informing, speaking in "medical tongues," offering choices…okay?, feeling uncomfortable, and using therapeutic techniques. The findings suggest the importance of using high-fidelity simulation to develop expertise in communication. In addition, the findings reinforce the recommendation to prioritize communication aspects of scenarios and debriefing for all simulations. Copyright 2015, SLACK Incorporated.

Coping with an unplanned pregnancy.

PubMed

Smolen, B

1993-10-01

A 15-year-old high school student from Johnstown, Pennsylvania, recounted her experience with an unplanned pregnancy. The student learned of her pregnancy by seeking out the help of a neighbor, who was a nurse. Her response to the positive results of the pregnancy test was tears and the fear that her parents would strongly disapprove. Her father's response to the knowledge about the pregnancy was apprehension about whether the baby's father was a drug user. Her mother responded by asking her daughter very personal questions, which created a very uncomfortable situation. Both parents felt hurt by their daughter's behavior and considered that their plans for their daughter's future were spoiled. Evidently, the daughter decided to keep the child, and the parents approved. The family's support helped the daughter through difficult morning sickness and her initial humiliation and secured the baby's future in a loving and caring household. Classmates and teachers also supported her decision to keep her baby. The new mother resumed classes after the birth of her baby and plans to graduate.

Primary Care Providers’ Initial Treatment Decisions and Antidepressant Prescribing for Adolescent Depression

PubMed Central

Radovic, Ana; Farris, Coreen; Reynolds, Kerry; Reis, Evelyn C.; Miller, Elizabeth; Stein, Bradley D.

2014-01-01

OBJECTIVE Adolescent depression is a serious and undertreated public health problem. Nonetheless, pediatric primary care providers (PCPs) may have low rates of antidepressant prescribing due to structural and training barriers. We examined the impact of symptom severity and provider characteristics on initial depression treatment decisions in a setting with fewer structural barriers, an integrated behavioral health network. METHOD We administered a cross sectional survey to 58 PCPs within a large pediatric practice network. We compared PCP reports of initial treatment decisions in response to two vignettes describing depressed adolescents with either moderate or severe symptoms. We measured PCP depression knowledge, attitudes toward addressing psychosocial concerns, demographics, and practice characteristics. RESULTS Few PCPs (25% for moderate, 32% for severe) recommended an antidepressant. Compared with treatment recommendations for moderate depression, severe depression was associated with a greater likelihood of child psychiatry referral (OR 5.50[95% CI 2.47-12.2] p<.001). Depression severity did not affect the likelihood of antidepressant recommendation (OR 1.58[95% CI 0.80-3.11] p=.19). Antidepressants were more likely to be recommended by PCPs with greater depression knowledge (OR 1.72[95% CI 1.14-2.59] p=.009) and access to an on-site mental health provider (OR 5.13[95% CI 1.24-21.2] p=.02) and less likely to be recommended by PCPs who reported higher provider burden when addressing psychosocial concerns (OR 0.85[95% CI 0.75-0.98] p=.02). CONCLUSION PCPs infrequently recommended antidepressants for adolescents, regardless of depression severity. Continued PCP support through experiential training, accounting for provider burden when addressing psychosocial concerns, and co-management with mental health providers may increase PCPs’ antidepressant prescribing. PMID:24336091

Availability and use of essential medicines in China: manufacturing, supply, and prescribing in Shandong and Gansu provinces

PubMed Central

2010-01-01

Background The current health care reform in China launched in 2009 tackles the problem of access to appropriate medicines for its 1.3 billion people by focusing on providing essential medicines to all. To provide evidence for the reform process, we investigated the manufacturing, purchasing, and prescribing of essential medicines in two provinces. Methods We conducted surveys in 2007 of all manufacturers (n = 253) and of 59 purposively selected retail and 63 hospital pharmacies in Shandong and Gansu provinces to assess production and supply of products on the 2004 National Essential Medicines List (NEML), as well as factors underlying decision making about production and supply. We also reviewed prescriptions (n = 5456) in health facilities to calculate standard indicators of appropriate medicines use. Results Overall, manufacturers in Shandong and Gansu produced only 62% and 50%, respectively, of the essential medicines they were licensed to produce. Of a randomly selected 10% of NEML products, retail pharmacies stocked up to 60% of Western products. Median availability in hospital pharmacies ranged from 19% to 69%. Manufacturer and retail pharmacy managers based decisions on medicines production and stocking on economic considerations, while hospital pharmacy managers cited clinical need. Between 64% and 86% of prescriptions contained an essential medicine. However, overprescribing of antibiotics (34%-77% of prescriptions) and injectables (22%-61%) for adult non-infectious outpatient consultations was common. Conclusions We found that manufacturers, retail pharmacies, and hospital pharmacies paid limited attention to China's 2004 NEML in their decisions to manufacture, purchase, and stock essential medicines. We also found that prescribing of essential medicines was frequently inappropriate. These results should inform strategies to improve affordable access to essential medicines under the current health care reform. PMID:20637116

What gives rise to clinician gut feeling, its influence on management decisions and its prognostic value for children with RTI in primary care: a prospective cohort study.

PubMed

Turnbull, Sophie; Lucas, Patricia J; Redmond, Niamh M; Christensen, Hannah; Thornton, Hannah; Cabral, Christie; Blair, Peter S; Delaney, Brendan C; Thompson, Matthew; Little, Paul; Peters, Tim J; Hay, Alastair D

2018-02-05

The objectives were to identify 1) the clinician and child characteristics associated with; 2) clinical management decisions following from, and; 3) the prognostic value of; a clinician's 'gut feeling something is wrong' for children presenting to primary care with acute cough and respiratory tract infection (RTI). Multicentre prospective cohort study where 518 primary care clinicians across 244 general practices in England assessed 8394 children aged ≥3 months and < 16 years for acute cough and RTI. The main outcome measures were: Self-reported clinician 'gut feeling'; clinician management decisions (antibiotic prescribing, referral for acute admission); and child's prognosis (reconsultation with evidence of illness deterioration, hospital admission in the 30 days following recruitment). Clinician years since qualification, parent reported symptoms (illness severity score ≥ 7/10, severe fever < 24 h, low energy, shortness of breath) and clinical examination findings (crackles/ crepitations on chest auscultation, recession, pallor, bronchial breathing, wheeze, temperature ≥ 37.8 °C, tachypnoea and inflamed pharynx) independently contributed towards a clinician 'gut feeling that something was wrong'. 'Gut feeling' was independently associated with increased antibiotic prescribing and referral for secondary care assessment. After adjustment for other associated factors, gut feeling was not associated with reconsultations or hospital admissions. Clinicians were more likely to report a gut feeling something is wrong, when they were more experienced or when children were more unwell. Gut feeling is independently and strongly associated with antibiotic prescribing and referral to secondary care, but not with two indicators of poor child health.

Availability and use of essential medicines in China: manufacturing, supply, and prescribing in Shandong and Gansu provinces.

PubMed

Chen, Wen; Tang, Shenglan; Sun, Jing; Ross-Degnan, Dennis; Wagner, Anita K

2010-07-17

The current health care reform in China launched in 2009 tackles the problem of access to appropriate medicines for its 1.3 billion people by focusing on providing essential medicines to all. To provide evidence for the reform process, we investigated the manufacturing, purchasing, and prescribing of essential medicines in two provinces. We conducted surveys in 2007 of all manufacturers (n = 253) and of 59 purposively selected retail and 63 hospital pharmacies in Shandong and Gansu provinces to assess production and supply of products on the 2004 National Essential Medicines List (NEML), as well as factors underlying decision making about production and supply. We also reviewed prescriptions (n = 5456) in health facilities to calculate standard indicators of appropriate medicines use. Overall, manufacturers in Shandong and Gansu produced only 62% and 50%, respectively, of the essential medicines they were licensed to produce. Of a randomly selected 10% of NEML products, retail pharmacies stocked up to 60% of Western products. Median availability in hospital pharmacies ranged from 19% to 69%. Manufacturer and retail pharmacy managers based decisions on medicines production and stocking on economic considerations, while hospital pharmacy managers cited clinical need. Between 64% and 86% of prescriptions contained an essential medicine. However, overprescribing of antibiotics (34%-77% of prescriptions) and injectables (22%-61%) for adult non-infectious outpatient consultations was common. We found that manufacturers, retail pharmacies, and hospital pharmacies paid limited attention to China's 2004 NEML in their decisions to manufacture, purchase, and stock essential medicines. We also found that prescribing of essential medicines was frequently inappropriate. These results should inform strategies to improve affordable access to essential medicines under the current health care reform.

Variation in minimum desired cardiovascular disease-free longevity benefit from statin and antihypertensive medications: a cross-sectional study of patient and primary care physician perspectives.

PubMed

Jaspers, Nicole E M; Visseren, Frank L J; Numans, Mattijs E; Smulders, Yvo M; van Loenen Martinet, Fere A; van der Graaf, Yolanda; Dorresteijn, Jannick A N

2018-05-26

Expressing therapy benefit from a lifetime perspective, instead of only a 10-year perspective, is both more intuitive and of growing importance in doctor-patient communication. In cardiovascular disease (CVD) prevention, lifetime estimates are increasingly accessible via online decision tools. However, it is unclear what gain in life expectancy is considered meaningful by those who would use the estimates in clinical practice. We therefore quantified lifetime and 10-year benefit thresholds at which physicians and patients perceive statin and antihypertensive therapy as meaningful, and compared the thresholds with clinically attainable benefit. Cross-sectional study. (1) continuing medical education conference in December 2016 for primary care physicians;(2) information session in April 2017 for patients. 400 primary care physicians and 523 patients in the Netherlands. Months gain of CVD-free life expectancy at which lifelong statin therapy is perceived as meaningful, and months gain at which 10 years of statin and antihypertensive therapy is perceived as meaningful. Physicians were framed as users for lifelong and prescribers for 10-year therapy. Meaningful benefit was reported as median (IQR). Meaningful lifetime statin benefit was 24 months (IQR 23-36) in physicians (as users) and 42 months (IQR 12-42) in patients willing to consider therapy. Meaningful 10-year statin benefit was 12 months (IQR 10-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Meaningful 10-year antihypertensive benefit was 12 months (IQR 8-12) for prescribing (physicians) and 14 months (IQR 10-14) for using (patients). Women desired greater benefit than men. Age, CVD status and co-medication had minimal effects on outcomes. Both physicians and patients report a large variation in meaningful longevity benefit. Desired benefit differs between physicians and patients and exceeds what is clinically attainable. Clinicians should recognise these discrepancies when prescribing therapy and implement individualised medicine and shared decision-making. Decision tools could provide information on realistic therapy benefit. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Temporal characteristics of decisions in hospital encounters: a threshold for shared decision making? A qualitative study.

PubMed

Ofstad, Eirik H; Frich, Jan C; Schei, Edvin; Frankel, Richard M; Gulbrandsen, Pål

2014-11-01

To identify and characterize physicians' statements that contained evidence of clinically relevant decisions in encounters with patients in different hospital settings. Qualitative analysis of 50 videotaped encounters from wards, the emergency room (ER) and outpatient clinics in a department of internal medicine at a Norwegian university hospital. Clinical decisions could be grouped in a temporal order: decisions which had already been made, and were brought into the encounter by the physician (preformed decisions), decisions made in the present (here-and-now decisions), and decisions prescribing future actions given a certain course of events (conditional decisions). Preformed decisions were a hallmark in the ward and conditional decisions a main feature of ER encounters. Clinical decisions related to a patient-physician encounter spanned a time frame exceeding the duration of the encounter. While a distribution of decisions over time and space fosters sharing and dilution of responsibility between providers, it makes the decision making process hard to access for patients. In order to plan when and how to involve patients in decisions, physicians need increased awareness of when clinical decisions are made, who usually makes them, and who should make them. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Cardiovascular care guideline implementation in community health centers in Oregon: a mixed-methods analysis of real-world barriers and challenges.

PubMed

Gold, Rachel; Bunce, Arwen; Cowburn, Stuart; Davis, James V; Hollombe, Celine; Nelson, Christine A; Puro, Jon; Muench, John; Hill, Christian; Jaworski, Victoria; Mercer, MaryBeth; Howard, Colleen; Perrin, Nancy; DeVoe, Jennifer

2017-04-05

Spreading effective, guideline-based cardioprotective care quality improvement strategies between healthcare settings could yield great benefits, particularly in under-resourced contexts. Understanding the diverse factors facilitating or impeding such guideline implementation could improve cardiovascular care quality and outcomes for vulnerable patients. We sought to identify multi-level factors affecting uptake of cardioprotective care guidelines in community health centers (CHCs), within a successful trial of cross-setting implementation of an effective intervention. Quantitative analyses used multivariable logistic regression to examine in-person patient encounters at 10 CHCs from June 2011-May 2014. At these encounters, a point-of-care alert flagged adults with diabetes who were clinically indicated for, but not currently prescribed, cardioprotective medications. The main outcome measure was the rate of relevant prescriptions issued within two days of encounters. Qualitative analyses focused on CHC providers and staff, and, guided by the constant comparative method, were used to enhance understanding of the factors that influenced this prescribing. Recommended prescribing occurred at 13-16% of encounters with patients who were indicated for such prescribing. The odds of this prescribing were higher when the patient was male, had HbA1c ≥7, was previously prescribed a similar medication, gave diabetes as the chief complaint, saw a mid-level practitioner, or saw their primary care provider. The odds were lower when the patient was insured, had ≥1 clinic visits in the past year, had kidney disease, or was prescribed certain other medications. Additional factors were associated with prescribing of each medication class. Qualitative results both supported and challenged the quantitative findings, illustrating important tensions involved in guideline-based prescribing. Clinic staff stressed the importance of the provider-patient relationship in guiding prescribing decisions in the face of competing priorities and care needs, and the impact of rapidly changing guidelines. Diverse factors associated with guideline-concordant prescribing illuminate the complexity of delivering evidence-based care in CHCs. We present possible strategies for addressing barriers to guideline-based prescribing. This trial was registered retrospectively. Currently Controlled Trials NCT02299791 . Retrospectively registered 10 November 2014.

Interventions to Improve Suboptimal Prescribing in Nursing Homes: A Narrative Review

PubMed Central

Marcum, Zachary A.; Handler, Steven M.; Wright, Rollin; Hanlon, Joseph T.

2010-01-01

Background Appropriate medication prescribing for nursing home residents remains a challenge. Objective The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes. Methods The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors’ files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents. Results Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention’s impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in ≥1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions. Conclusions Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature. PMID:20624609

Graphical user interface for a neonatal parenteral nutrition decision support system.

PubMed Central

Peverini, R. L.; Beach, D. S.; Wan, K. W.; Vyhmeister, N. R.

2000-01-01

We developed and implemented a decision support system for prescribing parenteral nutrition (PN) solutions for infants in our neonatal intensive care unit. We employed a graphical user interface to provide clinical guidelines and aid the understanding of the interaction among the various ingredients that make up a PN solution. In particular, by displaying the interaction between the PN total solution volume, protein, calcium and phosphorus, we have eliminated PN orders that previously would have resulted in calcium-phosphorus precipitation errors. PMID:11079964

Influence of patient payment on antibiotic prescribing in Irish general practice: a cohort study.

PubMed

Murphy, Marion; Byrne, Stephen; Bradley, Colin P

2011-09-01

Antibiotics are widely believed to be overused and misused. Approximately 80% of all prescriptions for antibiotics are written by GPs. There are many external factors that influence a GP's decision to prescribe, including patient pressure. Access to primary care services operates on a two-tier system in the Republic of Ireland: General Medical Service (GMS) card holders have free access to GPs and medications; and non-card holders (private patients) must pay a non-subsidised fee to visit their GP. To ascertain whether there was a difference in antibiotic prescribing practice between those who pay a fee for their GP consultation and those who attend free of charge. Cohort study in Irish general practice. All GPs attending continuing medical education (CME) groups nationwide were invited to participate from October 2008 until April 2010. GPs gathered data on 100 consecutive consultations including diagnosis and patient characteristics. Data were collected from 171 GPs (distributed throughout Ireland), which resulted in 16 899 consultations. Antibiotics were prescribed at 3407 (20.16%) consultations. Nearly half of the prescriptions were for GMS card holders (n = 1669; 48.99%) and 1526 (44.79%) were for private patients; for 212 (6.22%) the payment status of the patient was unknown. Private patients were more likely to receive a prescription for antibiotics (odds ratio 1.23, 95% confidence interval = 1.14 to 1.33). These results demonstrate that a GP's decision to provide a prescription for antibiotics may be influenced by whether or not the patient pays for their consultation at the GP interface. Private patients are more likely than GMS card holders to receive a prescription for antibiotics.

Educational Outreach to Opioid Prescribers: The Case for Academic Detailing.

PubMed

Trotter Davis, Margot; Bateman, Brian; Avorn, Jerry

2017-02-01

Nonmedical use of opioid medications constitutes a serious health threat as the rates of addiction, overdoses, and deaths have risen in recent years. Increasingly, inappropriate and excessively liberal prescribing of opioids by physicians is understood to be a central part of the crisis. Public health officials, hospital systems, and legislators are developing programs and regulations to address the problem in sustained and systematic ways that both insures effective treatment of pain and appropriate limits on the availability of opioids. Three approaches have obtained prominence as means of avoiding excessive and inappropriate prescribing, including: providing financial incentives to physicians to change their clinical decision through pay-for-performance contracts, monitoring patient medications through Prescription Drug Monitoring Programs, and educational outreach to physicians. A promising approach to educational outreach to physicians is an intervention known as "academic detailing." It was developed in the 1980s to provide one-on-one educational outreach to physicians using similar methods as the pharmaceutical industry that sends "detailers" to market their products to physician practices. Core to academic detailing, however, is the idea that medical decisions should be based on evidence-based information, including managing conditions with updated assessment measures, behavioral, and nonpharmacological interventions. With the pharmaceutical industry spending billions of dollars to advertise their products, individual practitioners can have difficulty gathering unbiased information, especially as the number of approved medications grows each year. Academic detailing has successfully affected the management of health conditions, such as atrial fibrillation, chronic obstructive pulmonary disease, and recently, has targeted physicians who prescribe opioids. This article discusses the approach as a potentially effective preventative intervention to address the epidemic of opioid overuse.Key words: Opioid abuse, opioid misuse, academic detailing, health policy, interactive education,prevention.

Clinical Decision Support Improves Initial Dosing and Monitoring of Tobramycin and Amikacin

PubMed Central

Cox, Zachary L.; Nelsen, Cori L.; Waitman, Lemuel R.; McCoy, Jacob A.; Peterson, Josh F.

2010-01-01

Purpose Clinical decision support (CDS) systems could be valuable tools in reducing aminoglycoside prescribing errors. We evaluated the impact of CDS on initial dosing, interval, and pharmacokinetic outcomes of amikacin and tobramycin therapy. Methods A complex CDS advisor to provide guidance on initial dosing and monitoring, using both traditional and extended interval dosing strategies, was integrated into computerized provider order entry (CPOE) and compared to a control group which featured close pharmacy monitoring of all aminoglycoside orders. A random sample of 118 patients from an academic, tertiary care medical center prescribed amikacin and tobramycin prior to advisor implementation was compared to 98 patients admitted following advisor implementation. Primary outcome was an initial dose within 10% of a dose calculated to be adherent to published dose guidelines. Secondary outcomes were a guideline-adherent interval, trough and peak concentrations in goal range, and incidence of nephrotoxicity. Results Of 216 patients studied, 97 were prescribed amikacin and 119 were prescribed tobramycin. The primary outcome of initial dosing consistent with guideline-based care increased from 40% in the pre-advisor arm to 80% in the post-advisor arm (p<0.001), with a number needed to treat of 3 patients to prevent one incorrect dose. Correct initial interval based on renal function also increased from 63% to 87% (p<0.001). The changes in initial dosing and interval resulted in an increase of trough concentrations in the goal range from 59% pre-advisor to 89% post-advisor implementation (p=0.0004). There was no significant difference in peak concentrations in goal range or incidence of nephrotoxicity (25% vs. 17%, p=0.2). Conclusion An advisor for aminoglycoside dosing and monitoring integrated into CPOE significantly improves initial dosing, selection of interval, and trough concentrations at goal compared to unassisted physician dosing. PMID:21411805

Automation bias in electronic prescribing.

PubMed

Lyell, David; Magrabi, Farah; Raban, Magdalena Z; Pont, L G; Baysari, Melissa T; Day, Richard O; Coiera, Enrico

2017-03-16

Clinical decision support (CDS) in e-prescribing can improve safety by alerting potential errors, but introduces new sources of risk. Automation bias (AB) occurs when users over-rely on CDS, reducing vigilance in information seeking and processing. Evidence of AB has been found in other clinical tasks, but has not yet been tested with e-prescribing. This study tests for the presence of AB in e-prescribing and the impact of task complexity and interruptions on AB. One hundred and twenty students in the final two years of a medical degree prescribed medicines for nine clinical scenarios using a simulated e-prescribing system. Quality of CDS (correct, incorrect and no CDS) and task complexity (low, low + interruption and high) were varied between conditions. Omission errors (failure to detect prescribing errors) and commission errors (acceptance of false positive alerts) were measured. Compared to scenarios with no CDS, correct CDS reduced omission errors by 38.3% (p < .0001, n = 120), 46.6% (p < .0001, n = 70), and 39.2% (p < .0001, n = 120) for low, low + interrupt and high complexity scenarios respectively. Incorrect CDS increased omission errors by 33.3% (p < .0001, n = 120), 24.5% (p < .009, n = 82), and 26.7% (p < .0001, n = 120). Participants made commission errors, 65.8% (p < .0001, n = 120), 53.5% (p < .0001, n = 82), and 51.7% (p < .0001, n = 120). Task complexity and interruptions had no impact on AB. This study found evidence of AB omission and commission errors in e-prescribing. Verification of CDS alerts is key to avoiding AB errors. However, interventions focused on this have had limited success to date. Clinicians should remain vigilant to the risks of CDS failures and verify CDS.

A longitudinal analysis of self-prescribed complementary and alternative medicine use by a nationally representative sample of 19,783 Australian women, 2006-2010.

PubMed

Bowe, Steven; Adams, Jon; Lui, Chi-Wai; Sibbritt, David

2015-10-01

Complementary and alternative medicine (CAM) use is increasingly popular amongst general populations around the world with women constituting substantial CAM users. However, self-prescribed CAM use does raise potential safety concerns and so it is important to identify those risk factors associated with self-prescribed CAM use. Data was obtained from the Australian Longitudinal Study on Women's Health (ALSWH). Longitudinal data analyses were conducted on questionnaire data from the 1973-78 cohort (n=9,145) and the 1946-51 cohort (n=10,638), collected over the period 2006-2010. In the 1973-78 cohort, use of self-prescribed CAM was 73.2% in 2006 and 75.3% in 2009. For the 1946-51 cohort, use of self-prescribed CAM was 73.9% in 2007 and 74.7% in 2010. There were similar levels of use of individual self-prescribed CAM, with the exception that the use of herbal medicine was much higher among the 1946-51 cohort (20% vs. 27%). There was a substantial increase over three years in the use of vitamins/minerals in both cohorts (21% and 19%, respectively). In contrast, there was a considerable decline over three years in use of aromatherapy oils in both cohorts (34% and 28%, respectively). Self-prescribed CAM use is popular amongst women in Australia and it is important that conventional practitioners providing women's health care be cognizant of such use amongst their patients. In order to ensure effective practice, there is a need for further research to explore women's decision-making and experiences around self-prescribed CAM use. Copyright © 2015 Elsevier Ltd. All rights reserved.

The effect of a computerized prescribing and calculating system on hypo- and hyperglycemias and on prescribing time efficiency in neonatal intensive care patients.

PubMed

Maat, Barbara; Rademaker, Carin M A; Oostveen, Marloes I; Krediet, Tannette G; Egberts, Toine C G; Bollen, Casper W

2013-01-01

Prescribing glucose requires complex calculations because glucose is present in parenteral and enteral nutrition and drug vehicles, making it error prone and contributing to the burden of prescribing errors. Evaluation of the impact of a computerized physician order entry (CPOE) system with clinical decision support (CDS) for glucose control in neonatal intensive care patients (NICU) focusing on hypo- and hyperglycemic episodes and prescribing time efficiency. An interrupted time-series design to examine the effect of CPOE on hypo- and hyperglycemias and a crossover simulation study to examine the influence of CPOE on prescribing time efficiency. NICU patients at risk for glucose imbalance hospitalized at the University Medical Center Utrecht during 2001-2007 were selected. The risks of hypo- and hyperglycemias were expressed as incidences per 100 patient days in consecutive 3-month intervals during 3 years before and after CPOE implementation. To assess prescribing time efficiency, time needed to calculate glucose intake with and without CPOE was measured. No significant difference was found between pre- and post-CPOE mean incidences of hypo- and hyperglycemias per 100 hospital days of neonates at risk in every 3-month period (hypoglycemias, 4.0 [95% confidence interval, 3.2-4.8] pre-CPOE and 3.1 [2.7-3.5] post-CPOE, P = .88; hyperglycemias, 6.0 [4.3-7.7] pre-CPOE and 5.0 [3.7-6.3] post-CPOE, P = .75). CPOE led to a significant time reduction of 16% (1.3 [0.3-2.3] minutes) for simple and 60% (8.6 [5.1-12.1] minutes) for complex calculations. CPOE including a special CDS tool preserved accuracy for calculation and control of glucose intake and increased prescribing time efficiency.

Understanding long-term opioid prescribing for non-cancer pain in primary care: a qualitative study.

PubMed

McCrorie, Carolyn; Closs, S José; House, Allan; Petty, Duncan; Ziegler, Lucy; Glidewell, Liz; West, Robert; Foy, Robbie

2015-09-11

The place of opioids in the management of chronic, non-cancer pain is limited. Even so their use is escalating, leading to concerns that patients are prescribed strong opioids inappropriately and alternatives to medication are under-used. We aimed to understand the processes which bring about and perpetuate long-term prescribing of opioids for chronic, non-cancer pain. We held semi-structured interviews with patients and focus groups with general practitioners (GPs). Participants included 23 patients currently prescribed long-term opioids and 15 GPs from Leeds and Bradford, United Kingdom (UK). We used a grounded approach to the analysis of transcripts. Patients are driven by the needs for pain relief, explanation, and improvement or maintenance of quality of life. GPs' responses are shaped by how UK general practice is organised, available therapeutic choices and their expertise in managing chronic pain, especially when facing diagnostic uncertainty or when their own approach is at odds with the patient's wishes. Four features of the resulting transaction between patients and doctors influence prescribing: lack of clarity of strategy, including the risk of any plans being subverted by urgent demands; lack of certainty about locus of control in decision-making, especially in relation to prescribing; continuity in the doctor-patient relationship; and mutuality and trust. Problematic prescribing occurs when patients experience repeated consultations that do not meet their needs and GPs feel unable to negotiate alternative approaches to treatment. Therapeutic short-termism is perpetuated by inconsistent clinical encounters and the absence of mutually-agreed formulations of underlying problems and plans of action. Apart from commissioning improved access to appropriate specialist services, general practices should also consider how they manage problematic opioid prescribing and be prepared to set boundaries with patients.

Multiple policies to enhance prescribing efficiency for established medicines in Europe with a particular focus on demand-side measures: findings and future implications.

PubMed

Godman, Brian; Wettermark, Bjorn; van Woerkom, Menno; Fraeyman, Jessica; Alvarez-Madrazo, Samantha; Berg, Christian; Bishop, Iain; Bucsics, Anna; Campbell, Stephen; Finlayson, Alexander E; Fürst, Jurij; Garuoliene, Kristina; Herholz, Harald; Kalaba, Marija; Laius, Ott; Piessnegger, Jutta; Sermet, Catherine; Schwabe, Ulrich; Vlahović-Palčevski, Vera V; Markovic-Pekovic, Vanda; Vončina, Luka; Malinowska, Kamila; Zara, Corinne; Gustafsson, Lars L

2014-01-01

The appreciable growth in pharmaceutical expenditure has resulted in multiple initiatives across Europe to lower generic prices and enhance their utilization. However, considerable variation in their use and prices. Assess the influence of multiple supply and demand-side initiatives across Europe for established medicines to enhance prescribing efficiency before a decision to prescribe a particular medicine. Subsequently utilize the findings to suggest potential future initiatives that countries could consider. An analysis of different methodologies involving cross national and single country retrospective observational studies on reimbursed use and expenditure of PPIs, statins, and renin-angiotensin inhibitor drugs among European countries. Nature and intensity of the various initiatives appreciably influenced prescribing behavior and expenditure, e.g., multiple measures resulted in reimbursed expenditure for PPIs in Scotland in 2010 56% below 2001 levels despite a 3-fold increase in utilization and in the Netherlands, PPI expenditure fell by 58% in 2010 vs. 2000 despite a 3-fold increase in utilization. A similar picture was seen with prescribing restrictions, i.e., (i) more aggressive follow-up of prescribing restrictions for patented statins and ARBs resulted in a greater reduction in the utilization of patented statins in Austria vs. Norway and lower utilization of patented ARBs vs. generic ACEIs in Croatia than Austria. However, limited impact of restrictions on esomeprazole in Norway with the first prescription or recommendation in hospital where restrictions do not apply. Similar findings when generic losartan became available in Western Europe. Multiple demand-side measures are needed to influence prescribing patterns. When combined with supply-side measures, activities can realize appreciable savings. Health authorities cannot rely on a "spill over" effect between classes to affect changes in prescribing.

Multiple policies to enhance prescribing efficiency for established medicines in Europe with a particular focus on demand-side measures: findings and future implications

PubMed Central

Godman, Brian; Wettermark, Bjorn; van Woerkom, Menno; Fraeyman, Jessica; Alvarez-Madrazo, Samantha; Berg, Christian; Bishop, Iain; Bucsics, Anna; Campbell, Stephen; Finlayson, Alexander E.; Fürst, Jurij; Garuoliene, Kristina; Herholz, Harald; Kalaba, Marija; Laius, Ott; Piessnegger, Jutta; Sermet, Catherine; Schwabe, Ulrich; Vlahović-Palčevski, Vera V.; Markovic-Pekovic, Vanda; Vončina, Luka; Malinowska, Kamila; Zara, Corinne; Gustafsson, Lars L.

2014-01-01

Introduction: The appreciable growth in pharmaceutical expenditure has resulted in multiple initiatives across Europe to lower generic prices and enhance their utilization. However, considerable variation in their use and prices. Objective: Assess the influence of multiple supply and demand-side initiatives across Europe for established medicines to enhance prescribing efficiency before a decision to prescribe a particular medicine. Subsequently utilize the findings to suggest potential future initiatives that countries could consider. Method: An analysis of different methodologies involving cross national and single country retrospective observational studies on reimbursed use and expenditure of PPIs, statins, and renin-angiotensin inhibitor drugs among European countries. Results: Nature and intensity of the various initiatives appreciably influenced prescribing behavior and expenditure, e.g., multiple measures resulted in reimbursed expenditure for PPIs in Scotland in 2010 56% below 2001 levels despite a 3-fold increase in utilization and in the Netherlands, PPI expenditure fell by 58% in 2010 vs. 2000 despite a 3-fold increase in utilization. A similar picture was seen with prescribing restrictions, i.e., (i) more aggressive follow-up of prescribing restrictions for patented statins and ARBs resulted in a greater reduction in the utilization of patented statins in Austria vs. Norway and lower utilization of patented ARBs vs. generic ACEIs in Croatia than Austria. However, limited impact of restrictions on esomeprazole in Norway with the first prescription or recommendation in hospital where restrictions do not apply. Similar findings when generic losartan became available in Western Europe. Conclusions: Multiple demand-side measures are needed to influence prescribing patterns. When combined with supply-side measures, activities can realize appreciable savings. Health authorities cannot rely on a “spill over” effect between classes to affect changes in prescribing. PMID:24987370

First Approximations of Prescribed Fire Risks Relative to Other Management Techniques Used on Private Lands.

PubMed

Twidwell, Dirac; Wonkka, Carissa L; Sindelar, Michael T; Weir, John R

2015-01-01

Fire is widely recognized as a critical ecological and evolutionary driver that needs to be at the forefront of land management actions if conservation targets are to be met. However, the prevailing view is that prescribed fire is riskier than other land management techniques. Perceived risks associated with the application of fire limits its use and reduces agency support for prescribed burning in the private sector. As a result, considerably less cost-share support is given for prescribed fire compared to mechanical techniques. This study tests the general perception that fire is a riskier technique relative to other land management options. Due to the lack of data available to directly test this notion, we use a combination of approaches including 1) a comparison of fatalities resulting from different occupations that are proxies for techniques employed in land management, 2) a comparison of fatalities resulting from wildland fire versus prescribed fire, and 3) an exploration of causal factors responsible for wildland fire-related fatalities. This approach establishes a first approximation of the relative risk of fatality to private citizens using prescribed fire compared to other management techniques that are readily used in ecosystem management. Our data do not support using risks of landowner fatalities as justification for the use of alternative land management techniques, such as mechanical (machine-related) equipment, over prescribed fire. Vehicles and heavy machinery are consistently leading reasons for fatalities within occupations selected as proxies for management techniques employed by ranchers and agricultural producers, and also constitute a large proportion of fatalities among firefighters. Our study provides the foundation for agencies to establish data-driven decisions regarding the degree of support they provide for prescribed burning on private lands.

First Approximations of Prescribed Fire Risks Relative to Other Management Techniques Used on Private Lands

PubMed Central

Twidwell, Dirac; Wonkka, Carissa L.; Sindelar, Michael T.; Weir, John R.

2015-01-01

Fire is widely recognized as a critical ecological and evolutionary driver that needs to be at the forefront of land management actions if conservation targets are to be met. However, the prevailing view is that prescribed fire is riskier than other land management techniques. Perceived risks associated with the application of fire limits its use and reduces agency support for prescribed burning in the private sector. As a result, considerably less cost-share support is given for prescribed fire compared to mechanical techniques. This study tests the general perception that fire is a riskier technique relative to other land management options. Due to the lack of data available to directly test this notion, we use a combination of approaches including 1) a comparison of fatalities resulting from different occupations that are proxies for techniques employed in land management, 2) a comparison of fatalities resulting from wildland fire versus prescribed fire, and 3) an exploration of causal factors responsible for wildland fire-related fatalities. This approach establishes a first approximation of the relative risk of fatality to private citizens using prescribed fire compared to other management techniques that are readily used in ecosystem management. Our data do not support using risks of landowner fatalities as justification for the use of alternative land management techniques, such as mechanical (machine-related) equipment, over prescribed fire. Vehicles and heavy machinery are consistently leading reasons for fatalities within occupations selected as proxies for management techniques employed by ranchers and agricultural producers, and also constitute a large proportion of fatalities among firefighters. Our study provides the foundation for agencies to establish data-driven decisions regarding the degree of support they provide for prescribed burning on private lands. PMID:26465329

Advantages and disadvantages of interdisciplinary consultation in the prescription of assistive technologies for mobility limitations.

PubMed

de Laat, Fred A; van Heerebeek, Bart; van Netten, Jaap J

2018-03-28

To explore the advantages and disadvantages experienced by professionals in interdisciplinary consultation involving the user, prescriber and technician in the prescription of assistive technologies for mobility limitations. Cross-sectional study. Prescribers (N = 39) and orthopaedic technicians (N = 50), who were regularly involved in an interdisciplinary consultation completed a questionnaire about advantages and disadvantages of the interdisciplinary consultation. Advantages of the interdisciplinary consultation were mentioned within all CanMEDS areas of medical practice, including better and quicker prescription of the assistive technology, shared knowledge of medical diagnosis and device possibilities, shared decision making of the device prescription and clear communication rules. Disadvantages were mentioned in the CanMEDS areas management and collaboration, including planning problems (financial) reimbursement of this type of consultation, and time efficiency. On a 10-point scale, mean (standard deviation) rates of interdisciplinary consultations were 7.9 (0.6) according to prescribers, and 7.8 (0.9) by technicians. All participants wanted to continue the interdisciplinary consultation. Prescribers and technicians in the field of assistive technologies for walking mobility limitations appreciate an interdisciplinary consultation. Advantages are found in all CanMEDS areas, whereas disadvantages only concern coordination. It should be encouraged to realize this kind of consultation in all situations where such technologies are prescribed. Implications for rehabilitation Interdisciplinary consultation involving the user, prescriber and technician to prescribe assistive technologies for mobility limitations has many advantages in all CanMEDS areas of medical practice, and few disadvantages, related to management and collaboration only. The disadvantages of interdisciplinary consultation, such as (financial) reimbursement by health insurance companies, have to be taken into account. Professionals in the field of ankle-foot-orthoses and orthopaedic shoes (medical specialist as prescriber and orthopaedic technician) who are involved in interdisciplinary consultation appreciate it and want to continue.

Developing an institutional framework to incorporate ecosystem services into decision making-Proceedings of a workshop

USGS Publications Warehouse

Hogan, Dianna; Arthaud, Greg; Brookshire, David; Gunther, Tom; Pincetl, Stephanie; Shapiro, Carl; Van Horne, Bea

2011-01-01

The appropriate use of institutional structures, including markets, to integrate ecosystem services into decision making depends on the players and characteristics of the specific situation (such as stakeholders, the ecosystem, resources, and the political environment). Incorporating ecosystem service values into decisions requires consideration of place-based social, cultural, economic, and landscape characteristics and institutions. Thus, a single, prescribed solution will not work-various institutional strategies must be used in different situations. Market-based approaches require appropriate regulations, monitoring, and enforcement, depending on the situation and place. Further, market approaches will need to be coupled with nonmarket approaches into an integrated institutional framework.

Indigestion

MedlinePlus

... usually have serious complications, it can affect your quality of life by making you feel uncomfortable and causing you to eat less. You might miss work or school because of your symptoms. When indigestion ...

e-Learning initiatives to support prescribing

PubMed Central

Maxwell, Simon; Mucklow, John

2012-01-01

Preparing medical students to prescribe is a major challenge of undergraduate education. They must develop an understanding of clinical pharmacology and acquire knowledge about drugs and therapeutics, as well as the skills to prescribe for individual patients in the face of multiple variables. The task of delivering the learning required to achieve these attributes relies upon limited numbers of teachers, who have increasingly busy clinical commitments. There is evidence that training is currently insufficient to meet the demands of the workplace. e-Learning provides an opportunity to improve the learning experience. The advantages for teachers are improved distribution of learning content, ease of update, standardization and tracking of learner activities. The advantages for learners are ease of access, greater interactivity and individual choice concerning the pace and mix of learning. Important disadvantages are the considerable resource required to develop e-Learning projects and difficulties in simulating some aspects of the real world prescribing experience. Pre-requisites for developing an e-Learning programme to support prescribing include academic expertise, institutional support, learning technology services and an effective virtual learning environment. e-Learning content might range from complex interactive learning sessions through to static web pages with links. It is now possible to simulate and provide feedback on prescribing decisions and this will improve with advances in virtual reality. Other content might include a student formulary, self-assessment exercises (e.g. calculations), a glossary and an on-line library. There is some evidence for the effectiveness of e-Learning but better research is required into its potential impact on prescribing. PMID:22509885

e-Learning initiatives to support prescribing.

PubMed

Maxwell, Simon; Mucklow, John

2012-10-01

Preparing medical students to prescribe is a major challenge of undergraduate education. They must develop an understanding of clinical pharmacology and acquire knowledge about drugs and therapeutics, as well as the skills to prescribe for individual patients in the face of multiple variables. The task of delivering the learning required to achieve these attributes relies upon limited numbers of teachers, who have increasingly busy clinical commitments. There is evidence that training is currently insufficient to meet the demands of the workplace. e-Learning provides an opportunity to improve the learning experience. The advantages for teachers are improved distribution of learning content, ease of update, standardization and tracking of learner activities. The advantages for learners are ease of access, greater interactivity and individual choice concerning the pace and mix of learning. Important disadvantages are the considerable resource required to develop e-Learning projects and difficulties in simulating some aspects of the real world prescribing experience. Pre-requisites for developing an e-Learning programme to support prescribing include academic expertise, institutional support, learning technology services and an effective virtual learning environment. e-Learning content might range from complex interactive learning sessions through to static web pages with links. It is now possible to simulate and provide feedback on prescribing decisions and this will improve with advances in virtual reality. Other content might include a student formulary, self-assessment exercises (e.g. calculations), a glossary and an on-line library. There is some evidence for the effectiveness of e-Learning but better research is required into its potential impact on prescribing. © 2012 The Authors. British Journal of Clinical Pharmacology © 2012 The British Pharmacological Society.

How Ghanaian, African-Surinamese and Dutch patients perceive and manage antihypertensive drug treatment: a qualitative study.

PubMed

Beune, Erik J A J; Haafkens, Joke A; Agyemang, Charles; Schuster, John S; Willems, Dick L

2008-04-01

To explore and compare how Ghanaian, African-Surinamese (Surinamese), and White-Dutch patients perceive and manage antihypertensive drug treatment in Amsterdam, the Netherlands. Qualitative study was conducted using detailed interviews with a purposive sample of 46 hypertensive patients without comorbidity who were prescribed antihypertensives. Patients in all the ethnic groups actively decided how to manage their prescribed antihypertensive regimens. In all the groups, confidence in the doctor and beneficial effects of medication were reasons for taking prescribed antihypertensive dosage. Particularly, ethnic-minority patients reported lowering or leaving off the prescribed medication dosage. Explanations for altering prescribed dosage comprised disliking chemical medications, fear of side effects and preference for alternative treatment. Surinamese and Ghanaian men also worried about the negative effects of antihypertensives on their sexual performance. Some Ghanaians mentioned fear of addiction or lack of money as explanations for altering prescribed dosage. Surinamese and Ghanaians often discontinued medication when visiting their homeland. Some respondents from all ethnic groups preferred natural treatments although treatment type varied. Patients' explanations for their decisions regarding the use of antihypertensives are often influenced by sociocultural issues and in ethnic-minority groups also by migration-related issues. Self-alteration of prescribed medication among Surinamese and Ghanaians may contribute to the low blood pressure (BP) control rate and high rate of malignant hypertension reported among these populations in the Netherlands. This study provides new information, which can help clinicians to understand how patients of diverse ethnic populations think about managing antihypertensive drug treatment and to address ethnic disparities in medication adherence and BP control.

Opioid Analgesics for Chronic Non-Cancer Pain: A Guideline on Opioid Prescribing.

PubMed

Van Demark, Robert; Chang, Peter; Heinemann, Daniel

2016-01-01

Over the past decade, the use of opioid analgesics has risen dramatically both in the U.S. and South Dakota. Opioids have been increasingly used to treat chronic non-cancer pain; however, the utilization of opioids for this role has limited and questionable utility. The U.S. has also seen a rise of opioid abuse, addiction, misuse, and overdose. The various pharmacological and non-pharmacological strategies to help physicians manage chronic non-cancer pain and a guideline on appropriate opioid prescribing are presented. Before the decision is made to begin opioid therapy for chronic non-cancer pain, other pharmacological and non-pharmacological therapeutic strategies should be explored. The schema for responsible opioid prescribing can be dived into the following: the initial assessment, initiating opioid therapy, maintenance therapy, and the discontinuation of opioid treatment. These categories are explored, and a general approach to prescribing opioids for chronic non-cancer pain is presented. The Centers for Disease Control and Prevention (CDC) has declared opioid prescription abuse an "epidemic." There are a variety of methods clinicians can utilize to relieve chronic non-cancer pain. If opioid therapy is sought, clinicians should be mindful of the current state of opioid abuse and misuse. This guideline may aid clinicians in appropriate opioid prescribing.

Social Phobia

MedlinePlus

... also unintentionally set an example by avoiding certain social interactions. A shy child who watches this learns that socializing is uncomfortable, distressing, and something to avoid. ... anxiety. People who constantly receive critical or disapproving ...

Plastic Surgery

MedlinePlus

... uncomfortable. For example, guys with a condition called gynecomastia (excess breast tissue) that doesn't go away ... Breasts Different Sizes? Can Acne Scars Be Removed? Gynecomastia Body Image and Self-Esteem Help! Is This ...

Vulvar Care

MedlinePlus

... products that women commonly use. These include some soaps, shower and bath products, laundry products, panty liners ... makes them feel more uncomfortable. Frequent washing with soap and other cleansing products also can increase pain ...

Fever

MedlinePlus

... 38.9 C) taken rectally Give your child acetaminophen (Tylenol, others). If your child is age 6 months ... If your child seems uncomfortable, give your child acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others). Read ...

Eye Exam

MedlinePlus

... may use a variety of instruments, shine bright lights directly at your eyes and request that you ... exam is complete, as daylight or other bright lights may be uncomfortable or cause blurred vision. Also, ...

The role of moral utility in decision making: an interdisciplinary framework.

PubMed

Tobler, Philippe N; Kalis, Annemarie; Kalenscher, Tobias

2008-12-01

What decisions should we make? Moral values, rules, and virtues provide standards for morally acceptable decisions, without prescribing how we should reach them. However, moral theories do assume that we are, at least in principle, capable of making the right decisions. Consequently, an empirical investigation of the methods and resources we use for making moral decisions becomes relevant. We consider theoretical parallels of economic decision theory and moral utilitarianism and suggest that moral decision making may tap into mechanisms and processes that have originally evolved for nonmoral decision making. For example, the computation of reward value occurs through the combination of probability and magnitude; similar computation might also be used for determining utilitarian moral value. Both nonmoral and moral decisions may resort to intuitions and heuristics. Learning mechanisms implicated in the assignment of reward value to stimuli, actions, and outcomes may also enable us to determine moral value and assign it to stimuli, actions, and outcomes. In conclusion, we suggest that moral capabilities can employ and benefit from a variety of nonmoral decision-making and learning mechanisms.

Impact of medical and nonmedical factors on physician decision making for HIV/AIDS antiretroviral treatment.

PubMed

Bogart, L M; Kelly, J A; Catz, S L; Sosman, J M

2000-04-15

To examine influences of medical factors (e.g., viral load) and nonmedical factors (e.g., patient characteristics) on treatment decisions for highly active antiretroviral therapy (HAART), we sent a survey to a random sample of 995 infectious disease physicians who treat patients with HIV/AIDS in the United States in August, 1998. The response rate was 53%. Respondents were asked to report their current practices with respect to antiretroviral treatment and the extent to which each of three medical and 17 nonmedical factors would influence them for or against prescribing HAART to a hypothetical HIV-positive patient. Most reported initiating HAART with findings of low CD4+ cell counts and high viral loads, and weighing CD4+ cell counts, viral load, and opportunistic infection heavily in their decisions to prescribe HAART. Patients' prior history of poor adherence was weighed very much against initiating HAART. Patient homelessness, heavy alcohol use, injection drug use, and prior psychiatric hospitalization were cited by most physicians as weighing against HAART initiation. Thus, most physicians in this sample follow guidelines for the use of HAART, and nonmedical factors related to patients' life situations are weighed as heavily as disease severity in treatment decisions. As HIV increasingly becomes a disease associated with economic disadvantage and other social health problems, it will be essential to develop interventions and care support systems to enable patients experiencing these problems to benefit from HIV treatment advances.

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01]--study protocol and baseline practice and provider characteristics.

PubMed

Persell, Stephen D; Friedberg, Mark W; Meeker, Daniella; Linder, Jeffrey A; Fox, Craig R; Goldstein, Noah J; Shah, Parth D; Knight, Tara K; Doctor, Jason N

2013-06-27

Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians. The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider's rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease. The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics. ClinicalTrials.gov: NCT01454947.

After Cancer Treatment

MedlinePlus

... through a range of emotions. These can include everything from relief to anxiety. Children may feel especially afraid that your cancer will return. They will need reassurance. Family members may seem uncomfortable talking about ...

Exploratory survey of Florida pharmacists' experience, knowledge, and perception of HIV pre-exposure prophylaxis.

PubMed

Shaeer, Kristy M; Sherman, Elizabeth M; Shafiq, Sami; Hardigan, Patrick

2014-01-01

To assess Florida pharmacists' experience, knowledge, and perception of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and to identify areas for pharmacist training. Cross-sectional survey. Florida in March through July 2013. Florida pharmacists. In-person and online anonymous survey. Florida pharmacists' experience, knowledge, and perceptions of PrEP. 225 completed surveys were analyzed. Survey respondents were predominantly community pharmacists with mean age of 45.7 years and less than 20 years of experience. Only 22% of respondents reported dispensing PrEP to patients. Although 75% had completed HIV-related continuing education in the last 2 years, 63% were unaware of Centers for Disease Control and Prevention PrEP guidelines and 71% answered that they did not have sufficient knowledge to counsel patients with PrEP prescriptions. Importantly, 47% of respondents answered they were uncomfortable counseling patients about PrEP. By self-report, most pharmacists agreed PrEP leads to risky behavior (68%) and increased rates of sexually transmitted infections (65%), and is too costly to promote patient access (92%). Surveyed Florida pharmacists reported limited understanding of PrEP. As a widely accessible health care counseling resource, pharmacists are positioned to improve patient understanding, promote medication adherence, and enhance PrEP efficacy. Especially during PrEP implementation, when patients may receive PrEP prescriptions from non-HIV specialist prescribers, improving pharmacists' PrEP education presents a salient opportunity.

77 FR 59918 - Energy Conservation Program for Consumer Products: Decision and Order Granting a Waiver to BSH...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-01

... that are reasonably designed to produce results that measure energy efficiency, energy use, or... more design characteristics that prevent testing according to the prescribed test procedure, or (2... true energy consumption characteristics as to provide materially inaccurate comparative data. 10 CFR...

78 FR 53446 - Energy Conservation Program for Consumer Products: Decision and Order Granting a Waiver to ASKO...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-29

... reasonably designed to produce results which measure energy efficiency, energy use, or estimated operating... or more design characteristics that prevent testing according to the prescribed test procedure, or (2... true energy consumption characteristics as to provide materially inaccurate comparative data. (10 CFR...

77 FR 59916 - Energy Conservation Program for Consumer Products: Decision and Order Granting a Waiver to BSH...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-01

... that are reasonably designed to produce results that measure energy efficiency, energy use, or... more design characteristics that prevent testing according to the prescribed test procedure, or (2... true energy consumption characteristics as to provide materially inaccurate comparative data. 10 CFR...

76 FR 70996 - Decision and Order Granting a Waiver to Samsung From the Department of Energy Residential Clothes...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-11-16

... test procedures that are reasonably designed to produce results which measure energy efficiency, energy... more design characteristics that prevent testing according to the prescribed test procedure, or (2... true energy consumption characteristics as to provide materially inaccurate comparative data. 10 CFR...

78 FR 57139 - Decision and Order Granting a Waiver to Panasonic Appliances Refrigeration Systems Corporation of...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-17

... procedures that are reasonably designed to produce results that measure energy efficiency, energy use, or... more design characteristics that prevent testing according to the prescribed test procedure, or (2... true energy consumption characteristics as to provide materially inaccurate comparative data. 10 CFR...

Prescribing silvicultural treatments in hardwood stands of the Alleghenies. (Revised)

Treesearch

David A. Marquis; Richard L. Ernst; Susan L. Stout

1992-01-01

This publication brings together the results of 20 years of research and experience in the silviculture of hardwood forests in the Allegheny region. It provides a summary of silvicultural knowledge, and guidelines, decision tables, and step-by-step instructions for determining silviculutural prescriptions in individual stands.

32 CFR 989.11 - Combining EIAP with other documentation.

Code of Federal Regulations, 2010 CFR

2010-07-01

... documentation. (a) The EPF combines environmental analysis with other related documentation when practicable (40 CFR 1506.4) following the procedures prescribed by the CEQ regulations and this part. (b) The EPF must... the EIAP. Prior to making a decision to proceed, the EPF must analyze the environmental impacts that...

76 FR 74838 - Agency Information Collection Activities: Proposed Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-01

... their disability or resources that might influence SSA's unfavorable determination. We may use the... hearing to appeal the decision. To request a hearing, individuals use Form HA-501, the associated... request within the prescribed time; is the proper party; and has taken the steps necessary to obtain the...

49 CFR 216.17 - Appeals.

Code of Federal Regulations, 2010 CFR

2010-10-01

... TRANSPORTATION SPECIAL NOTICE AND EMERGENCY ORDER PROCEDURES: RAILROAD TRACK, LOCOMOTIVE AND EQUIPMENT Special Notice for Repairs § 216.17 Appeals. (a) Upon receipt of a Special Notice prescribed in §§ 216.11, 216.13... of the Special Notice cease to be effective. If on reinspection the decision of the original...

40 CFR 1506.10 - Timing of agency action.

Code of Federal Regulations, 2010 CFR

2010-07-01

... period prescribed in paragraph (b)(2) of this section may run concurrently. In such cases the... health or safety, may waive the time period in paragraph (b)(2) of this section and publish a decision on...) day period may run concurrently. However, subject to paragraph (d) of this section agencies shall...

40 CFR 1506.10 - Timing of agency action.

Code of Federal Regulations, 2011 CFR

2011-07-01

... period prescribed in paragraph (b)(2) of this section may run concurrently. In such cases the... health or safety, may waive the time period in paragraph (b)(2) of this section and publish a decision on...) day period may run concurrently. However, subject to paragraph (d) of this section agencies shall...

A methodological protocol for selecting and quantifying low-value prescribing practices in routinely collected data: an Australian case study.

PubMed

Brett, Jonathan; Elshaug, Adam G; Bhatia, R Sacha; Chalmers, Kelsey; Badgery-Parker, Tim; Pearson, Sallie-Anne

2017-05-03

Growing imperatives for safety, quality and responsible resource allocation have prompted renewed efforts to identify and quantify harmful or wasteful (low-value) medical practices such as test ordering, procedures and prescribing. Quantifying these practices at a population level using routinely collected health data allows us to understand the scale of low-value medical practices, measure practice change following specific interventions and prioritise policy decisions. To date, almost all research examining health care through the low-value lens has focused on medical services (tests and procedures) rather than on prescribing. The protocol described herein outlines a program of research funded by Australia's National Health and Medical Research Council to select and quantify low-value prescribing practices within Australian routinely collected health data. We start by describing our process for identifying and cataloguing international low-value prescribing practices. We then outline our approach to translate these prescribing practices into indicators that can be applied to Australian routinely collected health data. Next, we detail methods of using Australian health data to quantify these prescribing practices (e.g. prevalence of low-value prescribing and related costs) and their downstream health consequences. We have approval from the necessary Australian state and commonwealth human research ethics and data access committees to undertake this work. The lack of systematic and transparent approaches to quantification of low-value practices in routinely collected data has been noted in recent reviews. Here, we present a methodology applied in the Australian context with the aim of demonstrating principles that can be applied across jurisdictions in order to harmonise international efforts to measure low-value prescribing. The outcomes of this research will be submitted to international peer-reviewed journals. Results will also be presented at national and international pharmacoepidemiology and health policy forums such that other jurisdictions have guidance to adapt this methodology.

Using theory to explore facilitators and barriers to delayed prescribing in Australia: a qualitative study using the Theoretical Domains Framework and the Behaviour Change Wheel.

PubMed

Sargent, Lucy; McCullough, Amanda; Del Mar, Chris; Lowe, John

2017-02-13

Delayed antibiotic prescribing reduces antibiotic use for acute respiratory infections in trials in general practice, but the uptake in clinical practice is low. The aim of the study was to identify facilitators and barriers to general practitioners' (GPs') use of delayed prescribing and to gain pharmacists' and the public's views about delayed prescribing in Australia. This study used the Theoretical Domains Framework and the Behaviour Change Wheel to explore facilitators and barriers to delayed prescribing in Australia. Forty-three semi-structured, face-to-face interviews with general practitioners, pharmacists and patients were conducted. Responses were coded into domains of the Theoretical Domains Framework, and specific criteria from the Behaviour Change Wheel were used to identify which domains were relevant to increasing the use of delayed prescribing by GPs. The interviews revealed nine key domains that influence GPs' use of delayed prescribing: knowledge; cognitive and interpersonal skills; memory, attention and decision-making processes; optimism; beliefs about consequences; intentions; goals; emotion; and social influences: GPs knew about delayed prescribing; however, they did not use it consistently, preferring to bring patients back for review and only using it with patients in a highly selective way. Pharmacists would support GPs and the public in delayed prescribing but would fill the prescription if people insisted. The public said they would delay taking their antibiotics if asked by their GP and given the right information on managing symptoms and when to take antibiotics. Using a theory-driven approach, we identified nine key domains that influence GPs' willingness to provide a delayed prescription to patients with an acute respiratory infection presenting to general practice. These data can be used to develop a structured intervention to change this behaviour and thus reduce antibiotic use for acute respiratory infections in general practice.

Everyday Ethics: Ethical Issues and Stress in Nursing Practice

PubMed Central

Ulrich, Connie M.; Taylor, Carol; Soeken, Karen; O'Donnell, Patricia; Farrar, Adrienne; Danis, Marion; Grady, Christine

2010-01-01

Aim This paper is a report of a study of the type, frequency, and level of stress of ethical issues encountered by nurses in their everyday practice. Background Everyday ethical issues in nursing practice attract little attention but can create stress for nurses. Nurses often feel uncomfortable in addressing the ethical issues they encounter in patient care. Methods A self-administered survey was sent in 2004 to 1000 nurses in four states in four different census regions of the United States of America. The adjusted response rate was 52%. Data were analyzed using descriptive statistics, cross-tabulations and Pearson correlations. Results A total of 422 questionnaires were used in the analysis. The five most frequently-occurring and most stressful ethical and patient care issues were protecting patients' rights; autonomy and informed consent to treatment; staffing patterns; advanced care planning; and surrogate decision-making. Other common occurrences were unethical practices of healthcare professionals; breaches of patient confidentiality or right to privacy; and end-of-life decision-making. Younger nurses and those with fewer years of experience encountered ethical issues more frequently and reported higher levels of stress. Nurses from different regions also experienced specific types of ethical problems more commonly. Conclusion Nurses face daily ethical challenges in the provision of quality care. To retain nurses, targeted ethics-related interventions that address caring for an increasingly complex patient population are needed. PMID:20735502

Everyday ethics: ethical issues and stress in nursing practice.

PubMed

Ulrich, Connie M; Taylor, Carol; Soeken, Karen; O'Donnell, Patricia; Farrar, Adrienne; Danis, Marion; Grady, Christine

2010-11-01

This paper is a report of a study of the type, frequency, and level of stress of ethical issues encountered by nurses in their everyday practice. Everyday ethical issues in nursing practice attract little attention but can create stress for nurses. Nurses often feel uncomfortable in addressing the ethical issues they encounter in patient care. A self-administered survey was sent in 2004 to 1000 nurses in four states in four different census regions of the United States of America. The adjusted response rate was 52%. Data were analysed using descriptive statistics, cross-tabulations and Pearson correlations. A total of 422 questionnaires were used in the analysis. The five most frequently occurring and most stressful ethical and patient care issues were protecting patients' rights; autonomy and informed consent to treatment; staffing patterns; advanced care planning; and surrogate decision-making. Other common occurrences were unethical practices of healthcare professionals; breaches of patient confidentiality or right to privacy; and end-of-life decision-making. Younger nurses and those with fewer years of experience encountered ethical issues more frequently and reported higher levels of stress. Nurses from different regions also experienced specific types of ethical problems more commonly. Nurses face daily ethical challenges in the provision of quality care. To retain nurses, targeted ethics-related interventions that address caring for an increasingly complex patient population are needed. © 2010 Blackwell Publishing Ltd.

Bone x-ray

MedlinePlus

... different views of the bone may be uncomfortable. Why the Test is Performed A bone x-ray ... neoplasia (MEN) II Multiple myeloma Osgood-Schlatter disease Osteogenesis imperfecta Osteomalacia Paget's disease Primary hyperparathyroidism Rickets Risks There ...

Date Rape (For Teens)

MedlinePlus

... room or the other person's. Wait until you trust your partner before going anywhere private or out ... with someone who makes you feel uncomfortable. Always trust your instincts. If a situation doesn't feel ...

The influence of outdoor thermal environment on young Japanese females.

PubMed

Kurazumi, Yoshihito; Ishii, Jin; Kondo, Emi; Fukagawa, Kenta; Bolashikov, Zhecho Dimitrov; Sakoi, Tomonori; Tsuchikawa, Tadahiro; Matsubara, Naoki; Horikoshi, Tetsumi

2014-07-01

The influence of short wave solar radiation appears to be strong outdoors in summer, and the influence of airflow appears to be strong outdoors in winter. The purpose of this paper was to clarify the influence of the outdoor environment on young Japanese females. This research shows the relationship between the physiological and psychological responses of humans and the enhanced conduction-corrected modified effective temperature (ETFe). Subjective experiments were conducted in an outdoor environment. Subjects were exposed to the thermal environment in a standing posture. Air temperature, humidity, air velocity, short wave solar radiation, long wave radiation, ground surface temperature, sky factor, and the green solid angle were measured. The temperatures of skin exposed to the atmosphere and in contact with the ground were measured. Thermal sensation and thermal comfort were measured by means of rating the whole-body thermal sensation (cold-hot) and the whole body thermal comfort (comfortable-uncomfortable) on a linear scale. Linear rating scales are given for the hot (100) and cold (0), and comfortable (100) and uncomfortable (0) directions only. Arbitrary values of 0 and 100 were assigned to each endpoint, the reported values read in, and the entire length converted into a numerical value with an arbitrary scale of 100 to give a linear rating scale. The ETFe considered to report a neither hot nor cold, thermally neutral sensation of 50 was 35.9 °C, with 32.3 °C and 42.9 °C, respectively, corresponding to the low and high temperature ends of the ETFe considered to report a neither comfortable nor uncomfortable comfort value of 50. The mean skin temperature considered to report a neither hot nor cold, thermally neutral sensation of 50 was 33.3 °C, with 31.0 °C and 34.3 °C, respectively, corresponding to the low and high temperature ends of the mean skin temperature considered to report a neither comfortable nor uncomfortable comfort value of 50. The acceptability raised the mean skin temperature even for thermal environment conditions in which ETFe was high.

The influence of outdoor thermal environment on young Japanese females

NASA Astrophysics Data System (ADS)

Kurazumi, Yoshihito; Ishii, Jin; Kondo, Emi; Fukagawa, Kenta; Bolashikov, Zhecho Dimitrov; Sakoi, Tomonori; Tsuchikawa, Tadahiro; Matsubara, Naoki; Horikoshi, Tetsumi

2014-07-01

The influence of short wave solar radiation appears to be strong outdoors in summer, and the influence of airflow appears to be strong outdoors in winter. The purpose of this paper was to clarify the influence of the outdoor environment on young Japanese females. This research shows the relationship between the physiological and psychological responses of humans and the enhanced conduction-corrected modified effective temperature (ETFe). Subjective experiments were conducted in an outdoor environment. Subjects were exposed to the thermal environment in a standing posture. Air temperature, humidity, air velocity, short wave solar radiation, long wave radiation, ground surface temperature, sky factor, and the green solid angle were measured. The temperatures of skin exposed to the atmosphere and in contact with the ground were measured. Thermal sensation and thermal comfort were measured by means of rating the whole-body thermal sensation (cold-hot) and the whole body thermal comfort (comfortable-uncomfortable) on a linear scale. Linear rating scales are given for the hot (100) and cold (0), and comfortable (100) and uncomfortable (0) directions only. Arbitrary values of 0 and 100 were assigned to each endpoint, the reported values read in, and the entire length converted into a numerical value with an arbitrary scale of 100 to give a linear rating scale. The ETFe considered to report a neither hot nor cold, thermally neutral sensation of 50 was 35.9 °C, with 32.3 °C and 42.9 °C, respectively, corresponding to the low and high temperature ends of the ETFe considered to report a neither comfortable nor uncomfortable comfort value of 50. The mean skin temperature considered to report a neither hot nor cold, thermally neutral sensation of 50 was 33.3 °C, with 31.0 °C and 34.3 °C, respectively, corresponding to the low and high temperature ends of the mean skin temperature considered to report a neither comfortable nor uncomfortable comfort value of 50. The acceptability raised the mean skin temperature even for thermal environment conditions in which ETFe was high.

Ethical violations and discriminatory behavior in the MedPhys Match.

PubMed

Hendrickson, Kristi R G; Juang, Titania; Rodrigues, Anna; Burmeister, Jay W

2017-09-01

The purpose of this survey study is to investigate behaviors in conflict with the ethical standards of the Medical Physics Residency (MedPhys) Match (MPM) process as stated in the MPM rules (a) and with the nondiscrimination regulations of the Equal Employment Opportunity Commission (EEOC) (b), in addition to other behaviors that may in other ways erode the fairness of the system. A survey was sent to all applicants and program directors registered for the 2015 and 2016 MPM. Survey questions asked about application, interview, and postinterview experiences, match results, and overall satisfaction with the process. Thirteen percent of 2015 respondents and 20% of 2016 respondents were asked by at least one program how highly they planned to rank them or which program they would rank first. Thirty-seven percent of 2015 and 40% of 2016 program directors indicated that candidates communicated to the program their rank intent, with 22.0% in 2015 and 12.5% in 2016 being told that their program would be ranked first. Twenty-three percent of 2015 respondents indicated being asked by at least one program during the interview about children or plans to have children; including 19% of males and 33% of females. In 2016, these values were 28% overall, 22% male, and 36% female. Fifty-seven percent of 2015 respondents who were asked this question indicated being uncomfortable or very uncomfortable answering, including 27.3% of males and 88.9% of females. In 2016, 42.9% of all respondents indicated being uncomfortable or very uncomfortable answering, including 10.0% of males and 80.0% of females. In the first two years of the MPM, there were widespread instances of ethical violations and discriminatory questioning during the interview process. Educating both interviewers and candidates on the MPM rules and general EEOC guidelines should decrease these instances and increase the fairness of the residency selection process. © 2017 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.

Design of decision support interventions for medication prescribing.

PubMed

Horsky, Jan; Phansalkar, Shobha; Desai, Amrita; Bell, Douglas; Middleton, Blackford

2013-06-01

Describe optimal design attributes of clinical decision support (CDS) interventions for medication prescribing, emphasizing perceptual, cognitive and functional characteristics that improve human-computer interaction (HCI) and patient safety. Findings from published reports on success, failures and lessons learned during implementation of CDS systems were reviewed and interpreted with regard to HCI and software usability principles. We then formulated design recommendations for CDS alerts that would reduce unnecessary workflow interruptions and allow clinicians to make informed decisions quickly, accurately and without extraneous cognitive and interactive effort. Excessive alerting that tends to distract clinicians rather than provide effective CDS can be reduced by designing only high severity alerts as interruptive dialog boxes and less severe warnings without explicit response requirement, by curating system knowledge bases to suppress warnings with low clinical utility and by integrating contextual patient data into the decision logic. Recommended design principles include parsimonious and consistent use of color and language, minimalist approach to the layout of information and controls, the use of font attributes to convey hierarchy and visual prominence of important data over supporting information, the inclusion of relevant patient data in the context of the alert and allowing clinicians to respond with one or two clicks. Although HCI and usability principles are well established and robust, CDS and EHR system interfaces rarely conform to the best known design conventions and are seldom conceived and designed well enough to be truly versatile and dependable tools. These relatively novel interventions still require careful monitoring, research and analysis of its track record to mature. Clarity and specificity of alert content and optimal perceptual and cognitive attributes, for example, are essential for providing effective decision support to clinicians. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Deep breathing after surgery

MedlinePlus

... and taking big breaths can be uncomfortable. A device called an incentive spirometer can help you take deep breaths correctly. If you do not have this device, you can still practice deep breathing on your ...

Prostate cancer decision-making, health services, and the family physician workforce.

PubMed

Bowman, Marjorie A; Neale, Anne Victoria

2012-01-01

Does untreated cancer equal death? Does having a registered nurse versus a licensed practical nurse versus a medical assistant affect diabetes quality outcomes? Do physicians caring for stressed patients experience vicarious traumatic stress? Oregon presents an operationalized definition of a patient-centered medical home for their state. Lots of important clinical topics in family medicine--adult attention deficit disorder office questionnaire; Bell palsy; cancer screening and treatment decisions; lubrication during Papanicolaou testing; changes in maternity care training by residencies; changing prescribing patterns for thiazide diuretics; and night sweats remain a mystery.

Information Presentation in Decision and Risk Analysis: Answered, Partly Answered, and Unanswered Questions.

PubMed

Keller, L Robin; Wang, Yitong

2017-06-01

For the last 30 years, researchers in risk analysis, decision analysis, and economics have consistently proven that decisionmakers employ different processes for evaluating and combining anticipated and actual losses, gains, delays, and surprises. Although rational models generally prescribe a consistent response, people's heuristic processes will sometimes lead them to be inconsistent in the way they respond to information presented in theoretically equivalent ways. We point out several promising future research directions by listing and detailing a series of answered, partly answered, and unanswered questions. © 2016 Society for Risk Analysis.

Predictors of warfarin use in atrial fibrillation in the United States: a systematic review and meta-analysis

PubMed Central

2012-01-01

Background Despite warfarin's marked efficacy, not all eligible patients receive it for stroke prevention in AF. The aim of this meta-analysis was to evaluate the association between prescriber and/or patient characteristics and subsequent prescription of warfarin for stroke prevention in patients with atrial fibrillation (AF). Methods Observational studies conducted in the US using multivariate analysis to determine the relationship between characteristics and the odds of receiving warfarin for stroke prevention were identified in MEDLINE, EMBASE and a manual review of references. Effect estimates of prescriber and/or patient characteristics from individual studies were pooled to calculate odds ratios (ORs) with 95% confidence intervals. Results Twenty-eight studies reporting results of 33 unique multivariate analyses were identified. Warfarin use across studies ranged from 9.1%-79.8% (median = 49.1%). There was a moderately-strong correlation between warfarin use and year of study (r = 0.60, p = 0.002). Upon meta-analysis, characteristics associated with a statistically significant increase in the odds of warfarin use included history of cerebrovascular accident (OR = 1.59), heart failure (OR = 1.36), and male gender (OR = 1.12). Those associated with a significant reduction in the odds of warfarin use included alcohol/drug abuse (OR = 0.62), perceived barriers to compliance (OR = 0.87), contraindication(s) to warfarin (OR = 0.81), dementia (OR = 0.32), falls (OR = 0.60), gastrointestinal hemorrhage (OR = 0.47), intracranial hemorrhage (OR = 0.39), hepatic (OR = 0.59), and renal impairment (OR = 0.69). While age per 10-year increase (OR = 0.78) and advancing age as a dichotomized variable (cut-off varied by study) (OR = 0.57) were associated with significant reductions in warfarin use; qualitative review of results of studies evaluating age as a categorical variable did not confirm this relationship. Conclusions Warfarin use has increased somewhat over time. The decision to prescribe warfarin for stroke prevention in atrial fibrillation is based upon multiple prescriber and patient characteristics. These findings can be used by family practice prescribers and other healthcare decision-makers to target interventions or methods to improve utilization of warfarin when it is indicated for stroke prevention. PMID:22304704

Ecological Assessment of Clinicians' Antipsychotic Prescription Habits in Psychiatric Inpatients: A Novel Web- and Mobile Phone-Based Prototype for a Dynamic Clinical Decision Support System.

PubMed

Berrouiguet, Sofian; Barrigón, Maria Luisa; Brandt, Sara A; Nitzburg, George C; Ovejero, Santiago; Alvarez-Garcia, Raquel; Carballo, Juan; Walter, Michel; Billot, Romain; Lenca, Philippe; Delgado-Gomez, David; Ropars, Juliette; de la Calle Gonzalez, Ivan; Courtet, Philippe; Baca-García, Enrique

2017-01-26

Electronic prescribing devices with clinical decision support systems (CDSSs) hold the potential to significantly improve pharmacological treatment management. The aim of our study was to develop a novel Web- and mobile phone-based application to provide a dynamic CDSS by monitoring and analyzing practitioners' antipsychotic prescription habits and simultaneously linking these data to inpatients' symptom changes. We recruited 353 psychiatric inpatients whose symptom levels and prescribed medications were inputted into the MEmind application. We standardized all medications in the MEmind database using the Anatomical Therapeutic Chemical (ATC) classification system and the defined daily dose (DDD). For each patient, MEmind calculated an average for the daily dose prescribed for antipsychotics (using the N05A ATC code), prescribed daily dose (PDD), and the PDD to DDD ratio. MEmind results found that antipsychotics were used by 61.5% (217/353) of inpatients, with the largest proportion being patients with schizophrenia spectrum disorders (33.4%, 118/353). Of the 217 patients, 137 (63.2%, 137/217) were administered pharmacological monotherapy and 80 (36.8%, 80/217) were administered polytherapy. Antipsychotics were used mostly in schizophrenia spectrum and related psychotic disorders, but they were also prescribed in other nonpsychotic diagnoses. Notably, we observed polypharmacy going against current antipsychotics guidelines. MEmind data indicated that antipsychotic polypharmacy and off-label use in inpatient units is commonly practiced. MEmind holds the potential to create a dynamic CDSS that provides real-time tracking of prescription practices and symptom change. Such feedback can help practitioners determine a maximally therapeutic drug treatment while avoiding unproductive overprescription and off-label use. ©Sofian Berrouiguet, Maria Luisa Barrigón, Sara A Brandt, George C Nitzburg, Santiago Ovejero, Raquel Alvarez-Garcia, Juan Carballo, Michel Walter, Romain Billot, Philippe Lenca, David Delgado-Gomez, Juliette Ropars, Ivan de la Calle Gonzalez, Philippe Courtet, Enrique Baca-García. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 26.01.2017.

Physicians’ perceptions of medical representative visits in Yemen: a qualitative study

PubMed Central

2013-01-01

Background The pharmaceutical industry invests heavily in promotion, and it uses a variety of promotional strategies to influence physicians’ prescribing decisions. Within this context, medical representatives (MRs) are the key personnel employed in promoting their products. One significant consequence of the interactions between physicians and medical representatives is a conflict of interests which may contribute to the over prescribing of medications and thus negative effects on patients’ health and economics. There is limited detailed information published on the reasons why physicians interact with pharmaceutical representatives. This study aims to qualitatively explore physicians’ attitudes about interactions with medical representatives and their reasons for accepting the medical representatives’ visits. Methods In-depth interviews were used to gain a better understanding of physicians’ perceptions of medical representative visits. A total of 32 physicians from both private and public hospitals were interviewed. The recordings of the interviews were transcribed verbatim and subject to thematic analysis using a framework analysis approach. Results The present qualitative study found that the majority of the physicians had positive interactions with medical representatives. The physicians’ main reasons stated for allowing medical representatives’ visits are the social contacts and mutual benefits they will gain from these representatives. They also emphasized that the meeting with representatives provides educational and scientific benefits. A few physicians stated that the main reasons behind refusing the meeting with medical representatives were lack of conviction about the product and obligation to prescribe medicine from the representative company. Most of the physicians believed that they were under marketing pressure to prescribe certain medicines. Conclusions Although physicians are aware that the medical representatives could influence their prescribing decision, they welcome representatives to visit them and consider receiving free samples, gifts and various kinds of support as a normal practice. The findings provided insight into possible target areas for educational interventions concerning pharmaceutical marketing. Such a finding will provide the basis for policymakers in the public and private health sector in Yemen to develop a suitable policy and regulations in terms of drug promotion. PMID:23962304

Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial.

PubMed

Meeker, Daniella; Knight, Tara K; Friedberg, Mark W; Linder, Jeffrey A; Goldstein, Noah J; Fox, Craig R; Rothfeld, Alan; Diaz, Guillermo; Doctor, Jason N

2014-03-01

"Nudges" that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice. To investigate the use of a behavioral "nudge" based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs). Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention). The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs. Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status. Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time. Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts. clinicaltrials.gov identifier: NCT01767064.

Visit complexity, diagnostic uncertainty, and antibiotic prescribing for acute cough in primary care: a retrospective study

PubMed Central

2013-01-01

Background Guidelines and performance measures recommend avoiding antibiotics for acute cough/acute bronchitis and presume visits are straightforward with simple diagnostic decision-making. We evaluated clinician-assigned diagnoses, diagnostic uncertainty, and antibiotic prescribing for acute cough visits in primary care. Methods We conducted a retrospective analysis of acute cough visits – cough lasting ≤21 days in adults 18–64 years old without chronic lung disease – in a primary care practice from March 2011 through June 2012. Results Of 56,301 visits, 962 (2%) were for acute cough. Clinicians diagnosed patients with 1, 2, or ≥ 3 cough-related diagnoses in 54%, 35%, and 11% of visits, respectively. The most common principal diagnoses were upper respiratory infection (46%), sinusitis (10%), acute bronchitis (9%), and pneumonia (8%). Clinicians prescribed antibiotics in 22% of all visits: 65% of visits with antibiotic-appropriate diagnoses and 4% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed diagnostic uncertainty in 16% of all visits: 43% of visits with antibiotic-appropriate diagnoses and 5% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed uncertainty more often when prescribing antibiotics than when not prescribing antibiotics (30% vs. 12%; p < 0.001). As the number of visit diagnoses increased from 1 to 2 to ≥ 3, clinicians were more likely to express diagnostic uncertainty (5%, 25%, 40%, respectively; p < 0.001) and prescribe antibiotics (16%, 25%, 41%, respectively; p < 0.001). Conclusions Acute cough may be more complex and have more diagnostic uncertainty than guidelines and performance measures presume. Efforts to reduce antibiotic prescribing for acute cough should address diagnostic complexity and uncertainty that clinicians face. PMID:23957228

"Psychiatry is not a science like others" - a focus group study on psychotropic prescribing in primary care.

PubMed

Hedenrud, Tove M; Svensson, Staffan A; Wallerstedt, Susanna M

2013-08-12

Psychotropic drug prescribing is problematic and knowledge of factors affecting the initiation and maintenance of such prescribing is incomplete. Such knowledge could provide a basis for the design of interventions to change prescribing patterns for psychotropics. The aim of this study was to explore the views of general practitioners (GPs), GP interns, and heads of primary care units on factors affecting the prescribing of psychotropic drugs in primary care. We performed four focus group discussions in Gothenburg, Sweden, with a total of 21 participants (GPs, GP interns, and heads of primary care units). The focus group discussions were transcribed verbatim and analyzed using manifest content analysis. Three different themes emerged from the focus group discussions. The first theme Seeking care for symptoms, reflects the participants' understanding of why patients approach primary care and comprised categories such as knowledge, attitudes, and society and the media. The second theme, Lacking a framework, resources, and treatment alternatives, which reflects the conditions for the physician-patient interaction, comprised categories such as economy and resources, technology, and organizational aspects. The third theme, Restricting or maintaining prescriptions, with the subthemes Individual factors and External influences, reflects the physicians' internal decision making and comprised categories such as emotions, knowledge, and pharmaceutical industry. The results of the present study indicate that a variety of factors may affect the prescribing of psychotropic medications in primary care. Many factors were related to characteristics of the patient, the physician or their interaction, rather than the patients' medical needs per se. The results may be useful for interventions to improve psychotropic prescribing in primary care.

Physicians' Perception of Teratogenic Risk and Confidence in Prescribing Drugs in Pregnancy-Influence of Norwegian Drug Information Centers.

PubMed

Bakkebø, Tina; Widnes, Sofia Frost; Aamlid, Synnøve Stubmo; Schjøtt, Jan

2016-05-01

Clinical decision support provided by drug information centers is an intervention that can ensure rational drug therapy for pregnant women. We have examined whether physicians' teratogenic risk perceptions and confidence in prescribing drugs to pregnant women is altered after advice from the Norwegian drug information centers, Regional Medicines and Pharmacovigilance Centres i Norway (RELIS). Physicians who consulted RELIS for advice on patient-specific drug use in pregnancy from November 2013 to April 2014 completed questionnaires before and after receiving the advice. A scale from 1 to 7 was used to rate confidence in prescribing and perception of teratogenic risk. The lower part of the scale represented a low perception of teratogenic risk and a high confidence in prescribing a drug in pregnancy. The data were analyzed using a mixed linear model. A total of 45 physicians participated in the study and they assessed 64 drugs or categories of drugs. Advice from RELIS increased confidence in prescribing, with a statistically significant mean change on the scale from 4.1 to 2.9. The assessment of teratogenic risk was reduced after advice from RELIS, with a mean change from 3.2 to 2.5, though this was not significant. A subgroup of 26 physicians completed questionnaires both before and after advice from RELIS and assessed a total of 32 drugs or categories of drugs. In 94% of these assessments, advice from RELIS altered the physician's confidence in prescribing. Perception of teratogenic risk was altered in 78% of the assessments. Our results show that physicians' perception of teratogenic risk and confidence in prescribing drugs to pregnant women is influenced by advice from Norwegian drug information centers. Copyright © 2016 Elsevier HS Journals, Inc. All rights reserved.

Warts (For Parents)

MedlinePlus

... Plantar warts. Found on the bottom of the foot, plantar warts can be very uncomfortable — like walking on a small stone. Filiform warts. These have a finger-like shape, are usually flesh-colored, and often grow on ...

Diabetes and Sexual and Urologic Problems

MedlinePlus

... lead to low sexual desire and response. Painful sex Some women with diabetes say they have uncomfortable ... and prevent you from enjoying activities, including having sex. Although some yeast infections can be treated at ...

Bladder catheterization, male (image)

MedlinePlus

... kept empty (decompressed) and urinary flow assured. The balloon holds the catheter in place for a duration of time. Catheterization in males is slightly more difficult and uncomfortable than in females because of the longer urethra.

Talking to Your Child about Menstruation

MedlinePlus

... with the details should depend on your child's maturity and ability to understand. Throughout childhood, kids ask ... two, what matters is a girl's physical and emotional comfort. A tampon can be uncomfortable in the ...

Research to support optimization of prescription drug monitoring programs.

PubMed

Doyle, Sheri; Leichtling, Gillian; Hildebran, Christi; Reilly, Cynthia

2017-11-01

Research is needed to evaluate the impact of prescription drug monitoring programs (PDMPs). This paper describes research priorities for PDMPs that were initially discussed at a 2015 meeting of PDMP administrators, researchers, public health officials, and other stakeholders. Meeting participants defined the current landscape of PDMP research and identified research gaps. Research priorities were grouped by theme. Prescription drug monitoring program research priorities were identified for 3 key areas: individual patient health outcomes, prescriber use and decision making, and population-level outcomes. Research areas for individual patient outcomes include examining drug-use thresholds that best predict risk for overdose or substance use disorder and unintended consequences of PDMP use. Proposed research on prescriber PDMP use include evaluating how enhancements to the content and format of PDMP reports informs clinical decision making and optimal clinician actions in response to a concerning PDMP report. Finally, research topics related to population-level outcomes include measuring the impact of PDMP policies on the incidence of substance misuse and harms and assessing the return on investment for these databases. The clinical, public health, and economic impacts of PDMPs must be evaluated, using both quantitative and qualitative methods. In addition to assessing patient outcomes, qualitative research should examine how clinicians use and interpret PDMP information. Research should also examine the impact of PDMP features and policies on prescriber utilization. Comparative analyses across states with differing PDMP policies should be conducted to inform best practices. Copyright © 2017 John Wiley & Sons, Ltd.

75 FR 76968 - Energy Conservation Program for Consumer Products: Decision and Order Granting a Waiver to the...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-10

... III of the Energy Policy and Conservation Act (EPCA) sets forth a variety of provisions designed to... procedures that are reasonably designed to produce results that measure energy efficiency, energy use, or... more design characteristics that prevent testing according to the prescribed test procedure, or (2...

78 FR 65623 - Decision and Order Granting a Waiver to Samsung From the Department of Energy Residential...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-01

... B authorizes the Secretary of Energy to prescribe test procedures that are reasonably designed to... for which the petition for waiver was submitted contains one or more design characteristics that... to provide materially inaccurate comparative data. 10 CFR 430.27(a)(1). Petitioners must include in...

Career and Life Management 20: Prescribed Course of Studies.

ERIC Educational Resources Information Center

Alberta Dept. of Education, Edmonton. Curriculum Branch.

The Career and Life Management 20 course is required of Alberta, Canada senior high school students. Through the course students are to be given the opportunity to realistically set and plan for personal goals; assess and consider their own abilities; determine how their personal characteristics affect their learning and decision-making processes;…

77 FR 4857 - Agency Information Collection Activities: Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2012-01-31

... that might influence SSA's unfavorable determination. We may use the information to: (1) Reconsider and... appeal the decision. To request a hearing, individuals use Form HA-501, the associated Modernized Claims... prescribed time; is the proper party; and has taken the steps necessary to obtain the right to a hearing. SSA...

76 FR 33271 - Energy Conservation Program for Consumer Products: Decision and Order Granting a Waiver to...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-08

... authorizes the Secretary of Energy to prescribe test procedures that are reasonably designed to produce... conditions is met: (1) The petitioner's basic model contains one or more design characteristics that prevent..., BSH asserts, design characteristics of these models prevent testing according to the currently...

75 FR 62127 - Energy Conservation Program for Consumer Products: Decision and Order Granting a Waiver to...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-07

... Secretary of Energy to prescribe test procedures that are reasonably designed to produce results that... the Department of Energy Residential Dishwasher Test Procedure AGENCY: Office of Energy Efficiency and... (Whirlpool) a waiver from the DOE dishwasher test procedure for certain basic models containing integrated or...

78 FR 17925 - Energy Conservation Program for Consumer Products: Decision and Order Granting a Waiver to BSH...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-25

... test procedures that are reasonably designed to produce results that measure energy efficiency, energy... contains one or more design characteristics that prevent testing according to the prescribed test procedure... Department of Energy Residential Dishwasher Test Procedure AGENCY: Office of Energy Efficiency and Renewable...

78 FR 17927 - Energy Conservation Program for Consumer Products: Decision and Order Granting a Waiver to BSH...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-25

... test procedures that are reasonably designed to produce results that measure energy efficiency, energy... contains one or more design characteristics that prevent testing according to the prescribed test procedure... Department of Energy Residential Dishwasher Test Procedure AGENCY: Office of Energy Efficiency and Renewable...

5 CFR 9701.706 - MSPB appellate procedures.

Code of Federal Regulations, 2010 CFR

2010-01-01

... is based on a finding of discrimination prohibited under 5 U.S.C. 2302(b)(1), the payment of... discipline in the workplace, an arbitrator, adjudicating official, or MSPB may not modify the penalty imposed... allegations of discrimination, judicial review of any final MSPB order or decision is as prescribed under 5 U...

17 CFR 10.102 - Review of initial decisions.

Code of Federal Regulations, 2010 CFR

2010-04-01

... the appeal with respect to the issues presented, and the reasons therefor, and citations to supporting... answering brief generally shall follow the same style as prescribed for the appeal brief but may omit a... reference citations to the record contained in its brief or in any other document. If an appellee deems it...

Curriculum Decisions--The Challenges of Teacher Autonomy over Knowledge Selection for History

ERIC Educational Resources Information Center

Ormond, Barbara Mary

2017-01-01

This paper explores the challenges for teachers in positioning them as independent curriculum makers. History teachers in New Zealand have recently entered uncharted territory with the abandonment of prescribed topics for history and a new-found authority to determine the selection of historical knowledge taught to their senior secondary students.…

Adolescents' Commitment to Continuing Psychotropic Medication: A Preliminary Investigation of Considerations, Contradictions, and Correlates

ERIC Educational Resources Information Center

Moses, Tally

2011-01-01

This mixed-method study examines (1) the extent to which fifty adolescents receiving wraparound treatment and prescribed psychotropic medication for various psychiatric disorders report that they would continue taking medication if the decision was entirely their own (termed "medication commitment"); (2) their general subjective experiences with…

A Pilot Study of a Computerized Decision Support System to Detect Invasive Fungal Infection in Pediatric Hematology/Oncology Patients.

PubMed

Bartlett, Adam; Goeman, Emma; Vedi, Aditi; Mostaghim, Mona; Trahair, Toby; O'Brien, Tracey A; Palasanthiran, Pamela; McMullan, Brendan

2015-11-01

Computerized decision support systems (CDSSs) can provide indication-specific antimicrobial recommendations and approvals as part of hospital antimicrobial stewardship (AMS) programs. The aim of this study was to assess the performance of a CDSS for surveillance of invasive fungal infections (IFIs) in an inpatient hematology/oncology cohort. Between November 1, 2012, and October 31, 2013, pediatric hematology/oncology inpatients diagnosed with an IFI were identified through an audit of the CDSS and confirmed by medical record review. The results were compared to hospital diagnostic-related group (DRG) coding for IFI throughout the same period. A total of 83 patients were prescribed systemic antifungals according to the CDSS for the 12-month period. The CDSS correctly identified 19 patients with IFI on medical record review, compared with 10 patients identified by DRG coding, of whom 9 were confirmed to have IFI on medical record review. CDSS was superior to diagnostic coding in detecting IFI in an inpatient pediatric hematology/oncology cohort. The functionality of CDSS lends itself to inpatient infectious diseases surveillance but depends on prescriber adherence.

Patient and prescriber perspectives on long-acting injectable (LAI) antipsychotics and analysis of in-office discussion regarding LAI treatment for schizophrenia

PubMed Central

2013-01-01

Background The research goal is to better understand prescriber, patient, and caregiver perspectives about long-acting injectable (LAI) antipsychotic therapy and how these perspectives affect LAI use. Addressing these perspectives in the clinic may lead to greater success in achieving therapeutic goals for the patient with schizophrenia. Methods Ethnographic information was collected from a non-random sample of 69 prescriber-patient conversations (60 with community mental health center [CMHC] psychiatrists; 9 with nurse-practitioners) recorded during treatment visits from August 2011 to February 2012, transcribed and analyzed. Discussions were categorized according to 11 predetermined CMHC topics. In-person observations were also conducted at 4 CMHCs, including home visits by researchers (n = 15 patients) prior to the CMHC visit and observations of patients receiving injections and interacting with staff. Telephone in-depth interviews with psychiatrists, patients, and caregivers to gather additional information on LAI discussion, prescription, or use were conducted. Results Antipsychotic treatment decisions were made without patient or caregiver input in 40 of 60 (67%) of psychiatrist-patient conversations. Involvement of patients or caregivers in treatment decisions was greater when discussing LAI (15 of 60 [25%]) vs oral antipsychotic treatment (5 of 60 [8%]). LAIs were not discussed by psychiatrists in 11 of 22 (50%) patients taking oral antipsychotics. When offered, more LAI-naïve patients expressed neutral (9 of 19 [47%]) rather than favorable (3 of 19 [16%]) or unfavorable (7 of 19 [37%]) responses. Prescribers were most concerned about potentially damaging the therapeutic relationship and side-effects when discussing LAIs while patient resistance was often related to negative feelings about injections. Psychiatrists had some success in overcoming patient objections to LAIs by addressing and decomposing initial resistance. More than half (11 of 19 [58%]) of LAI-naïve patients agreed to start LAI treatment following office visits. Patient-described benefits of LAIs vs orals included perceived rapid symptom improvement and greater overall efficacy. Conclusions In this study, many psychiatrists did not offer LAIs and most patients and caregivers were not involved in antipsychotic treatment decision making. Opportunities to increase active patient engagement, address resistances, guide patient drug-formulation selection, and provide better LAI-relevant information for more individualized approaches to treating the patient with schizophrenia were present. PMID:24131801

Proposed regulations submitted by the Environmental Protection Agency to the FAA: moise abatement minimum altitudes for turbojet-powered airplanes in terminal areas; turbojet-powered airplanes. Decision not to prescribe requlations: delayed landing flap procedure

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1976-11-29

The Federal Aviation Administration has determined not to prescribe the proposed amendment to the FAA Regulations as submitted by the Environmental Protection Agency (40 F.R. 1072) on January 6, 1975, regarding noise abatement minimum altitudes for civil turbojet-powered airplanes. Instead, an internal directive is being issued aimed at the air traffic control function, which is designed to firmly integrate safety, fuel conservation, and noise abatement objectives into a single national program. It provides the flexibility needed to allow and encourage change with experience. (PCS)

A prospective, longitudinal study to evaluate the clinical utility of a predictive algorithm that detects risk of opioid use disorder.

PubMed

Brenton, Ashley; Lee, Chee; Lewis, Katrina; Sharma, Maneesh; Kantorovich, Svetlana; Smith, Gregory A; Meshkin, Brian

2018-01-01

The purpose of this study was to determine the clinical utility of an algorithm-based decision tool designed to assess risk associated with opioid use. Specifically, we sought to assess how physicians were using the profile in patient care and how its use affected patient outcomes. A prospective, longitudinal study was conducted to assess the utility of precision medicine testing in 5,397 patients across 100 clinics in the USA. Using a patent-protected, validated algorithm combining specific genetic risk factors with phenotypic traits, patients were categorized into low-, moderate-, and high-risk patients for opioid abuse. Physicians who ordered precision medicine testing were asked to complete patient evaluations and document their actions, decisions, and perceptions regarding the utility of the precision medicine tests. The patient outcomes associated with each treatment action were carefully documented. Physicians used the profile to guide treatment decisions for over half of the patients. Of those, guided treatment decisions for 24.5% of the patients were opioid related, including changing the opioid prescribed, starting an opioid, or titrating a patient off the opioid. Treatment guidance was strongly influenced by profile-predicted opioid use disorder (OUD) risk. Most importantly, patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, including better pain management by medication adjustments, with an average pain decrease of 3.4 points on a scale of 1-10. Patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, as measured by decreased pain levels resulting from better pain management with prescribed medications. The clinical utility of the profile is twofold. It provides clinically actionable recommendations that can be used to 1) prevent OUD through limiting initial opioid prescriptions and 2) reduce pain in patients at low risk of developing OUD.

A prospective, longitudinal study to evaluate the clinical utility of a predictive algorithm that detects risk of opioid use disorder

PubMed Central

Brenton, Ashley; Lee, Chee; Lewis, Katrina; Sharma, Maneesh; Kantorovich, Svetlana; Smith, Gregory A; Meshkin, Brian

2018-01-01

Purpose The purpose of this study was to determine the clinical utility of an algorithm-based decision tool designed to assess risk associated with opioid use. Specifically, we sought to assess how physicians were using the profile in patient care and how its use affected patient outcomes. Patients and methods A prospective, longitudinal study was conducted to assess the utility of precision medicine testing in 5,397 patients across 100 clinics in the USA. Using a patent-protected, validated algorithm combining specific genetic risk factors with phenotypic traits, patients were categorized into low-, moderate-, and high-risk patients for opioid abuse. Physicians who ordered precision medicine testing were asked to complete patient evaluations and document their actions, decisions, and perceptions regarding the utility of the precision medicine tests. The patient outcomes associated with each treatment action were carefully documented. Results Physicians used the profile to guide treatment decisions for over half of the patients. Of those, guided treatment decisions for 24.5% of the patients were opioid related, including changing the opioid prescribed, starting an opioid, or titrating a patient off the opioid. Treatment guidance was strongly influenced by profile-predicted opioid use disorder (OUD) risk. Most importantly, patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, including better pain management by medication adjustments, with an average pain decrease of 3.4 points on a scale of 1–10. Conclusion Patients whose physicians used the profile to guide opioid-related treatment decisions had improved clinical outcomes, as measured by decreased pain levels resulting from better pain management with prescribed medications. The clinical utility of the profile is twofold. It provides clinically actionable recommendations that can be used to 1) prevent OUD through limiting initial opioid prescriptions and 2) reduce pain in patients at low risk of developing OUD. PMID:29379313

Split WHO in two: strengthening political decision-making and securing independent scientific advice.

PubMed

Hoffman, Steven J; Røttingen, John-Arne

2014-02-01

The World Health Organization (WHO) has never fulfilled its original mission of simultaneously serving as the world's pre-eminent public health authority and intergovernmental platform for global health negotiations. While WHO's secretariat works hard to fulfill both functions, it is undermined by an institutional design that mixes technical and political mandates. This forces staff to walk uncomfortably along many fine lines: advising but never directing; guiding but never governing; leading but never advocating; evaluating but never judging. The result is mediocrity on both fronts. Instead, WHO should be split in two, separating its technical and political stewardship functions into separate entities, with collaboration in areas of overlap. The Executive Board and secretariat would be bifurcated, with technical units reporting to a Technical Board and political units reporting to a Political Board. Both boards would report to the World Health Assembly where all member states would continue to provide ultimate oversight. Such bold changes can be implemented either by revising WHO's constitution or through simpler mechanisms. Either way, structural governance reforms would need to be accompanied by complementary changes in culture that support strengthened political decision-making and scientific independence. States' inability to act on WHO's institutional design challenges will only lead them and non-state actors to continue bypassing the organization through the creation of new entities as they have done over the last 15 years. The key will be to mobilize those advocates and decision-makers who have the audacity to demand more from WHO and convince member states to elevate their ambitions in current WHO reform efforts. Continued progress in global health depends on it. Copyright © 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Primary Care Physicians' Collection, Comfort, and Use of Race and Ethnicity in Clinical Practice in the United States.

PubMed

Bonham, Vence L; Umeh, Nkeiruka I; Cunningham, Brooke A; Abdallah, Khadijah E; Sellers, Sherrill L; Cooper, Lisa A

2017-01-01

The clinical utility of race and ethnicity has been debated. It is important to understand if and how race and ethnicity are communicated and collected in clinical settings. We investigated physicians' self-reported methods of collecting a patient's race and ethnicity in the clinical encounter, their comfort with collecting race and ethnicity, and associations with use of race in clinical decision-making. A national cross-sectional study of 787 clinically active general internists in the United States. Physicians' self-reported comfort with collecting patient race and ethnicity, their collection practices, and use of race in clinical care were assessed. Bivariate and multivariable regression analyses were conducted to examine associations between comfort, collection practices, and use of race. Most physicians asked patients to self-report their race or ethnicity (26.5%) on an intake form or collected this information directly from patients (26.2%). Most physicians were comfortable collecting patient race and ethnicity (84.3%). Physicians who were more comfortable collecting patient race and ethnicity ( β = 1.65; [95% confidence interval; CI 0.03-3.28]) or who directly collected patients' race and ethnicity ( β = 1.24 [95% CI 0.07-2.41]) were more likely to use race in clinical decision-making than physicians who were uncomfortable. This study documents variation in physician comfort level and practice patterns regarding patient race and ethnicity data collection. As the U.S. population becomes more diverse, future work should examine how physicians speak about race and ethnicity with patients and their use of race and ethnicity data impact patient-physician relationships, clinical decision-making, and patient outcomes.

Impact of physicians' sex on treatment choices for low back pain.

PubMed

Veldhuijzen, Dieuwke S; Karhof, Steffi; Leenders, Marianne E C; Karsch, Anne Mieke; van Wijck, Albert J M

2013-07-01

Little information is available regarding physicians' sex as a potential bias in making pain treatment decisions. This study investigated how sex of the medical care provider and patient characteristics influence choices that are made in the treatment of low back pain. Data of 186 charts of patients with low back pain (46% males) who were seen by trained residents were analyzed in this retrospective observational study. The primary outcome was the first treatment choice that was made, which was categorized in three groups: pharmacological therapy; invasive procedures; or other options at the time of first consultation. Chi-square statistics and multinominal logistic regression analysis were used to examine associations between physicians' and/or patients' sex and treatment choices. Physicians' sex was found to be a significant predictor of the first decision that was made in the treatment of low back pain. Female physicians tended to prescribe more pharmacological agents as their first treatment choice. No significant sex differences were found for invasive therapies or other treatment options as a first choice. These findings were found to be independent from previous received pain therapies before consultation by the specialized pain clinician. Further, patients' sex did not influence decisions on pain management nor did gender concordance or discordance in the patient-physician relationship. Physicians' sex had a significant impact on pain management decisions in patients with low back pain. Female physicians prescribed more pharmacological agents as their first choice compared to male physicians. © 2012 The Authors Pain Practice © 2012 World Institute of Pain.

Working at the intersection of context, culture, and technology: Provider perspectives on antimicrobial stewardship in the emergency department using electronic health record clinical decision support.

PubMed

Chung, Phillip; Scandlyn, Jean; Dayan, Peter S; Mistry, Rakesh D

2017-11-01

Antibiotic stewardship programs (ASPs) have not been fully developed for the emergency department (ED), in part the result of the barriers characteristic of this setting. Electronic health record-based clinical decision support (EHR CDS) represents a promising strategy to implement ASPs in the ED. We aimed to determine the cultural beliefs and structural barriers and facilitators to implementation of antimicrobial stewardship in the pediatric ED using EHR CDS. Interviews and focus groups were conducted with hospital and ED leadership, attending ED physicians, nurse practitioners, physician assistants, and residents at a single health system in Colorado. We reviewed and coded the data using constant comparative analysis and framework analysis until a final set of themes emerged. Two dominant perceptions shaped providers' perspectives on ASPs in the ED and EHR CDS: (1) maintaining workflow efficiency and (2) constrained decision-making autonomy. Clinicians identified structural barriers to ASPs, such as pace of the ED, and various beliefs that shaped patterns of practice, including accommodating the prescribing decisions of other providers and managing parental expectations. Recommendations to enhance uptake focused on designing a simple yet flexible user interface, providing clinicians with performance data, and on-boarding clinicians to enhance buy-in. Developing a successful ED-based ASP using EHR CDS should attend to technologic needs, the institutional context, and the cultural beliefs of practice associated with providers' antibiotic prescribing. Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Identification of features of electronic prescribing systems to support quality and safety in primary care using a modified Delphi process.

PubMed

Sweidan, Michelle; Williamson, Margaret; Reeve, James F; Harvey, Ken; O'Neill, Jennifer A; Schattner, Peter; Snowdon, Teri

2010-04-15

Electronic prescribing is increasingly being used in primary care and in hospitals. Studies on the effects of e-prescribing systems have found evidence for both benefit and harm. The aim of this study was to identify features of e-prescribing software systems that support patient safety and quality of care and that are useful to the clinician and the patient, with a focus on improving the quality use of medicines. Software features were identified by a literature review, key informants and an expert group. A modified Delphi process was used with a 12-member multidisciplinary expert group to reach consensus on the expected impact of the features in four domains: patient safety, quality of care, usefulness to the clinician and usefulness to the patient. The setting was electronic prescribing in general practice in Australia. A list of 114 software features was developed. Most of the features relate to the recording and use of patient data, the medication selection process, prescribing decision support, monitoring drug therapy and clinical reports. The expert group rated 78 of the features (68%) as likely to have a high positive impact in at least one domain, 36 features (32%) as medium impact, and none as low or negative impact. Twenty seven features were rated as high positive impact across 3 or 4 domains including patient safety and quality of care. Ten features were considered "aspirational" because of a lack of agreed standards and/or suitable knowledge bases. This study defines features of e-prescribing software systems that are expected to support safety and quality, especially in relation to prescribing and use of medicines in general practice. The features could be used to develop software standards, and could be adapted if necessary for use in other settings and countries.

Identification of features of electronic prescribing systems to support quality and safety in primary care using a modified Delphi process

PubMed Central

2010-01-01

Background Electronic prescribing is increasingly being used in primary care and in hospitals. Studies on the effects of e-prescribing systems have found evidence for both benefit and harm. The aim of this study was to identify features of e-prescribing software systems that support patient safety and quality of care and that are useful to the clinician and the patient, with a focus on improving the quality use of medicines. Methods Software features were identified by a literature review, key informants and an expert group. A modified Delphi process was used with a 12-member multidisciplinary expert group to reach consensus on the expected impact of the features in four domains: patient safety, quality of care, usefulness to the clinician and usefulness to the patient. The setting was electronic prescribing in general practice in Australia. Results A list of 114 software features was developed. Most of the features relate to the recording and use of patient data, the medication selection process, prescribing decision support, monitoring drug therapy and clinical reports. The expert group rated 78 of the features (68%) as likely to have a high positive impact in at least one domain, 36 features (32%) as medium impact, and none as low or negative impact. Twenty seven features were rated as high positive impact across 3 or 4 domains including patient safety and quality of care. Ten features were considered "aspirational" because of a lack of agreed standards and/or suitable knowledge bases. Conclusions This study defines features of e-prescribing software systems that are expected to support safety and quality, especially in relation to prescribing and use of medicines in general practice. The features could be used to develop software standards, and could be adapted if necessary for use in other settings and countries. PMID:20398294

What drives the prescribing of growth hormone preparations in England? Prices versus patient preferences

PubMed Central

Chapman, Stephen R; Fitzpatrick, Raymond W; Aladul, Mohammed I

2017-01-01

Objective The patent expiry of a number of biological medicines and the advent of biosimilars raised the expectations of healthcare commissioners that biosimilars would reduce the high cost of these medicines and produce potential savings to the NHS. We aimed to examine the prescribing pattern of different growth hormone preparations (ready to use and reconstitution requiring) in primary and secondary care in England to determine relative rates of decrease or increase and identify the possible factors influencing prescribing following the introduction of biosimilar growth hormone in 2008. Design Longitudinal observational study. Setting and data sources Primary care prescribing cost and volume data was derived from the NHS business services authority website, and for secondary care from the DEFINE database, between April 2011 and December 2015. Outcomes Quarterly prescribing analysis to examine trends and measure the relationship between usage and price. Results Expenditure and usage of growth hormone in primary care decreased by 17.91% and 7.29%, respectively, whereas expenditure and usage in secondary care increased by 68.41% and 100%, respectively, between April 2011 and December 2015. The usage of reconstitution requiring products significantly declined in primary care (R²=0.9292) and slightly increased in use in secondary care (R²=0.139). In contrast, the usage of ready-to-use products significantly increased in use in primary (R²=0.7526) and secondary care (R²=0.9633), respectively. Weak or no correlation existed between the usage and price of growth hormone preparations in primary and secondary care. Conclusions The price of growth hormone products was not the key factor influencing the prescribing of the biological medicines. The main driver for specific product selection was the ease of use and the number of steps in dose preparation. Prescribers appear to be taking into account patient preferences rather than cost in their prescribing decisions. PMID:28400458

What drives the prescribing of growth hormone preparations in England? Prices versus patient preferences.

PubMed

Chapman, Stephen R; Fitzpatrick, Raymond W; Aladul, Mohammed I

2017-04-11

The patent expiry of a number of biological medicines and the advent of biosimilars raised the expectations of healthcare commissioners that biosimilars would reduce the high cost of these medicines and produce potential savings to the NHS. We aimed to examine the prescribing pattern of different growth hormone preparations (ready to use and reconstitution requiring) in primary and secondary care in England to determine relative rates of decrease or increase and identify the possible factors influencing prescribing following the introduction of biosimilar growth hormone in 2008. Longitudinal observational study. Primary care prescribing cost and volume data was derived from the NHS business services authority website, and for secondary care from the DEFINE database, between April 2011 and December 2015. Quarterly prescribing analysis to examine trends and measure the relationship between usage and price. Expenditure and usage of growth hormone in primary care decreased by 17.91% and 7.29%, respectively, whereas expenditure and usage in secondary care increased by 68.41% and 100%, respectively, between April 2011 and December 2015. The usage of reconstitution requiring products significantly declined in primary care (R²=0.9292) and slightly increased in use in secondary care (R²=0.139). In contrast, the usage of ready-to-use products significantly increased in use in primary (R²=0.7526) and secondary care (R²=0.9633), respectively. Weak or no correlation existed between the usage and price of growth hormone preparations in primary and secondary care. The price of growth hormone products was not the key factor influencing the prescribing of the biological medicines. The main driver for specific product selection was the ease of use and the number of steps in dose preparation. Prescribers appear to be taking into account patient preferences rather than cost in their prescribing decisions. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01] - study protocol and baseline practice and provider characteristics

PubMed Central

2013-01-01

Background Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians. Methods/design The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider’s rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease. Discussion The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics. Trials registration ClinicalTrials.gov: NCT01454947 PMID:23806017

Development and Evaluation of an Ontology for Guiding Appropriate Antibiotic Prescribing

PubMed Central

Furuya, E. Yoko; Kuperman, Gilad J.; Cimino, James J.; Bakken, Suzanne

2011-01-01

Objectives To develop and apply formal ontology creation methods to the domain of antimicrobial prescribing and to formally evaluate the resulting ontology through intrinsic and extrinsic evaluation studies. Methods We extended existing ontology development methods to create the ontology and implemented the ontology using Protégé-OWL. Correctness of the ontology was assessed using a set of ontology design principles and domain expert review via the laddering technique. We created three artifacts to support the extrinsic evaluation (set of prescribing rules, alerts and an ontology-driven alert module, and a patient database) and evaluated the usefulness of the ontology for performing knowledge management tasks to maintain the ontology and for generating alerts to guide antibiotic prescribing. Results The ontology includes 199 classes, 10 properties, and 1,636 description logic restrictions. Twenty-three Semantic Web Rule Language rules were written to generate three prescribing alerts: 1) antibiotic-microorganism mismatch alert; 2) medication-allergy alert; and 3) non-recommended empiric antibiotic therapy alert. The evaluation studies confirmed the correctness of the ontology, usefulness of the ontology for representing and maintaining antimicrobial treatment knowledge rules, and usefulness of the ontology for generating alerts to provide feedback to clinicians during antibiotic prescribing. Conclusions This study contributes to the understanding of ontology development and evaluation methods and addresses one knowledge gap related to using ontologies as a clinical decision support system component—a need for formal ontology evaluation methods to measure their quality from the perspective of their intrinsic characteristics and their usefulness for specific tasks. PMID:22019377

Development and evaluation of an ontology for guiding appropriate antibiotic prescribing.

PubMed

Bright, Tiffani J; Yoko Furuya, E; Kuperman, Gilad J; Cimino, James J; Bakken, Suzanne

2012-02-01

To develop and apply formal ontology creation methods to the domain of antimicrobial prescribing and to formally evaluate the resulting ontology through intrinsic and extrinsic evaluation studies. We extended existing ontology development methods to create the ontology and implemented the ontology using Protégé-OWL. Correctness of the ontology was assessed using a set of ontology design principles and domain expert review via the laddering technique. We created three artifacts to support the extrinsic evaluation (set of prescribing rules, alerts and an ontology-driven alert module, and a patient database) and evaluated the usefulness of the ontology for performing knowledge management tasks to maintain the ontology and for generating alerts to guide antibiotic prescribing. The ontology includes 199 classes, 10 properties, and 1636 description logic restrictions. Twenty-three Semantic Web Rule Language rules were written to generate three prescribing alerts: (1) antibiotic-microorganism mismatch alert; (2) medication-allergy alert; and (3) non-recommended empiric antibiotic therapy alert. The evaluation studies confirmed the correctness of the ontology, usefulness of the ontology for representing and maintaining antimicrobial treatment knowledge rules, and usefulness of the ontology for generating alerts to provide feedback to clinicians during antibiotic prescribing. This study contributes to the understanding of ontology development and evaluation methods and addresses one knowledge gap related to using ontologies as a clinical decision support system component-a need for formal ontology evaluation methods to measure their quality from the perspective of their intrinsic characteristics and their usefulness for specific tasks. Copyright © 2011 Elsevier Inc. All rights reserved.

Assessment of a simulated contraceptive prescribing activity for pharmacy students.

PubMed

Lynch, Sarah E; Griffin, Brooke L; Vest, Kathleen M

2018-02-01

The role of the pharmacist has been shifting rapidly. One example of change is the passage of legislation allowing pharmacists to independently initiate self-administered hormonal contraceptives in several states. There is no evidence of this specific topic being covered in pharmacy school curricula, and many states are requiring additional post-graduate training. This activity was designed to determine the utility of a contraceptive prescribing simulation activity for pharmacy students. Pharmacy students enrolled in a women's health elective learned about relevant state legislation and attended a clinical skills center simulation activity where they utilized an available prescribing algorithm. Students completed two scenarios and received grades based on their clinical decision-making and patient interaction skills. An electronic survey was distributed post-activity to assess student satisfaction and confidence when prescribing contraceptives. Responses and grades on the assignment were analyzed to determine the activity's utility. Students finished with median scores of 15, 14.8, and 14.5 out of 15 possible points for the three scenarios. Students reported overall satisfaction with the activity, with general agreement that the activity was realistic and made them feel like they were prepared to prescribe contraceptives. Independently initiating contraceptives is a novel practice area for pharmacists. This activity introduced students to the process of prescribing using realistic forms and scenarios. The utility of the activity was twofold - it introduced students to the changing environment of pharmacy practice and allowed students to apply their knowledge of contraceptives and women's health. Students performed well on the activity and reported high levels of satisfaction. Copyright © 2017 Elsevier Inc. All rights reserved.

A Computer Prescribing Order Entry-Clinical Decision Support system designed for neonatal care: results of the 'preselected prescription' concept at the bedside.

PubMed

Gouyon, B; Iacobelli, S; Saliba, E; Quantin, C; Pignolet, A; Jacqz-Aigrain, E; Gouyon, J B

2017-02-01

The neonatal intensive care units (NICUs) are at the highest risk of drug dose error of all hospital wards. NICUs also have the most complicated prescription modalities. The computerization of the prescription process is currently recommended to decrease the risk of preventable adverse drug effects (pADEs) in NICUs. However, Computer Prescribing Order Entry-Clinical Decision Support (C.P.O.E./C.D.S.) systems have been poorly studied in NICUs, and their technical compatibility with neonatal specificities has been limited. We set up a performance study of the preselected prescription of drugs for neonates, which limited the role of the prescriber to choosing the drugs and their indications. A single 29 bed neonatal ward used this neonatal C.P.O.E./C.D.S. system for all prescriptions of all hospitalized newborns over an 18-month period. The preselected prescription of drugs was based on the indication, gestational age, body weight and post-natal age. The therapeutic protocols were provided by a formulary reference (330 drugs) that had been specifically designed for newborns. The preselected prescription also gave complete information about preparation and administration of drugs by nurses. The prescriber was allowed to modify the preselected prescription but alarms provided warning when the prescription was outside the recommended range. The main clinical characteristics and all items of each line of prescription were stored in a data warehouse, thus enabling this study to take place. Seven hundred and sixty successive newborns (from 24 to 42 weeks' gestation) were prescribed 52 392 lines of prescription corresponding to 65 drugs; About 30·4% of neonates had at least one out of licensed prescription; A prescription out of the recommended range for daily dose was recorded for 1·0% of all drug prescriptions. WHAT IS NEW?: The C.P.O.E./C.D.S. systems can currently provide a complete preselected prescription in NICUs according to dose rules, which are specific to newborns and also comply with local specificities (therapeutic protocols and formulation of drugs). The role of the prescriber is limited to the choice of drugs and their indications. The prescriber still retains the possibility of modifying each item of the prescription, with all other prescription items being calculated by the C.P.O.E. system. In these conditions, the prescribers rarely modified the preselected prescription and the rate of out of range prescription was low. A multicentric study is required to confirm and extend these observations. This study showed the feasibility of preselected prescription in NICUs and a low rate of out of range prescriptions. The preselected prescription could play a key role in lowering the dose error rate in NICUs. © 2016 John Wiley & Sons Ltd.

Alert dwell time: introduction of a measure to evaluate interruptive clinical decision support alerts

PubMed Central

McDaniel, Robert B; Burlison, Jonathan D; Baker, Donald K; Hasan, Murad; Robertson, Jennifer; Hartford, Christine; Howard, Scott C; Sablauer, Andras

2016-01-01

Metrics for evaluating interruptive prescribing alerts have many limitations. Additional methods are needed to identify opportunities to improve alerting systems and prevent alert fatigue. In this study, the authors determined whether alert dwell time—the time elapsed from when an interruptive alert is generated to when it is dismissed—could be calculated by using historical alert data from log files. Drug–drug interaction (DDI) alerts from 3 years of electronic health record data were queried. Alert dwell time was calculated for 25,965 alerts, including 777 unique DDIs. The median alert dwell time was 8 s (range, 1–4913 s). Resident physicians had longer median alert dwell times than other prescribers (P < .001). The 10 most frequent DDI alerts (n = 8759 alerts) had shorter median dwell times than alerts that only occurred once (P < .001). This metric can be used in future research to evaluate the effectiveness and efficiency of interruptive prescribing alerts. PMID:26499101

Therapeutic, prophylactic, untoward, and contraceptive effects of combined oral contraceptives: catholic teaching, natural law, and the principle of double effect when deciding to prescribe and use.

PubMed

Casey, Murray Joseph; Salzman, Todd A

2014-01-01

Combined oral contraceptives (COC) have been demonstrated to have significant benefits for the treatment and prevention of disease. These medications also are associated with untoward health effects, and they may be directly contraceptive. Prescribers and users must compare and weigh the intended beneficial health effects against foreseeable but unintended possible adverse effects in their decisions to prescribe and use. Additionally, those who intend to abide by Catholic teachings must consider prohibitions against contraception. Ethical judgments concerning both health benefits and contraception are approached in this essay through an overview of the therapeutic, prophylactic, untoward, and contraceptive effects of COC and discussion of magisterial and traditional Catholic teachings from natural law. Discerning through the principle of double effect, proportionate reason, and evidence gathered from the sciences, medical and moral conclusions are drawn that we believe to be fully compliant with good medicine and Catholic teaching.

(Too) optimistic about optimism: the belief that optimism improves performance.

PubMed

Tenney, Elizabeth R; Logg, Jennifer M; Moore, Don A

2015-03-01

A series of experiments investigated why people value optimism and whether they are right to do so. In Experiments 1A and 1B, participants prescribed more optimism for someone implementing decisions than for someone deliberating, indicating that people prescribe optimism selectively, when it can affect performance. Furthermore, participants believed optimism improved outcomes when a person's actions had considerable, rather than little, influence over the outcome (Experiment 2). Experiments 3 and 4 tested the accuracy of this belief; optimism improved persistence, but it did not improve performance as much as participants expected. Experiments 5A and 5B found that participants overestimated the relationship between optimism and performance even when their focus was not on optimism exclusively. In summary, people prescribe optimism when they believe it has the opportunity to improve the chance of success-unfortunately, people may be overly optimistic about just how much optimism can do. PsycINFO Database Record (c) 2015 APA, all rights reserved.

Why are antibiotics prescribed for asymptomatic bacteriuria in institutionalized elderly people? A qualitative study of physicians' and nurses' perceptions.

PubMed

Walker, S; McGeer, A; Simor, A E; Armstrong-Evans, M; Loeb, M

2000-08-08

Antibiotic therapy for asymptomatic bacteriuria in institutionalized elderly people has not been shown to be of benefit and may in fact be harmful; however, antibiotics are still frequently used to treat asymptomatic bacteriuria in this population. The aim of this study was to explore the perceptions, attitudes and opinions of physicians and nurses involved in the process of prescribing antibiotics for asymptomatic bacteriuria in institutionalized elderly people. Focus groups were conducted among physicians and nurses who provide care to residents of long-term care facilities in Hamilton, Ont. A total of 22 physicians and 16 nurses participated. The focus group discussions were tape-recorded, and the transcripts of each session were analysed for issues and themes emerging from the text. Content analysis using an open analytic approach was used to explore and understand the experience of the focus group participants. The data from the text were then coded according to the relevant and emergent themes and issues. We observed that the ordering of urine cultures and the prescribing of antibiotics for residents with asymptomatic bacteriuria were influenced by a wide range of nonspecific symptoms or signs in residents. The physicians felt that the presence of these signs justified a decision to order antibiotics. Nurses played a central role in both the ordering of urine cultures and the decision to prescribe antibiotics through their awareness of changes in residents' status and communication of this to physicians. Education about asymptomatic bacteriuria was viewed as an important priority for both physicians and nurses. The presence of non-urinary symptoms and signs is an important factor in the prescription of antibiotics for asymptomatic bacteriuria in institutionalized elderly people. However, no evidence exists to support this reason for antibiotic treatment. Health care providers at long-term care facilities need more education about antibiotic use and asymptomatic bacteriuria.

Protocol for evaluation of the cost-effectiveness of ePrescribing systems and candidate prototype for other related health information technologies

PubMed Central

2014-01-01

Background This protocol concerns the assessment of cost-effectiveness of hospital health information technology (HIT) in four hospitals. Two of these hospitals are acquiring ePrescribing systems incorporating extensive decision support, while the other two will implement systems incorporating more basic clinical algorithms. Implementation of an ePrescribing system will have diffuse effects over myriad clinical processes, so the protocol has to deal with a large amount of information collected at various ‘levels’ across the system. Methods/Design The method we propose is use of Bayesian ideas as a philosophical guide. Assessment of cost-effectiveness requires a number of parameters in order to measure incremental cost utility or benefit – the effectiveness of the intervention in reducing frequency of preventable adverse events; utilities for these adverse events; costs of HIT systems; and cost consequences of adverse events averted. There is no single end-point that adequately and unproblematically captures the effectiveness of the intervention; we therefore plan to observe changes in error rates and adverse events in four error categories (death, permanent disability, moderate disability, minimal effect). For each category we will elicit and pool subjective probability densities from experts for reductions in adverse events, resulting from deployment of the intervention in a hospital with extensive decision support. The experts will have been briefed with quantitative and qualitative data from the study and external data sources prior to elicitation. Following this, there will be a process of deliberative dialogues so that experts can “re-calibrate” their subjective probability estimates. The consolidated densities assembled from the repeat elicitation exercise will then be used to populate a health economic model, along with salient utilities. The credible limits from these densities can define thresholds for sensitivity analyses. Discussion The protocol we present here was designed for evaluation of ePrescribing systems. However, the methodology we propose could be used whenever research cannot provide a direct and unbiased measure of comparative effectiveness. PMID:25038609

Compensation procedures for facial asymmetries.

PubMed

Kozol, F

1995-01-01

Why would a patient complain of "fuzzy and uncomfortable" vision with a variety of glasses? Perhaps because the practitioner has failed to take facial asymmetry into account. Methods of measuring facial asymmetry and optically correcting for it are discussed.

Estimation of Comfortable/Uncomfortable Feeling Based on EEG by Using NN and k-means Algorithm for Massage Chair

NASA Astrophysics Data System (ADS)

Teramae, Tatsuya; Kushida, Daisuke; Takemori, Fumiaki; Kitamura, Akira

A present massage chair realizes the massage motion and force designed by a professional masseur. However, appropriate massage force to the user can not be provided by the massage chair in such a method. On the other hand, the professional masseur can realize an appropriate massage force to more than one patient, because, the masseur considers the physical condition of the patient. Our research proposed the intelligent massage system of applying masseur's procedure for the massage chair using estimated skin elasticity and DB to relate skin elasticity and massage force. However, proposed system has a problem that DB does not adjust to unknown user, because user's feeling by massage can not be estimated. Then, this paper proposed the estimation method of comfortable/uncomfortable feeling based on EEG using the neural network and k-means algorithm. The realizability of the proposed method is verified by the experimental works.

Ambient intelligence application based on environmental measurements performed with an assistant mobile robot.

PubMed

Martinez, Dani; Teixidó, Mercè; Font, Davinia; Moreno, Javier; Tresanchez, Marcel; Marco, Santiago; Palacín, Jordi

2014-03-27

This paper proposes the use of an autonomous assistant mobile robot in order to monitor the environmental conditions of a large indoor area and develop an ambient intelligence application. The mobile robot uses single high performance embedded sensors in order to collect and geo-reference environmental information such as ambient temperature, air velocity and orientation and gas concentration. The data collected with the assistant mobile robot is analyzed in order to detect unusual measurements or discrepancies and develop focused corrective ambient actions. This paper shows an example of the measurements performed in a research facility which have enabled the detection and location of an uncomfortable temperature profile inside an office of the research facility. The ambient intelligent application has been developed by performing some localized ambient measurements that have been analyzed in order to propose some ambient actuations to correct the uncomfortable temperature profile.

Ambient Intelligence Application Based on Environmental Measurements Performed with an Assistant Mobile Robot

PubMed Central

Martinez, Dani; Teixidó, Mercè; Font, Davinia; Moreno, Javier; Tresanchez, Marcel; Marco, Santiago; Palacín, Jordi

2014-01-01

This paper proposes the use of an autonomous assistant mobile robot in order to monitor the environmental conditions of a large indoor area and develop an ambient intelligence application. The mobile robot uses single high performance embedded sensors in order to collect and geo-reference environmental information such as ambient temperature, air velocity and orientation and gas concentration. The data collected with the assistant mobile robot is analyzed in order to detect unusual measurements or discrepancies and develop focused corrective ambient actions. This paper shows an example of the measurements performed in a research facility which have enabled the detection and location of an uncomfortable temperature profile inside an office of the research facility. The ambient intelligent application has been developed by performing some localized ambient measurements that have been analyzed in order to propose some ambient actuations to correct the uncomfortable temperature profile. PMID:24681671

Uncomfortable realities: the challenge of creating real change in Europe's consolidating hospital sector.

PubMed

Jeurissen, Patrick; Duran, Antonio; Saltman, Richard B

2016-05-24

This article examines uncomfortable realities that the European hospital sector currently faces and the potential impact of wide-spread rationalization policies such as (hospital) payment reform and privatization. Review of relevant international literature. Based on the evidence we present, rationalization policies such as (hospital) payment reform and privatization will probably fall short in delivering better quality of care and lower growth in health expenses. Reasons can be sought in a mix of evidence on the effectiveness of these rationalization policies. Nevertheless, pressures for different business models will gradually continue to increase and it seems safe to assume that more value-added process business and facilitated network models will eventually emerge. The overall argument of this article holds important implications for future research: how can policymakers generate adequate leverage to introduce such changes without destroying necessary hospital capacity and the ability to produce quality healthcare.

38 CFR 1.941 - Suspension of collection activity.

Code of Federal Regulations, 2010 CFR

2010-07-01

... administrative offset prescribed by 31 U.S.C. 3716(e)(1); or (3) The debtor agrees to pay interest on the amount... decision on the administrative review or waiver request. (d) When VA learns that a bankruptcy petition has... automatic stay does not apply, has been lifted, or is no longer in effect. VA shall seek legal advice...

78 FR 53448 - Energy Conservation Program for Consumer Products: Decision and Order Granting a Waiver to BSH...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-29

... Secretary of Energy to prescribe test procedures that are reasonably designed to produce results which... conditions is met: (1) The petitioner's basic model contains one or more design characteristics that prevent... to provide materially inaccurate comparative data. (10 CFR 430.27(a)(1)) Petitioners must include in...

77 FR 68752 - Decision and Order Granting a Waiver Granted to Fujitsu General Limited From the Department of...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-16

... prescribe test procedures that are reasonably designed to produce results that measure energy efficiency... one of the following conditions is met: (1) The petitioner's basic model contains one or more design... provide materially inaccurate comparative data. 10 CFR 431.401(a)(1). Petitioners must include in their...

Pain Management: Knowledge and Attitudes of Senior Nursing Students and Practicing Registered Nurses

ERIC Educational Resources Information Center

Messmer, Sherry

2009-01-01

Despite scientific advances in pain management, inadequate pain relief in hospitalized patients continues to be an on-going phenomenon. Although nurses do not prescribe medication for pain, the decision to administer pharmacological or other interventions for pain relief is part of nursing practice. Nurses play a critical role in the relief of…

3 CFR 8610 - Proclamation 8610 of December 1, 2010. National Impaired Driving Prevention Month, 2010

Code of Federal Regulations, 2011 CFR

2011-01-01

... sober, drug-free, and safe on the road. Impaired driving and its consequences can seriously alter or..., but also the growing problem of drugged driving. Drugs, including those prescribed by a physician, can... to make responsible decisions when driving or riding as a passenger, especially if drug use is...

Modeling fire and other disturbance processes using LANDIS

Treesearch

Stephen R. Shifley; Jian Yang; Hong He

2009-01-01

LANDIS is a landscape decision support tool that models spatial relationships to help managers and planners examine the large-scale, long-term, cumulative effects of succession, harvesting, wildfire, prescribed fire, insects, and disease. It can operate on forest landscapes from a few thousand to a few million acres in extent. Fire modeling capabilities in LANDIS are...

Integrative complexity of wildfire management: development of a scale

Treesearch

Joshua Carroll; Alan Bright

2007-01-01

Wildfire in the West has become a controversial natural resource issue that has divided the public's perceptions regarding its management, and forest managers are now faced with the difficult task of making sound decisions while balancing these varying concerns. Two widely used wildfi re management practices are prescribed fire and mechanical thinning. In order to...

20 CFR 416.556 - Waiver of adjustment or recovery-countable resources in excess of the limits prescribed in § 416...

Code of Federal Regulations, 2010 CFR

2010-04-01

... recovery of the subsequent overpayment. In making any determination or decision under this section... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Waiver of adjustment or recovery-countable... Employees' Benefits SOCIAL SECURITY ADMINISTRATION SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND...

Influences on USFS District Rangers' Decision to Authorize Wildland Fire Use

Treesearch

Martha A. Williamson

2006-01-01

United States wildland fire policy and program reviews in 1995 and 2000 required reduction of hazardous fuel and recognition of fire as a natural process. Although an existing policy, Wildland Fire Use (WFU), permitted managing natural ignitions to meet resource benefits, most fuel reduction is still achieved through mechanical treatments and prescribed burning....

20 CFR 703.205 - Filing of Agreement and Undertaking; deposit of security.

Code of Federal Regulations, 2011 CFR

2011-04-01

... Agreement and Undertaking, in a form prescribed and provided by OWCP, in which the carrier shall agree to... Branch, at its discretion, to bring suit under any deposited indemnity bond or to draw upon any deposited... Office's decision: (1) In the form of an indemnity bond with sureties satisfactory to the Branch and in...

20 CFR 703.205 - Filing of Agreement and Undertaking; deposit of security.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Agreement and Undertaking, in a form prescribed and provided by OWCP, in which the carrier shall agree to... Branch, at its discretion, to bring suit under any deposited indemnity bond or to draw upon any deposited... Office's decision: (1) In the form of an indemnity bond with sureties satisfactory to the Branch and in...

20 CFR 703.205 - Filing of Agreement and Undertaking; deposit of security.

Code of Federal Regulations, 2014 CFR

2014-04-01

... Agreement and Undertaking, in a form prescribed and provided by OWCP, in which the carrier shall agree to... Branch, at its discretion, to bring suit under any deposited indemnity bond or to draw upon any deposited... Office's decision: (1) In the form of an indemnity bond with sureties satisfactory to the Branch and in...

20 CFR 703.205 - Filing of Agreement and Undertaking; deposit of security.

Code of Federal Regulations, 2013 CFR

2013-04-01

... Agreement and Undertaking, in a form prescribed and provided by OWCP, in which the carrier shall agree to... Branch, at its discretion, to bring suit under any deposited indemnity bond or to draw upon any deposited... Office's decision: (1) In the form of an indemnity bond with sureties satisfactory to the Branch and in...

20 CFR 703.205 - Filing of Agreement and Undertaking; deposit of security.

Code of Federal Regulations, 2012 CFR

2012-04-01

... Agreement and Undertaking, in a form prescribed and provided by OWCP, in which the carrier shall agree to... Branch, at its discretion, to bring suit under any deposited indemnity bond or to draw upon any deposited... Office's decision: (1) In the form of an indemnity bond with sureties satisfactory to the Branch and in...

Actionable Science for Sea Level Rise and Coastal Flooding to Help Avoid Maladaptation

NASA Astrophysics Data System (ADS)

Buchanan, M. K.

2017-12-01

Rising sea levels increase the frequency of flooding at all levels, from nuisance to extreme, along coastlines across the world. Although recent flooding has increased the saliency of sea level rise (SLR) and the risks it presents to governments and communities, the effect of SLR on coastal hazards is complex and filled with uncertainty that is often uncomfortable for decision-makers. Although it is certain that SLR is occurring and will continue, its rate remains ambiguous. Because extreme flooding is by definition rare, there is also uncertainty in the effect of natural variability on flood frequency. These uncertainties pose methodological obstacles for integrating SLR into flood hazard projections and risk management. A major challenge is how to distill this complexity into information geared towards public sectors to help inform adaptation decision-making. Because policy windows are limited, budgets are tight, and decisions may have long-term consequences, it is especially important that this information accounts for uncertainty to help avoid damage and maladaptation. The U.S. Global Research Program, and others, describe this type of science—data and tools that help decision-makers plan for climate change impacts—as actionable [1]. We produce actionable science to support decision-making for adaptation to coastal impacts, despite uncertainty in projections of SLR and flood frequency. We found that SLR will boost the occurrence of minor rather than severe flooding in some regions of the U.S., while in other regions the reverse is true. For many cities, the current ten-year flood level will become a regular occurrence as the century progresses and by 2100 will occur every few days for some cities. This creates a mismatch with current planning in some cases. For example, a costly storm surge barrier may be built to protect parts of New York City from extreme flood levels but these are not often used because they are expensive to operate and obstructive to navigation and ecological systems. The current 10-yr flood will become a nuisance flood in the future and large episodic protection may not be especially helpful. [1] Beier, Paul, et al. "A How-to Guide for Coproduction of Actionable Science." Conservation Letters (2016).

Probabilistic Radiological Performance Assessment Modeling and Uncertainty

NASA Astrophysics Data System (ADS)

Tauxe, J.

2004-12-01

A generic probabilistic radiological Performance Assessment (PA) model is presented. The model, built using the GoldSim systems simulation software platform, concerns contaminant transport and dose estimation in support of decision making with uncertainty. Both the U.S. Nuclear Regulatory Commission (NRC) and the U.S. Department of Energy (DOE) require assessments of potential future risk to human receptors of disposal of LLW. Commercially operated LLW disposal facilities are licensed by the NRC (or agreement states), and the DOE operates such facilities for disposal of DOE-generated LLW. The type of PA model presented is probabilistic in nature, and hence reflects the current state of knowledge about the site by using probability distributions to capture what is expected (central tendency or average) and the uncertainty (e.g., standard deviation) associated with input parameters, and propagating through the model to arrive at output distributions that reflect expected performance and the overall uncertainty in the system. Estimates of contaminant release rates, concentrations in environmental media, and resulting doses to human receptors well into the future are made by running the model in Monte Carlo fashion, with each realization representing a possible combination of input parameter values. Statistical summaries of the results can be compared to regulatory performance objectives, and decision makers are better informed of the inherently uncertain aspects of the model which supports their decision-making. While this information may make some regulators uncomfortable, they must realize that uncertainties which were hidden in a deterministic analysis are revealed in a probabilistic analysis, and the chance of making a correct decision is now known rather than hoped for. The model includes many typical features and processes that would be part of a PA, but is entirely fictitious. This does not represent any particular site and is meant to be a generic example. A practitioner could, however, start with this model as a GoldSim template and, by adding site specific features and parameter values (distributions), use this model as a starting point for a real model to be used in real decision making.

Sexual Abuse of Children: Current Concepts.

ERIC Educational Resources Information Center

Jones, Jerry G.

1982-01-01

Acts of pedophilia, rape, and incest are uncomfortable subjects that are underdiagnosed and underreported. Effective management involves a multidisciplinary approach that is difficult to achieve without a special program for sexually abused children. Journal availability: see EC 143 201. (Author)

Minorities and Women and Honors Education.

ERIC Educational Resources Information Center

Harvey, Maria Luisa Alvarez

1986-01-01

Although honors education can be a key to the liberation of women and minorities, both groups continue to be underrepresented, perhaps because bright women and minority students are uncomfortable displaying their talents and adding pressure in an already stressful situation. (MSE)

Construction monitoring of paving fabrics systems to reduce reflective cracking.

DOT National Transportation Integrated Search

2008-08-01

Reflective cracking has been a major issue in pavement rehabilitation for many decades, due in part to shrinkage, constant expansion and contraction of pavement. These cracks result in uncomfortable rides and further deteriorate highways and local st...

Uncertainty in anticipation of uncomfortable rectal distension is modulated by the autonomic nervous system--a fMRI study in healthy volunteers.

PubMed

Rubio, Amandine; Van Oudenhove, Lukas; Pellissier, Sonia; Ly, Huynh Giao; Dupont, Patrick; Lafaye de Micheaux, Hugo; Tack, Jan; Dantzer, Cécile; Delon-Martin, Chantal; Bonaz, Bruno

2015-02-15

The human brain responds both before and during the application of aversive stimuli. Anticipation allows the organism to prepare its nociceptive system to respond adequately to the subsequent stimulus. The context in which an uncomfortable stimulus is experienced may also influence neural processing. Uncertainty of occurrence, timing and intensity of an aversive event may lead to increased anticipatory anxiety, fear, physiological arousal and sensory perception. We aimed to identify, in healthy volunteers, the effects of uncertainty in the anticipation of uncomfortable rectal distension, and the impact of the autonomic nervous system (ANS) activity and anxiety-related psychological variables on neural mechanisms of anticipation of rectal distension using fMRI. Barostat-controlled uncomfortable rectal distensions were preceded by cued uncertain or certain anticipation in 15 healthy volunteers in a fMRI protocol at 3T. Electrocardiographic data were concurrently registered by MR scanner. The low frequency (LF)-component of the heart rate variability (HRV) time-series was extracted and inserted as a regressor in the fMRI model ('LF-HRV model'). The impact of ANS activity was analyzed by comparing the fMRI signal in the 'standard model' and in the 'LF-HRV model' across the different anticipation and distension conditions. The scores of the psychological questionnaires and the rating of perceived anticipatory anxiety were included as covariates in the fMRI data analysis. Our experiments led to the following key findings: 1) the subgenual anterior cingulate cortex (sgACC) is the only activation site that relates to uncertainty in healthy volunteers and is directly correlated to individual questionnaire score for pain-related anxiety; 2) uncertain anticipation of rectal distension involved several relevant brain regions, namely activation of sgACC and medial prefrontal cortex and deactivation of amygdala, insula, thalamus, secondary somatosensory cortex, supplementary motor area and cerebellum; 3) most of the brain activity during anticipation, but not distension, is associated with activity of the central autonomic network. This approach could be applied to study the ANS impact on brain activity in various pathological conditions, namely in patients with chronic digestive conditions characterized by visceral discomfort and ANS imbalance such as irritable bowel syndrome or inflammatory bowel diseases. Copyright © 2014 Elsevier Inc. All rights reserved.

Decisions of black parents about infant bedding and sleep surfaces: a qualitative study.

PubMed

Ajao, Taiwo I; Oden, Rosalind P; Joyner, Brandi L; Moon, Rachel Y

2011-09-01

The goal of this qualitative study was to examine factors influencing decisions by black parents regarding use of soft bedding and sleep surfaces for their infants. We conducted focus groups and individual interviews with black mothers of lower and higher socioeconomic status (SES). Mothers were asked about many infant care practices, including sleep surface and bedding. Eighty-three mothers were interviewed, 73 (47 lower and 26 higher SES) in focus groups and 10 (7 lower and 3 higher SES) in individual interviews. The primary reason for using soft surfaces was infant comfort. Parents perceived that infants were uncomfortable if the surface was not soft. Many parents also interpreted "firm sleep surface" to mean taut; they were comfortable with and believed that they were following recommendations for a firm sleep surface when they placed pillows/blankets on the mattress as long as a sheet was pulled tautly over the pillows/blankets. The primary reasons for using soft bedding (including bumper pads) were comfort, safety, and aesthetics. In addition to using bedding to soften sleep surfaces, bedding was used to prevent infant rollover and falls, particularly for infants sleeping on a bed or sofa. Some parents used soft bedding to create an attractive space for the infant. Many black parents believe that soft bedding will keep their infant safe and comfortable. There is much misunderstanding about the meaning of a "firm" sleep surface. Additional educational messages apparently are needed to change parental perceptions and practices.

Decision technology.

PubMed

Edwards, W; Fasolo, B

2001-01-01

This review is about decision technology-the rules and tools that help us make wiser decisions. First, we review the three rules that are at the heart of most traditional decision technology-multi-attribute utility, Bayes' theorem, and subjective expected utility maximization. Since the inception of decision research, these rules have prescribed how we should infer values and probabilities and how we should combine them to make better decisions. We suggest how to make best use of all three rules in a comprehensive 19-step model. The remainder of the review explores recently developed tools of decision technology. It examines the characteristics and problems of decision-facilitating sites on the World Wide Web. Such sites now provide anyone who can use a personal computer with access to very sophisticated decision-aiding tools structured mainly to facilitate consumer decision making. It seems likely that the Web will be the mode by means of which decision tools will be distributed to lay users. But methods for doing such apparently simple things as winnowing 3000 options down to a more reasonable number, like 10, contain traps for unwary decision technologists. The review briefly examines Bayes nets and influence diagrams-judgment and decision-making tools that are available as computer programs. It very briefly summarizes the state of the art of eliciting probabilities from experts. It concludes that decision tools will be as important in the 21st century as spreadsheets were in the 20th.

The use of psychotropic medications in young children: the facts, the controversy, and the practice.

PubMed

Stubbe, D E; Martin, A

2000-06-01

There has been recent concern by the public and physicians alike over reports that increasing numbers of young children are being prescribed psychotropic medications. The report by Zito and colleagues addressing this subject that appeared in the 23 February 2000 issue of JAMA sparked enormous controversy and was the impetus for a White House Conference just one month in its wake (20 March 2000). State and federal agencies have considered legislation to regulate the practice of prescribing psychotropic medications to preschool children. Special aspects of the use of psychotropic medication in preschool children are reviewed, with recommendations for evaluation and treatment decisions. The need for data and research in this area is highlighted.

A Markov Chain Approach to Probabilistic Swarm Guidance

NASA Technical Reports Server (NTRS)

Acikmese, Behcet; Bayard, David S.

2012-01-01

This paper introduces a probabilistic guidance approach for the coordination of swarms of autonomous agents. The main idea is to drive the swarm to a prescribed density distribution in a prescribed region of the configuration space. In its simplest form, the probabilistic approach is completely decentralized and does not require communication or collabo- ration between agents. Agents make statistically independent probabilistic decisions based solely on their own state, that ultimately guides the swarm to the desired density distribution in the configuration space. In addition to being completely decentralized, the probabilistic guidance approach has a novel autonomous self-repair property: Once the desired swarm density distribution is attained, the agents automatically repair any damage to the distribution without collaborating and without any knowledge about the damage.

A decision support tool for adaptive management of native prairie ecosystems

USGS Publications Warehouse

Hunt, Victoria M.; Jacobi, Sarah; Gannon, Jill J.; Zorn, Jennifer E.; Moore, Clinton; Lonsdorf, Eric V.

2016-01-01

The Native Prairie Adaptive Management initiative is a decision support framework that provides cooperators with management-action recommendations to help them conserve native species and suppress invasive species on prairie lands. We developed a Web-based decision support tool (DST) for the U.S. Fish and Wildlife Service and the U.S. Geological Survey initiative. The DST facilitates cross-organizational data sharing, performs analyses to improve conservation delivery, and requires no technical expertise to operate. Each year since 2012, the DST has used monitoring data to update ecological knowledge that it translates into situation-specific management-action recommendations (e.g., controlled burn or prescribed graze). The DST provides annual recommendations for more than 10,000 acres on 20 refuge complexes in four U.S. states. We describe how the DST promotes the long-term implementation of the program for which it was designed and may facilitate decision support and improve ecological outcomes of other conservation efforts.

"I'm Dr Jekyll and Mr Hyde": are GPs' antibiotic prescribing patterns contextually dependent? A qualitative focus group study.

PubMed

Strandberg, Eva Lena; Brorsson, Annika; Hagstam, Charlotta; Troein, Margareta; Hedin, Katarina

2013-09-01

To explore factors and circumstances contributing to prudent antibiotic prescribing for respiratory tract infections in primary care. Two focus groups representing rural and urban areas. A semi-structured interview guide with open-ended questions and an editing analysis style was used. They were examined to identify meaning units that were sorted into categories in an iterative process throughout the analysis. Primary health care in two counties in southern Sweden. Two groups including seven and six general practitioners (GPs) respectively, men and women of different ages with different professional experiences. Exploration of categories, determination of themes, construction of models. The decision to prescribe antibiotics takes place in the encounter between GP and patient, initially characterized by harmony or fight and the subsequent process by collaboration or negotiation, resulting in agreement, compromise, or disagreement. Several factors influence the meeting and contribute to enhancing the conditions for rational prescribing. These conditions are connected to the GP, the relationship, and the setting; organization as well as professional culture. The findings indicate synergies between the factors, and that one factor can sometimes compensate for lack of another. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills. The findings emphasize the importance of the encounter between the GP and the patient for prudent antibiotic prescribing. Furthermore, the importance of an appropriate organization of primary care, which promotes continuity and encourages professional autonomy, is demonstrated.

Optimizing carbapenem use through a national quality improvement programme.

PubMed

Robson, Siân E; Cockburn, Alison; Sneddon, Jacqueline; Mohana, Abdulrhman; Bennie, Marion; Mullen, Alexander B; Malcolm, William; Armstrong, Jennifer; Patton, Andrea; Seaton, Ronald Andrew

2018-05-24

Concern about increasing carbapenem and piperacillin/tazobactam use led the Scottish Antimicrobial Prescribing Group (SAPG) to develop national guidance on optimal use of these agents, and to implement a quality improvement programme to assess the impact of guidance on practice. To evaluate how SAPG guidance had been implemented by health boards, assess how this translated into clinical practice, and investigate clinicians' views and behaviours about prescribing carbapenems and alternative agents. Local implementation of SAPG guidance was assessed using an online survey. A bespoke point prevalence survey was used to evaluate prescribing. Clinicians' experience of using carbapenems and alternatives was examined through semi-structured interviews. National prescribing data were analysed to assess the impact of the programme. There were greater local restrictions for carbapenems than for piperacillin/tazobactam. Laboratory result suppression was inconsistent between boards and carbapenem-sparing antibiotics were not widely available. Compliance with local guidelines was good for meropenem but lower for piperacillin/tazobactam. Indication for use was well documented but review/stop dates were poorly documented for both antibiotics. Decisions to prescribe a carbapenem were influenced by local guidelines and specialist advice. Many clinicians lacked confidence to de-escalate treatment. Use of both antibiotics decreased during the course of the programme. A multifaceted quality improvement programme was used to gather intelligence, promote behaviour change, and focus interventions on the use of carbapenems and piperacillin/tazobactam. Use of these antimicrobials decreased during the programme-a trend not seen elsewhere in Europe. The programme could be generalized to other antimicrobials.

Outcomes of red blood cell transfusions prescribed in organ donors by the Digital Intern, an electronic decision support algorithm.

PubMed

Connor, Joseph P; Raife, Thomas; Medow, Joshua E

2018-02-01

The Digital Intern (DI) is an electronic decision support tool for the management of organ donors. One algorithm determines the dose, in units of red blood cells to be transfused, based on hematocrit (Hct) thresholds and targets. The effectiveness of the transfusion dose calculated by the DI in terms of achieving the selected Hct target and the duration of the targeted dose is not known. This was a retrospective study to describe the outcomes of transfusions prescribed by the DI. Pre- and posttransfusion Hct levels were compared to define response and all posttransfusion Hct values were plotted to evaluate the duration of the prescribed dose. A total of 120 organ donors were studied and 22 donors had 28 transfusions (six were transfused twice). The transfused donors were a mix of trauma and medical admissions and brain death and cardiac death donors. The transfusion target of 24% Hct was attained in 96% of transfusions. The mean number of units transfused was 1.4 and the mean time from transfusion to procurement was 19.8 hours. There was a decline in Hct over time after transfusion in all but one case with a mean decline of 1.9% Hct over 13 hours. Six donors were transfused twice, likely due to a longer donor time period (41.7 hr vs. 27 hr). The DI provided transfusion dosing that achieved the desired threshold in the majority of organ donors transfused. Ongoing work focuses on application of this technology to transfusions in general patient populations. © 2017 AABB.

The prevalence and characteristics of chronic ocular itch: a cross-sectional survey.

PubMed

Stull, Carolyn; Valdes-Rodriguez, Rodrigo; Shafer, Brian M; Shevchenko, Alina; Nattkemper, Leigh A; Chan, Yiong-Huak; Tabaac, Sydney; Schardt, Martin J; Najjar, Dany M; Foster, William J; Yosipovitch, Gil

2017-03-01

In this cross-sectional study, we aimed to determine the prevalence and characteristics of chronic ocular itch in an outpatient ophthalmology and optometry clinic. Four hundred patients from an outpatient ophthalmology and optometry clinic were enrolled. The presence and characteristics of chronic ocular itch were assessed by a questionnaire. Data regarding ophthalmologic, dermatologic, and systemic conditions as well as current medications were extracted from medical records. Chronic ocular itch was present in 118 (29.5%) of 400 participants. Chronic ocular pruritus was significantly more prevalent in females [ P =0.015; odds ratio (OR)=1.8; 95% confidence interval (CI), 1.1-2.8] and was significantly associated with the presence of allergic conjunctivitis [51.8% (n=45); P <0.001; OR=5.0; 95% CI, 3.0-8.3], dry eye syndrome [40.1% (75); P <0.001; OR=2.6; 95% CI, 1.7-4.1], blepharitis [43.8% (n=21); P =0.021; OR=2.0; 95% CI, 1.1-3.8], and atopic dermatitis [50.0% (n=10); P =0.023; OR=2.6; 95% CI, 1.1-5.8]. Chronic ocular itch was not significantly associated with systemic conditions, or the use of prescribed ophthalmologic medications. Chronic ocular itch is common and may be related to ophthalmologic or dermatologic pathologies. The present findings highlight the importance of identifying and managing this uncomfortable symptom that may negatively impact the quality of life and sleep of affected patients.

Satellite data driven modeling system for predicting air quality and visibility during wildfire and prescribed burn events

NASA Astrophysics Data System (ADS)

Nair, U. S.; Keiser, K.; Wu, Y.; Maskey, M.; Berendes, D.; Glass, P.; Dhakal, A.; Christopher, S. A.

2012-12-01

The Alabama Forestry Commission (AFC) is responsible for wildfire control and also prescribed burn management in the state of Alabama. Visibility and air quality degradation resulting from smoke are two pieces of information that are crucial for this activity. Currently the tools available to AFC are the dispersion index available from the National Weather Service and also surface smoke concentrations. The former provides broad guidance for prescribed burning activities but does not provide specific information regarding smoke transport, areas affected and quantification of air quality and visibility degradation. While the NOAA operational air quality guidance includes surface smoke concentrations from existing fire events, it does not account for contributions from background aerosols, which are important for the southeastern region including Alabama. Also lacking is the quantification of visibility. The University of Alabama in Huntsville has developed a state-of-the-art integrated modeling system to address these concerns. This system based on the Community Air Quality Modeling System (CMAQ) that ingests satellite derived smoke emissions and also assimilates NASA MODIS derived aerosol optical thickness. In addition, this operational modeling system also simulates the impact of potential prescribed burn events based on location information derived from the AFC prescribed burn permit database. A lagrangian model is used to simulate smoke plumes for the prescribed burns requests. The combined air quality and visibility degradation resulting from these smoke plumes and background aerosols is computed and the information is made available through a web based decision support system utilizing open source GIS components. This system provides information regarding intersections between highways and other critical facilities such as old age homes, hospitals and schools. The system also includes satellite detected fire locations and other satellite derived datasets relevant for fire and smoke management.

Antibiotic prescribing for acute respiratory tract infections in Norwegian primary care out-of-hours service

PubMed Central

Lindberg, Bent H.; Gjelstad, Svein; Foshaug, Mats; Høye, Sigurd

2017-01-01

Purpose To examine factors correlating with antibiotic prescribing for acute respiratory tract infections (ARTIs) in Norwegian primary care out-of-hours service. Materials and methods Retrospective data analysis for the year 2014 in two out-of-hours primary care units located in the towns of Hamar and Tønsberg in Norway, analysing type and frequency of different antibiotics prescribed by 117 medical doctors for ARTIs, and factors correlating with these. Results The 117 doctors in two out-of-hours units diagnosed 6757 cases of ARTIs. 2310 (34.2%) of these resulted in an antibiotic prescription, where of 1615 (69.9%) were penicillin V (PcV). Tonsillitis and sinusitis were the two ARTI diagnoses with the highest antibiotic prescription rate. The antibiotic prescription rate increased successively with increasing activity level, measured as shorter median duration of consultations per session, from 28.7% (reference) in the least busy quintile of sessions to 36.6% (OR: 1.38 (95% CI =1.06–1.80)) in the busiest quintile of sessions. Prescribing of broad-spectrum antibiotics was not correlated with median duration of consultations per session. Female doctors had an OR of 0.61 (0.40–0.92) of a broad-spectrum antibiotic prescription compared to their male colleagues. Conclusions Antibiotic prescribing for ARTIs in the primary care out-of-hours services investigated is at the same level as in Norwegian general practice, but with a higher prescription rate of PcV. Antibiotic prescribing increases on busy sessions, measured as median duration of consultations per session. The work frame in primary care out-of-hours service might influence the quality of clinical decisions. PMID:28569649

Temporal and other factors that influence the time doctors take to prescribe using an electronic prescribing system

PubMed Central

Coleman, Jamie J; Hodson, James; Thomas, Sarah K; Brooks, Hannah L; Ferner, Robin E

2015-01-01

Background A computerized physician order entry (CPOE) system with embedded clinical decision support can reduce medication errors in hospitals, but might increase the time taken to generate orders. Aims We aimed to quantify the effects of temporal (month, day of week, hour of shift) and other factors (grade of doctor, prior experience with the system, alert characteristics, and shift type) on the time taken to generate a prescription order. Setting A large university teaching hospital using a locally developed CPOE system with an extensive audit database. Design We retrospectively analyzed prescription orders from the audit database between August 2011 and July 2012. Results The geometric mean time taken to generate a prescription order within the CPOE system was 11.75 s (95% CI 11.72 to 11.78). Time to prescribe was most affected by the display of high-level (24.59 s (24.43 to 24.76); p<0.001) or previously unseen (18.87 s (18.78 to 18.96); p<0.001) alerts. Prescribers took significantly less time at weekends (11.29 s (11.23 to 11.35)) than on weekdays (11.88 s (11.84 to 11.91); p<0.001), in the first (11.25 s (11.16 to 11.34); p<0.001) and final (11.56 s (11.47 to 11.66); p<0.001) hour of their shifts, and after the first month of using the system. Conclusions The display of alerts, prescribing experience, system familiarity, and environment all affect the time taken to generate a prescription order. Our study reinforces the need for appropriate alerts to be presented to individuals at an appropriate place in the workflow, in order to improve prescribing efficiency. PMID:25074989

Assessing the Value of Moving More-The Integral Role of Qualified Health Professionals.

PubMed

Arena, Ross; McNeil, Amy; Lavie, Carl J; Ozemek, Cemal; Forman, Daniel; Myers, Jonathan; Laddu, Deepika R; Popovic, Dejana; Rouleau, Codie R; Campbell, Tavis S; Hills, Andrew P

2018-04-01

Being physically active or, in a broader sense, simply moving more throughout each day is one of the most important components of an individual's health plan. In conjunction with regular exercise training, taking more steps in a day and sitting less are also important components of one's movement portfolio. Given this priority, health care professionals must develop enhanced skills for prescribing and guiding individualized movement programs for all their patients. An important component of a health care professional's ability to prescribe movement as medicine is competency in assessing an individual's risk for untoward events if physical exertion was increased. The ability to appropriately assess one's risk before advising an individual to move more is integral to clinical decision-making related to subsequent testing if needed, exercise prescription, and level of supervision with exercise training. At present, there is a lack of clarity pertaining to how a health care professional should go about assessing an individual's readiness to move more on a daily basis in a safe manner. Therefore, this perspectives article clarifies key issues related to prescribing movement as medicine and presents a new process for clinical assessment before prescribing an individualized movement program. Copyright © 2018 Elsevier B.V. All rights reserved.

Engaging healthcare providers to implement HIV pre-exposure prophylaxis.

PubMed

Krakower, Douglas; Mayer, Kenneth H

2012-11-01

Recent randomized controlled trials have demonstrated that HIV pre-exposure prophylaxis (PrEP) can decrease HIV incidence among several at-risk populations, including men who have sex with men, serodiscordant couples, and heterosexual men and women. As PrEP is a biomedical intervention that requires clinical monitoring and a high level of medication adherence, maximizing the public health effectiveness of PrEP in real-world settings will require the training of a cadre of healthcare providers to prescribe PrEP. Therefore it is critical to understand provider knowledge, practices, and attitudes towards PrEP prescribing, and to develop strategies for engaging and training providers to provide PrEP. Limited numbers of studies have focused on PrEP implementation by healthcare providers. These studies suggest that some providers are knowledgeable about PrEP, but many are not, or express misgivings. Although many clinicians report willingness to provide PrEP, few have prescribed PrEP in clinical practice. Provider comfort and skills in HIV risk assessment are suboptimal, which could limit identification of individuals who are most likely to benefit from PrEP use. Further studies to understand facilitators and barriers to HIV-risk assessment and PrEP prescribing by practicing clinicians are needed. Innovative training strategies and decision-support interventions for providers could optimize PrEP implementation and therefore merit additional research.

Combining statistical inference and decisions in ecology

USGS Publications Warehouse

Williams, Perry J.; Hooten, Mevin B.

2016-01-01

Statistical decision theory (SDT) is a sub-field of decision theory that formally incorporates statistical investigation into a decision-theoretic framework to account for uncertainties in a decision problem. SDT provides a unifying analysis of three types of information: statistical results from a data set, knowledge of the consequences of potential choices (i.e., loss), and prior beliefs about a system. SDT links the theoretical development of a large body of statistical methods including point estimation, hypothesis testing, and confidence interval estimation. The theory and application of SDT have mainly been developed and published in the fields of mathematics, statistics, operations research, and other decision sciences, but have had limited exposure in ecology. Thus, we provide an introduction to SDT for ecologists and describe its utility for linking the conventionally separate tasks of statistical investigation and decision making in a single framework. We describe the basic framework of both Bayesian and frequentist SDT, its traditional use in statistics, and discuss its application to decision problems that occur in ecology. We demonstrate SDT with two types of decisions: Bayesian point estimation, and an applied management problem of selecting a prescribed fire rotation for managing a grassland bird species. Central to SDT, and decision theory in general, are loss functions. Thus, we also provide basic guidance and references for constructing loss functions for an SDT problem.

Differing Experiences with Pre-Exposure Prophylaxis in Boston Among Lesbian, Gay, Bisexual, and Transgender Specialists and Generalists in Primary Care: Implications for Scale-Up.

PubMed

Krakower, Douglas S; Ware, Norma C; Maloney, Kevin M; Wilson, Ira B; Wong, John B; Mayer, Kenneth H

2017-07-01

The Centers for Disease Control and Prevention estimates that one in four sexually active men who have sex with men (MSM) could decrease their HIV risk by using HIV pre-exposure prophylaxis (PrEP). Because many MSM access healthcare from primary care providers (PCPs), these clinicians could play an important role in providing access to PrEP. Semistructured qualitative interviews were conducted with 31 PCPs in Boston, MA, to explore how they approach decisions about prescribing PrEP to MSM and their experiences with PrEP provision. Purposive sampling included 12 PCPs from an urban community health center specializing in the care of lesbian, gay, bisexual, and transgender persons ("LGBT specialists") and 19 PCPs from a general academic medical center ("generalists"). Analyses utilized an inductive approach to identify emergent themes. Both groups of PCPs approached prescribing decisions about PrEP as a process of informed decision-making with patients. Providers would defer to patients' preferences if they were unsure about the appropriateness of PrEP. LGBT specialists and generalists were at vastly different stages of adopting PrEP into practice. For LGBT specialists, PrEP was a disruptive innovation that rapidly became normative in practice. Generalists had limited experience with PrEP; however, they desired succinct decision-support tools to help them achieve proficiency, because they considered preventive medicine to be central to their professional role. As generalists vastly outnumber LGBT specialists in the United States, interventions to support PrEP provision by generalists could accelerate the scale-up of PrEP for MSM nationally, which could in turn decrease HIV incidence for this priority population.

The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature.

PubMed

Georgiou, Andrew; Prgomet, Mirela; Paoloni, Richard; Creswick, Nerida; Hordern, Antonia; Walter, Scott; Westbrook, Johanna

2013-06-01

We undertake a systematic review of the quantitative literature related to the effect of computerized provider order entry systems in the emergency department (ED). We searched MEDLINE, EMBASE, Inspec, CINAHL, and CPOE.org for English-language studies published between January 1990 and May 2011. We identified 1,063 articles, of which 22 met our inclusion criteria. Sixteen used a pre/post design; 2 were randomized controlled trials. Twelve studies reported outcomes related to patient flow/clinical work, 7 examined decision support systems, and 6 reported effects on patient safety. There were no studies that measured decision support systems and its effect on patient flow/clinical work. Computerized provider order entry was associated with an increase in time spent on computers (up to 16.2% for nurses and 11.3% for physicians), with no significant change in time spent on patient care. Computerized provider order entry with decision support systems was related to significant decreases in prescribing errors (ranging from 17 to 201 errors per 100 orders), potential adverse drug events (0.9 per 100 orders), and prescribing of excessive dosages (31% decrease for a targeted set of renal disease medications). There are tangible benefits associated with computerized provider order entry/decision support systems in the ED environment. Nevertheless, when considered as part of a framework of technical, clinical, and organizational components of the ED, the evidence base is neither consistent nor comprehensive. Multimethod research approaches (including qualitative research) can contribute to understanding of the multiple dimensions of ED care delivery, not as separate entities but as essential components of a highly integrated system of care. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Breakthrough Performance: Creating the Innovative Enterprise.

ERIC Educational Resources Information Center

Hanson, Diane; Bapst, Jerry

1998-01-01

Illustrates a new model for innovative enterprises by reviewing the process an instruments and control systems manufacturer used to implement changes in its corporate operating philosophy. Outlines the "Quantum Model": spheres of control, influence, interest, and UNs (unknown, unpredictable, uncontrollable, uncomfortable). Discusses…

Manage Emotions Without Cigarettes

Cancer.gov

Maybe you used to reach for a cigarette after a tough day at the office. Or found comfort in the companionship of a cigarette on a lonely night. Maybe you used to have cigarettes available as one way to help you deal with uncomfortable emotions.

Effectiveness and cost-effectiveness of salicylic acid and cryotherapy for cutaneous warts. An economic decision model.

PubMed

Thomas, K S; Keogh-Brown, M R; Chalmers, J R; Fordham, R J; Holland, R C; Armstrong, S J; Bachmann, M O; Howe, A H; Rodgers, S; Avery, A J; Harvey, I; Williams, H C

2006-08-01

To estimate the costs of commonly used treatments for cutaneous warts, as well as their health benefits and risk. To create an economic decision model to evaluate the cost-effectiveness of these treatments, and, as a result, assess whether a randomised controlled trial (RCT) would be feasible and cost-effective. Focus groups, structured interviews and observation of practice. Postal survey sent to 723 patients. A recently updated Cochrane systematic review and published cost and prescribing data. Primary and secondary data collection methods were used to inform the development of an economic decision model. Data from the postal survey provided estimates of the effectiveness of wart treatments in a primary care setting. These estimates were compared with outcomes reported in the Cochrane review of wart treatment, which were largely obtained from RCTs conducted in secondary care. A decision model was developed including a variety of over-the-counter (OTC) and GP-prescribed treatments. The model simulated 10,000 patients and adopted a societal perspective. OTC treatments were used by a substantial number of patients (57%) before attending the GP surgery. By far the most commonly used OTC preparation was salicylic acid (SA). The results of the economic model suggested that of the treatments prescribed by a GP, the most cost-effective treatment was SA, with an incremental cost-effectiveness ratio (ICER) of 2.20 pound/% cured. The ICERs for cryotherapy varied widely (from 1.95 to 7.06 pound/% cured) depending on the frequency of applications and the mode of delivery. The most cost-effective mode of delivery was through nurse-led cryotherapy clinics (ICER = 1.95 pound/% cured) and this could be a cost-effective alternative to GP-prescribed SA. Overall, the OTC therapies were the most cost-effective treatment options. ICERs ranged from 0.22 pound/% cured for OTC duct tape and 0.76 pound/% cured for OTC cryotherapy to 1.12 pound/% cured for OTC SA. However, evidence in support of OTC duct tape and OTC cryotherapy is very limited. Side-effects were commonly reported for both SA and cryotherapy, particularly a burning sensation, pain and blistering. Cryotherapy delivered by a doctor is an expensive option for the treatment of warts in primary care. Alternative options such as GP-prescribed SA and nurse-led cryotherapy clinics provide more cost-effective alternatives, but are still expensive compared with self-treatment. Given the minor nature of most cutaneous warts, coupled with the fact that the majority spontaneously resolve in time, it may be concluded that a shift towards self-treatment is warranted. Although both duct tape and OTC cryotherapy appear promising new self-treatment options from both a cost and an effectiveness perspective, more research is required to confirm the efficacy of these two methods of wart treatment. If these treatments are shown to be as cost-effective as or more cost-effective than conventional treatments, then a shift in service delivery away from primary care towards more OTC treatment is likely. A public awareness campaign would be useful to educate patients about the self-limiting nature of warts and the possible alternative OTC treatment options available. Two future RCTs are recommended for consideration: a trial of SA compared with nurse-led cryotherapy in primary care, and a trial of home treatments. Greater understanding of the efficacy of these home treatments will give doctors a wider choice of treatment options, and may help to reduce the overall demand for cryotherapy in primary care.

Nudging Guideline-Concordant Antibiotic Prescribing

PubMed Central

Meeker, Daniella; Knight, Tara K.; Friedberg, Mark W.; Linder, Jeffrey A.; Goldstein, Noah J.; Fox, Craig R.; Rothfeld, Alan; Diaz, Guillermo; Doctor, Jason N.

2015-01-01

IMPORTANCE “Nudges” that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice. OBJECTIVE To investigate the use of a behavioral “nudge” based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention). INTERVENTIONS The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs. MAIN OUTCOMES AND MEASURES Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status. RESULTS Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time. CONCLUSIONS AND RELEVANCE Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01767064 PMID:24474434

Antibiotic prescribing of village doctors for children under 15 years with upper respiratory tract infections in rural China

PubMed Central

Zhang, Zhixia; Zhan, Xingxin; Zhou, Hongjun; Sun, Fang; Zhang, Heng; Zwarenstein, Merrick; Liu, Qian; Li, Yingxue; Yan, Weirong

2016-01-01

Abstract The aim of this study was to explore the knowledge, attitudes, and practices of village doctors regarding the prescribing of antibiotics for children under 15 years with upper respiratory tract infections (URTIs) in rural China. Twelve focus group discussions (FGDs) were conducted in Xianning, a prefecture-level city in rural China, during December 2014. We conducted 6 FGDs with 35 village doctors, 3 with 13 primary caregivers (11 parents), and 3 with 17 directors of township hospitals, county-level health bureaus, county-level Centers for Disease Control and Prevention, or county-level Chinese Food and Drug Administration offices. Audio records of the interviews were transcribed verbatim and analyzed using the thematic analysis approach. Participants believed that unnecessary antibiotic prescribing for children under 15 years with The occurrence of URTIs was a problem in village clinics in rural China. The discussions revealed that most of the village doctors had inadequate knowledge and misconceptions about antibiotic use, which was an important factor in the unnecessary prescribing. Village doctors and directors reported that the doctors’ fear of complications, the primary caregivers’ pressure for antibiotic treatment, and the financial considerations of patient retention were the main factors influencing the decision to prescribe antibiotics. Most of the primary caregivers insisted on antibiotics, even when the village doctors were reluctant to prescribe them, and they preferred to go to see those village doctors who prescribed antibiotics. The interviewees also gave their opinions on what would be the most effective measures for optimizing antibiotic prescriptions; these included educational/training campaigns, strict regulations on antibiotic prescription, and improved supervision. Findings emphasized the need to improve the dissemination of information and training/education, and implement legislation on the rational use of antibiotics. And it also provided helpful information to guide the design of more effective interventions to promote prudent antibiotic use and good antimicrobial stewardship. PMID:27281082

Behavioral medicine perspectives on the design of health information technology to improve decision-making, guideline adherence, and care coordination in chronic pain management.

PubMed

Midboe, Amanda M; Lewis, Eleanor T; Cronkite, Ruth C; Chambers, Dallas; Goldstein, Mary K; Kerns, Robert D; Trafton, Jodie A

2011-03-01

Development of clinical decision support systems (CDSs) has tended to focus on facilitating medication management. An understanding of behavioral medicine perspectives on the usefulness of a CDS for patient care can expand CDSs to improve management of chronic disease. The purpose of this study is to explore feedback from behavioral medicine providers regarding the potential for CDSs to improve decision-making, care coordination, and guideline adherence in pain management. Qualitative methods were used to analyze semi-structured interview responses from behavioral medicine stakeholders following demonstration of an existing CDS for opioid prescribing, ATHENA-OT. Participants suggested that a CDS could assist with decision-making by educating providers, providing recommendations about behavioral therapy, facilitating risk assessment, and improving referral decisions. They suggested that a CDS could improve care coordination by facilitating division of workload, improving patient education, and increasing consideration and knowledge of options in other disciplines. Clinical decision support systems are promising tools for improving behavioral medicine care for chronic pain.

77 FR 47096 - Physicians Pharmacy, L.L.C.; Decision and Order

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-07

... true that the DI testified regarding the prescribing practices of Dr. Paul Volkman, an ex-registrant... would be inconsistent with the public interest as that term is defined in 21 U.S.C. 823(f). (ALJ Ex. 1... of facts and law'' in support of the OSC. ALJ Ex.1, at 1. 1. On January 12, 2011, [Respondent...

A review of the Forest Service Remote Automated Weather Station (RAWS) network

Treesearch

John Zachariassen; Karl F. Zeller; Ned Nikolov; Tom McClelland

2003-01-01

The RAWS network and RAWS data-use systems are closely reviewed and summarized in this report. RAWS is an active program created by the many land-management agencies that share a common need for accurate and timely weather data from remote locations for vital operational and program decisions specific to wildland and prescribed fires. A RAWS measures basic observable...

The Fire and Fire Surrogates Study: Providing guidelines for fire in future forest watershed management decisions

Treesearch

Carleton B. Edminster; C. Phillip Weatherspoon; Daniel G. Neary

2000-01-01

As part of the 1998 Joint USDA/USDI Fire Science Program, the Fire and Fire Surrogates Study was proposed to establish and evaluate cross-comparisons of fuels treatment practices and techniques to reduce wildfire risk. This study evaluates prescribed fire, thinning, and various mechanical treatment methods for treating, removing, or using woody biomass. Site-specific...

Central States forest management guides as applied in STEMS.

Treesearch

Nancy R. Walters

1988-01-01

Describes a management prescription system for Central States cover types developed for use in the Central States Stand and Tree Evaluation and Modeling System (STEMS). It includes one management guide for each of the six major cover types in the region. Each guide consists of a decision key that prescribes management, based on stand characteristics and a set of...

Ocean Variability Effects on Underwater Acoustic Communications

DTIC Science & Technology

2011-09-01

schemes for accessing wide frequency bands. Compared with OFDM schemes, the multiband MIMO transmission combined with time reversal processing...systems, or multiple- input/multiple-output ( MIMO ) systems, decision feedback equalization and interference cancellation schemes have been integrated...unclassified Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 2 MIMO receiver also iterates channel estimation and symbol demodulation with

Breakthrough at the Missouri River Breaks: A quick tool for comparing burned and unburned sites

Treesearch

Rachael Clark; Theresa Jain

2009-01-01

A quantitative understanding of how forests work, both before and after (prescribed and wild) fire, is essential to management. Yet acquiring the kind of broad yet detailed information needed for many management decisions can be costly, tedious, and time-consuming. After two sweeping wildfires in the Missouri River Breaks area of eastern Montana - the Indian and...

Sales promotion by wholesalers affects general practitioners' prescription behaviours in Japan.

PubMed

Shimura, Hirohisa

2018-01-01

Background : One method for promoting drugs in Japan has been utilizing wholesalers for promotion; however, the effectiveness of the sales promotion has been brought into question. Methods : A total of 74,552 responses were collected from an internet survey of 511 prescribing doctors in hospitals with less than 19 beds, which recalled the visits by wholesalers' sales representatives (MS) in 2014. Each assessed the degree to which MS and/or sales representatives from a pharmaceutical company (MR) influenced a decision to prescribe each drug. The responses were analysed using the chi-square test and Goodman-Kruskal's gamma to evaluate the association between MS calls and doctors' prescription orders. Results : Results showed a significant effect of the MS calls on doctors' behaviours in terms of new drug prescriptions and subsequent behaviours. The results by therapeutic category showed a similar strong influence of the joint calls on new prescriptions on some therapeutic classes. The MS calls significantly influenced doctors to maintain and increase the prescription volume (p < 0.01). Conclusion : This paper demonstrates that sales promotion on the part of MSs and MRs adds value to the prescription decisions. Moreover, results suggest that MSs enhance prescription outcomes in competitive therapeutic categories.

Psychotropic medication management in persons with co-occurring psychiatric and substance use disorders.

PubMed

Sowers, W; Golden, S

1999-01-01

Persons presenting with concurrent psychiatric and substance problems present unique challenges for diagnosis and for effective and rational treatment planning. This is especially true for psychiatrists attempting to prescribe pharmacologic interventions which will promote recovery from both disorders and improve function. In order to be effective in this endeavor it is important to have a clear understanding of the dynamics of addiction as well as the particular issues and struggles related to mental illness which will affect an individual's attitude toward and use of medication. This article discusses some of the common problems related to diagnostic decision making and initiation of medication in persons with co-occurring disorders. An algorithm for guiding these decisions is presented. Common misconceptions held by these individuals regarding medication, as distinguished from "drugs," are considered. Unique psychodynamic issues that may lead these persons to actively seek medication as a solution to their problems, or which may, conversely, lead them to an outright rejection of medication as a part of their recovery, are discussed. Countertransferential issues influencing the physician's approach to prescribing for this population are also considered. The article concludes with recommendations for pharmacologic approaches to address specific psychiatric syndromes which may present in this population.

What factors affect the carriage of epinephrine auto-injectors by teenagers?

PubMed

Macadam, Clare; Barnett, Julie; Roberts, Graham; Stiefel, Gary; King, Rosemary; Erlewyn-Lajeunesse, Michel; Holloway, Judith A; Lucas, Jane S

2012-02-02

Teenagers with allergies are at particular risk of severe and fatal reactions, but epinephrine auto-injectors are not always carried as prescribed. We investigated barriers to carriage. Patients aged 12-18 years old under a specialist allergy clinic, who had previously been prescribed an auto-injector were invited to participate. Semi-structured interviews explored the factors that positively or negatively impacted on carriage. Twenty teenagers with food or venom allergies were interviewed. Only two patients had used their auto-injector in the community, although several had been treated for severe reactions in hospital. Most teenagers made complex risk assessments to determine whether to carry the auto-injector. Most but not all decisions were rational and were at least partially informed by knowledge. Factors affecting carriage included location, who else would be present, the attitudes of others and physical features of the auto-injector. Teenagers made frequent risk assessments when deciding whether to carry their auto-injectors, and generally wanted to remain safe. Their decisions were complex, multi-faceted and highly individualised. Rather than aiming for 100% carriage of auto-injectors, which remains an ambitious ideal, personalised education packages should aim to empower teenagers to make and act upon informed risk assessments.

The Pharmacokinetics of Second-Generation Long-Acting Injectable Antipsychotics: Limitations of Monograph Values.

PubMed

Lee, Lik Hang N; Choi, Charles; Collier, Abby C; Barr, Alasdair M; Honer, William G; Procyshyn, Ric M

2015-12-01

Product monographs (also known by terms such as Summary of Product Characteristics and Highlights of Prescribing Information, depending on the jurisdiction) provide essential information to ensure the safe and effective use of a drug. Medical practitioners often rely on these monographs for guidance on matters related to pharmacokinetics as well as indications, contraindications, clinical pharmacology, and adverse reactions. The clinical and scientific information found within these documents, forming the basis for decision making, are presumed to be derived from well-designed studies. The objective of this review is to examine the source and validity of the pharmacokinetic data used in establishing the half-lives and times to steady-state reported in the product monographs of second-generation long-acting injectable antipsychotics. Thus, we have critically evaluated the clinical trials from which the pharmacokinetic parameters listed in the product monographs were determined. In many cases, the pharmacokinetic information presented in product monographs is of limited use to clinicians wishing to optimize the effectiveness and tolerability of second-generation long-acting injectable antipsychotics. Under such circumstances, off-label prescribing practices may actually produce better clinical outcomes than if decisions were made based on the product monographs alone.

A decision support tool for identifying abuse of controlled substances by ForwardHealth Medicaid members.

PubMed

Mailloux, Allan T; Cummings, Stephen W; Mugdh, Mrinal

2010-01-01

Our objective was to use Wisconsin's Medicaid Evaluation and Decision Support (MEDS) data warehouse to develop and validate a decision support tool (DST) that (1) identifies Wisconsin Medicaid fee-for-service recipients who are abusing controlled substances, (2) effectively replicates clinical pharmacist recommendations for interventions intended to curb abuse of physician and pharmacy services, and (3) automates data extraction, profile generation and tracking of recommendations and interventions. From pharmacist manual reviews of medication profiles, seven measures of overutilization of controlled substances were developed, including (1-2) 6-month and 2-month "shopping" scores, (3-4) 6-month and 2-month forgery scores, (5) duplicate/same day prescriptions, (6) count of controlled substance claims, and the (7) shopping 6-month score for the individual therapeutic class with the highest score. The pattern analysis logic for the measures was encoded into SQL and applied to the medication profiles of 190 recipients who had already undergone manual review. The scores for each measure and numbers of providers were analyzed by exhaustive chi-squared automatic interaction detection (CHAID) to determine significant thresholds and combinations of predictors of pharmacist recommendations, resulting in a decision tree to classify recipients by pharmacist recommendations. The overall correct classification rate of the decision tree was 95.3%, with a 2.4% false positive rate and 4.0% false negative rate for lock-in versus prescriber-alert letter recommendations. Measures used by the decision tree include the 2-month and 6-month shopping scores, and the number of pharmacies and prescribers. The number of pharmacies was the best predictor of abuse of controlled substances. When a Medicaid recipient receives prescriptions for controlled substances at 8 or more pharmacies, the likelihood of a lock-in recommendation is 90%. The availability of the Wisconsin MEDS data warehouse has enabled development and application of a decision tree for detecting recipient fraud and abuse of controlled substance medications. Using standard pharmacy claims data, the decision tree effectively replicates pharmacist manual review recommendations. The DST has automated extraction and evaluation of pharmacy claims data for creating recommendations for guiding pharmacists in the selection of profiles for manual review. The DST is now the primary method used by the Wisconsin Medicaid program to detect fraud and abuse of physician and pharmacy services committed by recipients.

Communication relating to family members' involvement and understandings about patients' medication management in hospital.

PubMed

Manias, Elizabeth

2015-10-01

Many patients with complex health-care needs are prescribed several medications on a daily basis. With admission to hospital, patients are often placed in a vulnerable position. Family members can therefore play an important role in supporting patients in decision making about managing medications and negotiating communication exchange with health professionals. From the perspective of family members, to explore family members' involvement with health professionals and patients about how patients' medications are managed in hospital. Using an ethnographic design, interviews were conducted with family members of patients admitted to hospital who had at least five medications prescribed in hospital. A purposive sampling approach was used for recruitment. A thematic framework process was used for analysis. Interviews took place in four surgical and four medical wards in each of two Australian hospitals. Forty interviews were conducted with family members in relation to their respective relative's medications. Family members tended to participate in passive, rather than active or shared decision-making activities. Those who demonstrated active or shared decision making were extensively involved in managing medications and in addressing problems relating to continuity of care. Communication with health professionals was generally insufficient, despite family members' keenness to speak with them. Improved communication is needed between family members, health professionals and patients in hospitals. Greater attention should be played by health professionals in initiating communication proactively. Family members possessed valuable, unique information about patients' medications that can be utilized to facilitate patient safety. © 2013 Blackwell Publishing Ltd.

Disrupting Ethnography through Rhizoanalysis

ERIC Educational Resources Information Center

Masny, Diana

2014-01-01

This article interrogates principles of ethnography in education proposed by Mills and Morton: raw tellings, analytic pattern, vignette and empathy. This article adopts a position that is uncomfortable, unconventional and interesting. It involves a deterritorialization/rupture of ethnography in education in order to reterritorialize a different…

Bootstrapping Student Understanding of What Is Going on in Econometrics.

ERIC Educational Resources Information Center

Kennedy, Peter E.

2001-01-01

Explains that econometrics is an intellectual game played by rules based on the sampling distribution concept. Contains explanations for why many students are uncomfortable with econometrics. Encourages instructors to use explain-how-to-bootstrap exercises to promote student understanding. (RLH)

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation

PubMed Central

Yang, Cheng-Yi; Lo, Yu-Sheng; Chen, Ray-Jade

2018-01-01

Background A computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients’ integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients’ medication records prescribed by different health care facilities across Taiwan. Objective This study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters. Methods A CDS engine was developed that can download patients’ up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians’ responses to handling the alerts for each encounter. Results The CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5.83% (1843/31,614) of prescriptions. When prescribing using the CDS engine, the median encounter time was 4.3 (IQR 2.3-7.3) min, longer than that without using the CDS engine (median 3.6, IQR 2.0-6.3 min). From the physicians’ responses, we found that 42.06% (1908/4536) of the potential duplicate medications were recognized by the physicians and the medication orders were canceled. Conclusions The CDS engine could easily extend functions for detection of adverse drug reactions when more and more electronic health record systems are adopted. Moreover, the CDS engine can retrieve more updated and completed medication histories in the PharmaCloud, so it can have better performance for detection of duplicate medications. Although our CDS engine approach could enhance medication safety, it would make for a longer encounter time. This problem can be mitigated by careful evaluation of adopted solutions for implementation of the CDS engine. The successful key component of a CDS engine is the completeness of the patient’s medication history, thus further research to assess the factors in increasing the PharmaCloud consent rate is required. PMID:29351893

A Monte-Carlo game theoretic approach for Multi-Criteria Decision Making under uncertainty

NASA Astrophysics Data System (ADS)

Madani, Kaveh; Lund, Jay R.

2011-05-01

Game theory provides a useful framework for studying Multi-Criteria Decision Making problems. This paper suggests modeling Multi-Criteria Decision Making problems as strategic games and solving them using non-cooperative game theory concepts. The suggested method can be used to prescribe non-dominated solutions and also can be used as a method to predict the outcome of a decision making problem. Non-cooperative stability definitions for solving the games allow consideration of non-cooperative behaviors, often neglected by other methods which assume perfect cooperation among decision makers. To deal with the uncertainty in input variables a Monte-Carlo Game Theory (MCGT) approach is suggested which maps the stochastic problem into many deterministic strategic games. The games are solved using non-cooperative stability definitions and the results include possible effects of uncertainty in input variables on outcomes. The method can handle multi-criteria multi-decision-maker problems with uncertainty. The suggested method does not require criteria weighting, developing a compound decision objective, and accurate quantitative (cardinal) information as it simplifies the decision analysis by solving problems based on qualitative (ordinal) information, reducing the computational burden substantially. The MCGT method is applied to analyze California's Sacramento-San Joaquin Delta problem. The suggested method provides insights, identifies non-dominated alternatives, and predicts likely decision outcomes.

Designing for Clinical Change: Creating an Intervention to Implement New Statin Guidelines in a Primary Care Clinic.

PubMed

DeJonckheere, Melissa; Robinson, Claire H; Evans, Lindsey; Lowery, Julie; Youles, Bradley; Tremblay, Adam; Kelley, Caitlin; Sussman, Jeremy B

2018-04-24

Recent clinical practice guidelines from major national organizations, including a joint United States Department of Veterans Affairs (VA) and Department of Defense (DoD) committee, have substantially changed recommendations for the use of the cholesterol-lowering statin medications after years of relative stability. Because statin medications are among the most commonly prescribed treatments in the United States, any change in their use may have significant implications for patients and providers alike. Prior research has shown that effective implementation interventions should be both user centered and specifically chosen to address identified barriers. The objectives of this study were to identify potential determinants of provider uptake of the new statin guidelines and to use that information to tailor a coordinated and streamlined local quality improvement intervention focused on prescribing appropriate statins. We employed user-centered design principles to guide the development and testing of a multicomponent guideline implementation intervention to improve statin prescribing. This paper describes the intervention development process whereby semistructured qualitative interviews with providers were conducted to (1) illuminate the knowledge, attitudes, and behaviors of providers and (2) elicit feedback on intervention prototypes developed to align with and support the use of the VA/DoD guidelines. Our aim was to use this information to design a local quality improvement intervention focused on statin prescribing that was tailored to the needs of primary care providers at our facility. Cabana's Clinical Practice Guidelines Framework for Improvement and Nielsen's Usability Heuristics were used to guide the analysis of data obtained in the intervention development process. Semistructured qualitative interviews were conducted with 15 primary care Patient Aligned Care Team professionals (13 physicians and 2 clinical pharmacists) at a single VA medical center. Findings highlight that providers were generally comfortable with the paradigm shift to risk-based guidelines but less clear on the need for the VA/DoD guidelines in specific. Providers preferred a clinical decision support tool that helped them calculate patient risk and guide their care without limiting autonomy. They were less comfortable with risk communication and performance measurement systems that do not account for shared decision making. When possible, we incorporated their recommendations into the intervention. By combining qualitative methods and user-centered design principles, we could inform the design of a multicomponent guideline implementation intervention to better address the needs and preferences of providers, including clear and direct language, logical decision prompts with an option to dismiss a clinical decision support tool, and logical ordering of feedback information. Additionally, this process allowed us to identify future design considerations for quality improvement interventions. ©Melissa DeJonckheere, Claire H Robinson, Lindsey Evans, Julie Lowery, Bradley Youles, Adam Tremblay, Caitlin Kelley, Jeremy B Sussman. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 24.04.2018.

A pilot study to understand feasibility and acceptability of stool and cord blood sample collection for a large-scale longitudinal birth cohort.

PubMed

Bailey, S R; Townsend, C L; Dent, H; Mallet, C; Tsaliki, E; Riley, E M; Noursadeghi, M; Lawley, T D; Rodger, A J; Brocklehurst, P; Field, N

2017-12-28

Few data are available to guide biological sample collection around the time of birth for large-scale birth cohorts. We are designing a large UK birth cohort to investigate the role of infection and the developing immune system in determining future health and disease. We undertook a pilot to develop methodology for the main study, gain practical experience of collecting samples, and understand the acceptability of sample collection to women in late pregnancy. Between February-July 2014, we piloted the feasibility and acceptability of collecting maternal stool, baby stool and cord blood samples from participants recruited at prolonged pregnancy and planned pre-labour caesarean section clinics at University College London Hospital. Participating women were asked to complete acceptability questionnaires. Overall, 265 women were approached and 171 (65%) participated, with ≥1 sample collected from 113 women or their baby (66%). Women had a mean age of 34 years, were primarily of white ethnicity (130/166, 78%), and half were nulliparous (86/169, 51%). Women undergoing planned pre-labour caesarean section were more likely than those who delivered vaginally to provide ≥1 sample (98% vs 54%), but less likely to provide maternal stool (10% vs 43%). Pre-sample questionnaires were completed by 110/171 women (64%). Most women reported feeling comfortable with samples being collected from their baby (<10% uncomfortable), but were less comfortable about their own stool (19% uncomfortable) or a vaginal swab (24% uncomfortable). It is possible to collect a range of biological samples from women around the time of delivery, and this was acceptable for most women. These data inform study design and protocol development for large-scale birth cohorts.

A Novel Visual Psychometric Test for Light-Induced Discomfort Using Red and Blue Light Stimuli Under Binocular and Monocular Viewing Conditions.

PubMed

Zivcevska, Marija; Lei, Shaobo; Blakeman, Alan; Goltz, Herbert C; Wong, Agnes M F

2018-03-01

To develop an objective psychophysical method to quantify light-induced visual discomfort, and to measure the effects of viewing condition and stimulus wavelength. Eleven visually normal subjects participated in the study. Their pupils were dilated (2.5% phenylephrine) before the experiment. A Ganzfeld system presented either red (1.5, 19.1, 38.2, 57.3, 76.3, 152.7, 305.3 cd/m2) or blue (1.4, 7.1, 14.3, 28.6, 42.9, 57.1, 71.4 cd/m2) randomized light intensities (1 s each) in four blocks. Constant white-light stimuli (3 cd/m2, 4 s duration) were interleaved with the chromatic trials. Participants reported each stimulus as either "uncomfortably bright" or "not uncomfortably bright." The experiment was done binocularly and monocularly in separate sessions, and the order of color/viewing condition sequence was randomized across participants. The proportion of "uncomfortable" responses was used to generate individual psychometric functions, from which 50% discomfort thresholds were calculated. Light-induced discomfort was higher under blue compared with red light stimulation, both during binocular (t(10) = 3.58, P < 0.01) and monocular viewing (t(10) = 3.15, P = 0.01). There was also a significant difference in discomfort between viewing conditions, with binocular viewing inducing more discomfort than monocular viewing for blue (P < 0.001), but not for red light stimulation. The light-induced discomfort characteristics reported here are consistent with features of the melanopsin-containing intrinsically photosensitive retinal ganglion cell light irradiance pathway, which may mediate photophobia, a prominent feature in many clinical disorders. This is the first psychometric assessment designed around melanopsin spectral properties that can be customized further to assess photophobia in different clinical populations.

Long-Term Opioid Therapy Reconsidered

PubMed Central

Von Korff, Michael; Kolodny, Andrew; Deyo, Richard A.; Chou, Roger

2012-01-01

In the past 20 years, primary care physicians have greatly increased prescribing of long-term opioid therapy. However, the rise in opioid prescribing has outpaced the evidence regarding this practice. Increased opioid availability has been accompanied by an epidemic of opioid abuse and overdose. The rate of opioid addiction among patients receiving long-term opioid therapy remains unclear, but research suggests that opioid misuse is not rare. Recent studies report increased risks for serious adverse events, including fractures, cardiovascular events, and bowel obstruction, although further research on medical risks is needed. New data indicate that opioid-related risks may increase with dose. From a societal perspective, higher-dose regimens account for the majority of opioids dispensed, so cautious dosing may reduce both diversion potential and patient risks for adverse effects. Limiting long-term opioid therapy to patients for whom it provides decisive benefits could also reduce risks. Given the warning signs and knowledge gaps, greater caution and selectivity are needed in prescribing long-term opioid therapy. Until stronger evidence becomes available, clinicians should err on the side of caution when considering this treatment. PMID:21893626

Factors influencing antibiotic prescribing habits and use of sensitivity testing amongst veterinarians in Europe.

PubMed

De Briyne, N; Atkinson, J; Pokludová, L; Borriello, S P; Price, S

2013-11-16

The Heads of Medicines Agencies and the Federation of Veterinarians of Europe undertook a survey to gain a better insight into the decision-making process of veterinarians in Europe when deciding which antibiotics to prescribe. The survey was completed by 3004 practitioners from 25 European countries. Analysis was to the level of different types of practitioner (food producing (FP) animals, companion animals, equines) and country for Belgium, Czech Republic, France, Germany, Spain, Sweden and the UK. Responses indicate no single information source is universally considered critical, though training, published literature and experience were the most important. Factors recorded which most strongly influenced prescribing behaviour were sensitivity tests, own experience, the risk for antibiotic resistance developing and ease of administration. Most practitioners usually take into account responsible use warnings. Antibiotic sensitivity testing is usually performed where a treatment failure has occurred. Significant differences were observed in the frequency of sensitivity testing at the level of types of practitioners and country. The responses indicate a need to improve sensitivity tests and services, with the availability of rapid and cheaper testing being key factors.

Factors influencing antibiotic prescribing habits and use of sensitivity testing amongst veterinarians in Europe

PubMed Central

De Briyne, N.; Atkinson, J.; Pokludová, L.; Borriello, S. P.; Price, S.

2013-01-01

The Heads of Medicines Agencies and the Federation of Veterinarians of Europe undertook a survey to gain a better insight into the decision-making process of veterinarians in Europe when deciding which antibiotics to prescribe. The survey was completed by 3004 practitioners from 25 European countries. Analysis was to the level of different types of practitioner (food producing (FP) animals, companion animals, equines) and country for Belgium, Czech Republic, France, Germany, Spain, Sweden and the UK. Responses indicate no single information source is universally considered critical, though training, published literature and experience were the most important. Factors recorded which most strongly influenced prescribing behaviour were sensitivity tests, own experience, the risk for antibiotic resistance developing and ease of administration. Most practitioners usually take into account responsible use warnings. Antibiotic sensitivity testing is usually performed where a treatment failure has occurred. Significant differences were observed in the frequency of sensitivity testing at the level of types of practitioners and country. The responses indicate a need to improve sensitivity tests and services, with the availability of rapid and cheaper testing being key factors. PMID:24068699

Heal the damage: prescription drug consumer advertisements and relative choices.

PubMed

Gilhooley, Margaret

2005-01-01

The process of choosing and prescribing prescription drugs is complex. While the choice about which drug to prescribe is made by the physician, the physician may be influenced by patient demand, which, in turn, may be influenced by consumer advertisements. As a result, consumer advertisements for prescription drugs need to provide information that gives consumers an understanding, not only of drug risks and efficacy but also of the notable limits on benefits claimed. This Article examines the drug-specific focus of consumer advertising for prescription drugs from two perspectives: the need to prevent confusion that could affect medical decisions about alternative treatments and the need to prevent misimpressions about the value of a drug that can create consumer demand on physicians and insurers for more expensive drugs than needed.

Managed care cost-containment strategies and their impact on physician prescribing and treatment of depression. Based on a presentation by Robert K. Schreter, MD.

PubMed

2000-02-01

Pharmacy costs are outpacing other healthcare expenditures, with psychotropic medications accounting for 16% to 25% of the total pharmacy costs. Managed care organizations (MCOs) can be expected to exert considerable pressure to control such costs. Avenues for cost containment include changing the management and spending decisions of MCOs, influencing physician prescribing patterns, encouraging economically efficient pharmacy policies and procedures, and controlling patient access to prescription drugs. From the cost standpoint of an MCO, briefer approaches to treating depressed patients are desirable. The MCOs prefer a limited number of psychotherapeutic sessions, rapid titration and prescription of higher dosage levels of appropriate drugs, and a longer continuation phase of pharmacological treatment to avert a relapse.

Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol.

PubMed

Prior, Maria; Elouafkaoui, Paula; Elders, Andrew; Young, Linda; Duncan, Eilidh M; Newlands, Rumana; Clarkson, Jan E; Ramsay, Craig R

2014-04-24

Antibiotic prescribing in dentistry accounts for 9% of total antibiotic prescriptions in Scottish primary care. The Scottish Dental Clinical Effectiveness Programme (SDCEP) published guidance in April 2008 (2nd edition, August 2011) for Drug Prescribing in Dentistry, which aims to assist dentists to make evidence-based antibiotic prescribing decisions. However, wide variation in prescribing persists and the overall use of antibiotics is increasing. RAPiD is a 12-month partial factorial cluster randomised trial conducted in NHS General Dental Practices across Scotland. Its aim is to compare the effectiveness of individualised audit and feedback (A&F) strategies for the translation into practice of SDCEP recommendations on antibiotic prescribing. The trial uses routinely collected electronic healthcare data in five aspects of its design in order to: identify the study population; apply eligibility criteria; carry out stratified randomisation; generate the trial intervention; analyse trial outcomes. Eligibility was determined on contract status and a minimum level of recent NHS treatment provision. All eligible dental practices in Scotland were simultaneously randomised at baseline either to current audit practice or to an intervention group. Randomisation was stratified by single-handed/multi-handed practices. General dental practitioners (GDPs) working at intervention practices will receive individualised graphical representations of their antibiotic prescribing rate from the previous 14 months at baseline and an update at six months. GDPs could not be blinded to their practice allocation. Intervention practices were further randomised using a factorial design to receive feedback with or without: a health board comparator; a supplementary text-based intervention; additional feedback at nine months. The primary outcome is the total antibiotic prescribing rate per 100 courses of treatment over the year following delivery of the baseline intervention. A concurrent qualitative process evaluation will apply theory-based approaches using the Consolidated Framework for Implementation Research to explore the acceptability of the interventions and the Theoretical Domains Framework to identify barriers and enablers to evidence-based antibiotic prescribing behaviour by GDPs. RAPiD will provide a robust evaluation of A&F in dentistry in Scotland. It also demonstrates that linked administrative datasets have the potential to be used efficiently and effectively across all stages of an randomised controlled trial. Current Controlled Trials ISRCTN49204710.

Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol

PubMed Central

2014-01-01

Background Antibiotic prescribing in dentistry accounts for 9% of total antibiotic prescriptions in Scottish primary care. The Scottish Dental Clinical Effectiveness Programme (SDCEP) published guidance in April 2008 (2nd edition, August 2011) for Drug Prescribing in Dentistry, which aims to assist dentists to make evidence-based antibiotic prescribing decisions. However, wide variation in prescribing persists and the overall use of antibiotics is increasing. Methods RAPiD is a 12-month partial factorial cluster randomised trial conducted in NHS General Dental Practices across Scotland. Its aim is to compare the effectiveness of individualised audit and feedback (A&F) strategies for the translation into practice of SDCEP recommendations on antibiotic prescribing. The trial uses routinely collected electronic healthcare data in five aspects of its design in order to: identify the study population; apply eligibility criteria; carry out stratified randomisation; generate the trial intervention; analyse trial outcomes. Eligibility was determined on contract status and a minimum level of recent NHS treatment provision. All eligible dental practices in Scotland were simultaneously randomised at baseline either to current audit practice or to an intervention group. Randomisation was stratified by single-handed/multi-handed practices. General dental practitioners (GDPs) working at intervention practices will receive individualised graphical representations of their antibiotic prescribing rate from the previous 14 months at baseline and an update at six months. GDPs could not be blinded to their practice allocation. Intervention practices were further randomised using a factorial design to receive feedback with or without: a health board comparator; a supplementary text-based intervention; additional feedback at nine months. The primary outcome is the total antibiotic prescribing rate per 100 courses of treatment over the year following delivery of the baseline intervention. A concurrent qualitative process evaluation will apply theory-based approaches using the Consolidated Framework for Implementation Research to explore the acceptability of the interventions and the Theoretical Domains Framework to identify barriers and enablers to evidence-based antibiotic prescribing behaviour by GDPs. Discussion RAPiD will provide a robust evaluation of A&F in dentistry in Scotland. It also demonstrates that linked administrative datasets have the potential to be used efficiently and effectively across all stages of an randomised controlled trial. Trial registration Current Controlled Trials ISRCTN49204710 PMID:24758164

Eldercare at Home: Caregiving

MedlinePlus

... Nursing Home section will give you guidance on how to get information you need and what professionals to talk ... things and notice how easy it is and how much people enjoy helping. If asking makes you very uncomfortable, then get someone else to ask for you. Problem "The ...

Leadership, Charisma, Personality, and Power.

ERIC Educational Resources Information Center

Beaven, Mary H.

Transformational, charismatic leadership occurs in a conflict-ridden situation, where attendant emotional travail is so uncomfortable that macro and micro structures will admit to change in efforts to relieve the tension. An inspirational message that redefines and reprioritizes deeply cherished values and the leader's role-modeling influence…

Preparing Tomorrow's Science Teachers

ERIC Educational Resources Information Center

Hammer, Margaret; Polnick, Barbara

2007-01-01

Many undergraduates seeking elementary teaching certification are uncomfortable with or uninterested in science; however, these future teachers are charged with the responsibility of teaching science to young students. Hammer and Polnick surveyed science methods students at Sam Houston State University and found that only about half of them rated…

A New Approach to Assessing Self-Regulation by Older Drivers: Development and Testing of a Questionnaire Instrument

DOT National Transportation Integrated Search

2009-12-01

Appropriate self-regulation of driving; that is, adjusting ones driving patterns by driving less or avoiding specific situations in which one feels unsafe or uncomfortable, shows considerable promise as a strategy for compensating for functional d...

A new approach to assessing self-regulation by older drivers : development and testing of a questionnaire instrument.

DOT National Transportation Integrated Search

2010-12-01

Appropriate self-regulation of driving; that is, adjusting ones driving patterns by driving less or avoiding specific : situations in which one feels unsafe or uncomfortable, shows considerable promise as a strategy for compensating for : function...

Microprocessor Control For Liquid-Cooled Garment

NASA Technical Reports Server (NTRS)

Weaver, Charles S.

1990-01-01

Automatic control system maintains temperature of water-cooled garment within comfort zone while wearer's level of physical activity varies. Uncomfortable overshoots and undershoots of temperature eliminated. Designed for use in space suit, adaptable to other protective garments and to enclosed environments operating according to similar principles.

"Our Time is Up": A Relational Perspective on the Ending of a Single Psychotherapy Session.

PubMed

Gans, Jerome S

2016-12-31

This paper, written from a relational perspective, examines the final minutes of an individual psychotherapy session, and is organized around the topics of boundary negotiation, unwitting self-disclosures, visual challenges, and countertransference. Attending to session-ending material is important because the separation involved lends heightened emotional intensity to the oftensignificant material that appears in the final minutes. This material often serves as a bridge to the psychotherapeutic work to be taken up in subsequent sessions. Session-ending dynamics call upon the therapist to prioritize empathy, validation, and support for the patient suffering from early deprivation; identify and heal narcissistic injury in the patient wishing to be special; judiciously alter the frame when doing so will benefit the patient and not constitute a boundary violation; avoid re-traumatization; admit mistakes; confront blatant denial; advance agency; address uncomfortable topics; set appropriate limits; and deal authentically with uncomfortable countertransference. Numerous clinical examples serve to illustrate these clinical phenomena.

Red or uncomfortable eye.

PubMed Central

Davey, C.; Hurwitz, B.

1992-01-01

1. A red, uncomfortable eye may be accompanied by other symptoms such as blurred, decreased, or double vision, haloes, photophobia, pain or discharge. 2. A careful history and brief systematic examination will sort out most problems. 3. Examine eyelids, the conjunctivae and corneas. Checking visual acuity is often important. 4. The most common underlying causes can usually be managed within general practice, though a few patients will require urgent eye assessment, or routine referral to ophthalmic outpatients. 5. The following are typical eye problems which require urgent referral: History of pain as opposed to discomfort, Trauma including foreign bodies, chemicals and suspected penetrating injury, Unexplained drop in visual acuity of two lines or more in a painful eye. Specific conditions: preseptal cellulitis, herpes simplex ulcer, scleritis, orbital cellulitis, herpes zoster, bacterial corneal ulcer, dacryocystitis. 6. The following are typical problems which may require routine referral: Persistence of the problem not relieved by simple measures, Recurrent disorders of uncertain diagnosis, Eyelid swelling such as chalazion, cysts, basal cell carcinoma, Gradual loss of vision, for example cataract, macular degeneration. PMID:1345157

Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation

PubMed Central

Fleming, Aoife; Bradley, Colin; Cullinan, Shane; Byrne, Stephen

2014-01-01

Objectives To explore healthcare professionals’ views of antibiotic prescribing in long-term care facilities (LTCFs). To use the findings to recommend intervention strategies for antimicrobial stewardship in LTCFs. Design Qualitative semistructured interviews were conducted. The data were analysed by thematic content analysis. After the interviews, the emerging findings were mapped to the theoretical domains framework (TDF), and the behaviour change wheel and behaviour change technique (BCT) taxonomy were used to recommend future intervention strategies. Participants Interviews were conducted with 37 healthcare professionals who work in LTCFs (10 general practitioners, 4 consultants, 14 nurses, 9 pharmacists) between December 2012 and March 2013. Setting Interviews were conducted in the greater Cork region. Results The main domains from the TDF which emerged were: ‘Knowledge’, ‘Environmental context and resources’, ‘Social influences’, ‘Beliefs about consequences’, ‘Memory, attention and decision making’, with the findings identifying a need for ‘Behavioural regulation’. Many participants believed that antibiotic prescribing was satisfactory at their LTCF, despite the lack of surveillance activities. Conclusions This study, using the TDF and BCT taxonomy, has found that antibiotic prescribing in LTCFs is influenced by many social and contextual factors. The challenges of the setting and patient population, the belief about consequences to the patient, and the lack of implementation of guidelines and knowledge regarding antibiotic prescribing patterns are significant challenges to address. On the basis of the study findings and the application of the TDF and BCT taxonomy, we suggest some practical intervention functions for antimicrobial stewardship in LTCFs. PMID:25377014

Why do general practitioners prescribe antibiotics for acute infective conjunctivitis in children? Qualitative interviews with GPs and a questionnaire survey of parents and teachers.

PubMed

Rose, Peter W; Ziebland, Sue; Harnden, Anthony; Mayon-White, Richard; Mant, David

2006-04-01

Acute infective conjunctivitis in children is a common presentation in primary care. Treatment is usually with antibiotics and prescribing may be affected by non-clinical factors. To investigate the non-clinical determinants of the management of acute infective conjunctivitis in children. Qualitative interviews with GPs and a questionnaire survey of parents of children with acute infective conjunctivitis and teachers. GPs in Sheffield and Berkshire and parents of children with acute infective conjunctivitis and schools in Oxfordshire. Semi-structured telephone interviews of 39 GPs. Questionnaire survey of 326 parents of children enrolled into a trial of acute infective conjunctivitis treatment. Questionnaire survey of 223 nurseries and primary schools in Oxfordshire. All three groups agreed that acute infective conjunctivitis was a mild condition. Parents were certain about the benefits of antibiotic treatment and sought early consultations with their GP in a desire to get their child back to school. GPs sometimes collude with a parent's request to prescribe to enable school attendance. Despite this 54.2% (95%CI 48.5-59.8%) children missed a mean of 1.85 days from school and 28.6% of parents (95%CI 23.5-33.7%) missed a mean of 1.5 days off work. Social factors, including the need for children to attend day care or school and parents to go to work, contribute to the decision to prescribe antibiotics for children with acute infective conjunctivitis. Understanding these issues and changing school policies in line with national guidance may reduce pressure on GPs to prescribe for this condition.

An Integrative Review of Empirical Research on Perceptions and Behaviors Related to Prescribed Burning and Wildfire in the United States

NASA Astrophysics Data System (ADS)

Dupéy, Lauren Nicole; Smith, Jordan W.

2018-06-01

Social science research from a variety of disciplines has generated a collective understanding of how individuals prepare for, and respond to, the risks associated with prescribed burning and wildfire. We provide a systematic compilation, review, and quantification of dominant trends in this literature by collecting all empirical research conducted within the U.S. that has addressed perceptions and behaviors surrounding various aspects of prescribed burning and wildfire. We reviewed and quantified this literature using four thematic categories covering: (1) the theory and methods that have been used in previous research; (2) the psychosocial aspects of prescribed burning and wildfire that have been studied; (3) the biophysical characteristics of the fires which have been studied; and (4) the types of fire and management approaches that have been examined. Our integrative review builds on previous literature reviews on the subject by offering new insight on the dominant trends, underutilized approaches, and under-studied topics within each thematic category. For example, we found that a select set of theories (e.g., Protection Motivation Theory, Attribution Theory, etc.) and approaches (e.g., mixed-methods) have only been used sparingly in previous research, even though these theories and approaches can produce insightful results that can readily be implemented by fire-management professionals and decision makers. By identifying trends and gaps in the literature across the thematic categories, we were able to answer four questions that address how future research can make the greatest contribution to our understanding of perceptions and behaviors related to prescribed burning and wildfire.

An Integrative Review of Empirical Research on Perceptions and Behaviors Related to Prescribed Burning and Wildfire in the United States.

PubMed

Dupéy, Lauren Nicole; Smith, Jordan W

2018-06-01

Social science research from a variety of disciplines has generated a collective understanding of how individuals prepare for, and respond to, the risks associated with prescribed burning and wildfire. We provide a systematic compilation, review, and quantification of dominant trends in this literature by collecting all empirical research conducted within the U.S. that has addressed perceptions and behaviors surrounding various aspects of prescribed burning and wildfire. We reviewed and quantified this literature using four thematic categories covering: (1) the theory and methods that have been used in previous research; (2) the psychosocial aspects of prescribed burning and wildfire that have been studied; (3) the biophysical characteristics of the fires which have been studied; and (4) the types of fire and management approaches that have been examined. Our integrative review builds on previous literature reviews on the subject by offering new insight on the dominant trends, underutilized approaches, and under-studied topics within each thematic category. For example, we found that a select set of theories (e.g., Protection Motivation Theory, Attribution Theory, etc.) and approaches (e.g., mixed-methods) have only been used sparingly in previous research, even though these theories and approaches can produce insightful results that can readily be implemented by fire-management professionals and decision makers. By identifying trends and gaps in the literature across the thematic categories, we were able to answer four questions that address how future research can make the greatest contribution to our understanding of perceptions and behaviors related to prescribed burning and wildfire.

SILVAH 5.1: developing interim guidelines for managing oak in Pennsylvania through multi-agency cooperation

Treesearch

Patrick Brose; Susan Stout; Gary Miller; Kurt Gottschalk

2003-01-01

The SILVAH decision-support system developed by numerous researchers at the Forestry Sciences Lab in Irvine, PA, has a proven track record for prescribing appropriate silvicultural treatments for the cherry-maple and northern hardwood forests of the Allegheny Plateau region. However, it has had only limited usage in mixed-oak forests of the same region and virtually no...

A Delphi Study to Develop a Standard List of Activities that Comprise Routine Clinical Pharmacy Services

DTIC Science & Technology

2012-06-08

The 2009 ASHP national survey on monitoring and patient education incorporates this generalist concept in its description of the three hospital...counseling Intravenous-to-oral medication conversion Drug selection recommendation Patient education Prospective order review Provider encounters...of Drug Information to Health Professionals Drug selection recommendation Decision to Prescribe a Medicine Patient education Provision of Drug

Bridging EOS remote sensing measurements and fire emissions, smoke dispersion, and air quality DSS in the Eastern US

Treesearch

John J. Qu; Xianjun Hao; Ruixin Yang; Swarvanu Dasgupta; Sanjeeb Bhoi; Menas Kafatos

1999-01-01

Fire eniissions, smoke dispersiotl. ancl air quality are very important for fire fighting and planing of prescribed burning. BlueskyRATNS (BSR) is a comprehenisive and state-of-the-art Decision Support System (DSS) for fire managers and air quality managers to plan fiiels treatments and support state air qiiality smoke regulatory actions, especially related to...

Mental health promotion system.

PubMed

Farooq, Umar; Jang, Dae-Geun; Jang, Jae-Keun; Park, Seung-Hun

2011-01-01

Mental activity promotion system is presented that analyzes, quantifies, trains and prescribes based on analysis of logical, memorizing, concentrative, decisive, in conditions where time and space is involved, possibility of dementia, and on evaluation of lifestyle of subjects. Special consideration has been made to make the system motivational, persuasive, attractive and fun to use. The system has been successfully deployed in Bitgeoul Senior health town, Gwangju, South Korea.

Under-age girls and contraception: the parent's right to be informed.

PubMed

Brahams, Diana

1983-08-06

A British barrister considers the issue of whether the giving of advice or the prescribing of contraceptives to girls younger than 16 without parental consent constitutes criminal conduct by the physician. Brahams examines relevant criminal and family law, common law, recent court decisions, and Department of Health and Human Services policy concerning the minor's right to consent, parental interests, and physician responsibilities.

Miracle Workers: When Appropriately Prescribed and Supported by Solid Instruction, Alternative and Augmentative Communication Devices Can Give Voices to Students Otherwise "Trapped" by Their Disabilities

ERIC Educational Resources Information Center

Bainbridge, Marc

2005-01-01

The Individuals with Disabilities Education Act (IDEA-PL 101-478) of 1990 assures the right to assistive technology for individuals with disabilities. Later versions of the law increased spending, support, and consumer decision making and encouraged research and development for a range of assistive instructional technologies. As a result, the…

Factors in United States Forest Service district rangers' decision to manage a fire for resource benefit

Treesearch

Martha A. Williamson

2007-01-01

United States wildland fire policy and program reviews in 1995 and 2000 required both the reduction of hazardous fuel and recognition of fire as a natural process. Despite the fact that existing policy permits managing natural ignitions to meet resource benefits, or Wildland Fire Use (WFU), most fuel reduction projects rely on mechanical treatments and prescribed fire...

Decision support tools to improve the effectiveness of hazardous fuel reduction treatments in the New Jersey Pine Barrens

Treesearch

Kenneth L. Clark; Nicholas Skowronski; John Hom; Matthew Duveneck; Yude Pan; Stephen Van Tuyl; Jason Cole; Matthew Patterson; Stephen Maurer

2009-01-01

Our goal is to assist the New Jersey Forest Fire Service and federal wildland fire managers in the New Jersey Pine Barrens evaluate where and when to conduct hazardous fuel reduction treatments. We used remotely sensed LIDAR (Light Detection and Ranging System) data and field sampling to estimate fuel loads and consumption during prescribed fire treatments. This...

75 FR 7306 - Petition for Waiver of the Terms of the Order Limiting Scheduled Operations at LaGuardia Airport

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-18

... waiver should not be read to prejudice or predetermine any long-term policy decisions relating to... policy goals prescribed for the Secretary in 49 U.S.C. 40101(a)(4), (6), (10-13) and the pro-competition policies followed by Congress in adopting legislation on matters such as slot exemptions and airport grant...

Effect of the Tool to Reduce Inappropriate Medications on Medication Communication and Deprescribing.

PubMed

Fried, Terri R; Niehoff, Kristina M; Street, Richard L; Charpentier, Peter A; Rajeevan, Nallakkandi; Miller, Perry L; Goldstein, Mary K; O'Leary, John R; Fenton, Brenda T

2017-10-01

To examine the effect of the Tool to Reduce Inappropriate Medications (TRIM), a web tool linking an electronic health record (EHR) to a clinical decision support system, on medication communication and prescribing. Randomized clinical trial. Primary care clinics at a Veterans Affairs Medical Center. Veterans aged 65 and older prescribed seven or more medications randomized to receipt of TRIM or usual care (N = 128). TRIM extracts information on medications and chronic conditions from the EHR and contains data entry screens for information obtained from brief chart review and telephonic patient assessment. These data serve as input for automated algorithms identifying medication reconciliation discrepancies, potentially inappropriate medications (PIMs), and potentially inappropriate regimens. Clinician feedback reports summarize discrepancies and provide recommendations for deprescribing. Patient feedback reports summarize discrepancies and self-reported medication problems. Primary: subscales of the Patient Assessment of Care for Chronic Conditions (PACIC) related to shared decision-making; clinician and patient communication. Secondary: changes in medications. 29.7% of TRIM participants and 15.6% of control participants provided the highest PACIC ratings; this difference was not significant. Adjusting for covariates and clustering of patients within clinicians, TRIM was associated with significantly more-active patient communication and facilitative clinician communication and with more medication-related communication among patients and clinicians. TRIM was significantly associated with correction of medication discrepancies but had no effect on number of medications or reduction in PIMs. TRIM improved communication about medications and accuracy of documentation. Although there was no association with prescribing, the small sample size provided limited power to examine medication-related outcomes. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Technological viewpoints (frames) about electronic prescribing in physician practices.

PubMed

Agarwal, Ritu; Angst, Corey M; DesRoches, Catherine M; Fischer, Michael A

2010-01-01

Physician practices may adopt and use electronic prescribing (eRx) in response to mandates, incentives, and perceived value of the technology. Yet, for the most part, diffusion has been limited and geographically confined, and even when adopted, use of eRx in many practices has been low. One explanation for this phenomenon is that decision-makers in the practices possess different technological viewpoints (frames) related to eRx and these frames have formed the basis for the adoption decision, expectations about the technology, and patterns of use. In this study eRx technological frames were examined. Focus groups, direct observation, and semi-structured interviews were conducted with physicians, practice managers, nurses, and other medical staff. Focus groups were observed, taped, transcribed, and analyzed to reveal themes. These themes guided the observational visits and subsequent interviews. A triangulation process was used to confirm the findings. Seven frames emerged from the qualitative analysis ranging from positive to neutral to negative: (1) eRx as an efficiency and effectiveness enhancing tool; (2) eRx as the harbinger of new practices; (3) eRx as core to the clinical workflow; (4) eRx as an administrative tool; (5) eRx: the artifact; (6) eRx as a necessary evil; and (7) eRx as an unwelcome disruption. Frames provide a unique perspective within which to explore the adoption and use of eRx and may explain why perceptions of value vary greatly. Some frames facilitate effective use of eRx while others impose barriers. Electronic prescribing can be viewed as a transitional technology on the path to greater digitization at the physician practice level. Understanding the impact of technological frames on the effectiveness of eRx use may provide lessons for the implementation of future health information technology innovations.

Factors controlling seedling germination after fire in Mediterranean gorse shrublands. Implications for fire prescription.

PubMed

De Luis, M; Raventós, J; González-Hidalgo, J C

2005-07-01

In Western Mediterranean areas, fires are frequent in forests established on old croplands where woody resprouting species are scarce and post-fire regeneration is limited to obligate-seeder species, such as Mediterranean gorse (Ulex parviflorus), that accumulate a great deal of fine dry fuel, increasing the risk of other severe fires. Under these conditions, fuel control techniques are required in order to prevent fires of high intensity and severity and the subsequent economic and ecological damage. Prescribed fires present an alternative to fuel control, and recent studies demonstrate that, under optimum climatic conditions, fire-line intensity values fall within the limits of those recommended for fire prescription. However, a better understanding of the consequences of fire on the regeneration of vegetation is needed in order to evaluate the suitability of prescribed fires as a technique for fuel reduction in Mediterranean gorse ecosystems. This paper analyses the factors controlling seedling germination after fire to make an evaluation from an ecological perspective of whether fire prescription is a suitable technique for fuel control in mature Mediterranean gorse shrublands. The results show that small differences in the composition of vegetation play a decisive role in fire behaviour, and have a decisive influence on the system's capacity for regeneration. Fire severity is low in mixed Mediterranean gorse communities with a low continuity of dead fine fuel (including Cistus sp., Rosmarinus sp., etc.) and fire creates a wide range of microhabitats where seedling emergence is high. In contrast, where U. parviflorus is more dominant, fire severity is higher and the regeneration of vegetation could be hindered. Our conclusions suggest that detailed studies of the composition of plant communities are required in order to decide whether prescribed burning should be applied.

Eliminating Health Care Disparities With Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example.

PubMed

Lau, Brandyn D; Haider, Adil H; Streiff, Michael B; Lehmann, Christoph U; Kraus, Peggy S; Hobson, Deborah B; Kraenzlin, Franca S; Zeidan, Amer M; Pronovost, Peter J; Haut, Elliott R

2015-01-01

All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services. This was a retrospective cohort study of a quality improvement intervention. The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients. In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated. Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort. Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.

Technological viewpoints (frames) about electronic prescribing in physician practices

PubMed Central

Agarwal, Ritu; DesRoches, Catherine M; Fischer, Michael A

2010-01-01

Objective Physician practices may adopt and use electronic prescribing (eRx) in response to mandates, incentives, and perceived value of the technology. Yet, for the most part, diffusion has been limited and geographically confined, and even when adopted, use of eRx in many practices has been low. One explanation for this phenomenon is that decision-makers in the practices possess different technological viewpoints (frames) related to eRx and these frames have formed the basis for the adoption decision, expectations about the technology, and patterns of use. In this study eRx technological frames were examined. Design Focus groups, direct observation, and semi-structured interviews were conducted with physicians, practice managers, nurses, and other medical staff. Measurements Focus groups were observed, taped, transcribed, and analyzed to reveal themes. These themes guided the observational visits and subsequent interviews. A triangulation process was used to confirm the findings. Results Seven frames emerged from the qualitative analysis ranging from positive to neutral to negative: (1) eRx as an efficiency and effectiveness enhancing tool; (2) eRx as the harbinger of new practices; (3) eRx as core to the clinical workflow; (4) eRx as an administrative tool; (5) eRx: the artifact; (6) eRx as a necessary evil; and (7) eRx as an unwelcome disruption. Conclusion Frames provide a unique perspective within which to explore the adoption and use of eRx and may explain why perceptions of value vary greatly. Some frames facilitate effective use of eRx while others impose barriers. Electronic prescribing can be viewed as a transitional technology on the path to greater digitization at the physician practice level. Understanding the impact of technological frames on the effectiveness of eRx use may provide lessons for the implementation of future health information technology innovations. PMID:20595310

Impact of Computerized Decision Support on Blood Pressure Management and Control: A Randomized Controlled Trial

PubMed Central

Sequist, Thomas D.; Ayanian, John Z.; Shaykevich, Shimon; Fairchild, David G.; Orav, E. John; Bates, David W.

2008-01-01

BACKGROUND We conducted a cluster randomized controlled trial to examine the effectiveness of computerized decision support (CDS) designed to improve hypertension care and outcomes in a racially diverse sample of primary care patients. METHODS We randomized 2,027 adult patients receiving hypertension care in 14 primary care practices to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without computerized support for the control group. We assessed prescribing of guideline-recommended drug therapy and levels of blood pressure control for patients in each group and examined if the effects of the intervention differed by patients’ race/ethnicity using interaction terms. MEASUREMENTS AND MAIN RESULTS Rates of blood pressure control were 42% at baseline and 46% at the outcome visit with no significant differences between groups. After adjustment for patients’ demographic and clinical characteristics, number of prior visits, and levels of baseline blood pressure control, there were no differences between intervention groups in the odds of outcome blood pressure control. The use of CDS to providers significantly improved Joint National Committee (JNC) guideline adherent medication prescribing compared to usual care (7% versus 5%, P < 0.001); the effects of the intervention remained after multivariable adjustment (odds ratio [OR] 1.39 [CI, 1.13–1.72]) and the effects of the intervention did not differ by patients’ race and ethnicity. CONCLUSIONS CDS improved appropriate medication prescribing with no improvement in disparities in care and overall blood pressure control. Future work focusing on improvement of these interventions and the study of other practical interventions to reduce disparities in hypertension-related outcomes is needed. PMID:18373141

[Structural elements of critical thinking of nurses in emergency care].

PubMed

Crossetti, Maria da Graça Oliveira; Bittencourt, Greicy Kelly Gouveia Dias; Lima, Ana Amélia Antunes; de Góes, Marta Georgina Oliveira; Saurin, Gislaine

2014-09-01

The objective of this study was to analyze the structural elements of critical thinking (CT) of nurses in the clinical decision-making process. This exploratory, qualitative study was conducted with 20 emergency care nurses in three hospitals in southern Brazil. Data were collected from April to June 2009, and a validated clinical case was applied from which nurses listed health problems, prescribed care and listed the structural elements of CT. Content analysis resulted in categories used to determine priority structural elements of CT, namely theoretical foundations and practical relationship to clinical decision making; technical and scientific knowledge and clinical experience, thought processes and clinical decision making: clinical reasoning and basis for clinical judgments of nurses: patient assessment and ethics. It was concluded that thinking critically is a skill that enables implementation of a secure and effective nursing care process.

Combining statistical inference and decisions in ecology.

PubMed

Williams, Perry J; Hooten, Mevin B

2016-09-01

Statistical decision theory (SDT) is a sub-field of decision theory that formally incorporates statistical investigation into a decision-theoretic framework to account for uncertainties in a decision problem. SDT provides a unifying analysis of three types of information: statistical results from a data set, knowledge of the consequences of potential choices (i.e., loss), and prior beliefs about a system. SDT links the theoretical development of a large body of statistical methods, including point estimation, hypothesis testing, and confidence interval estimation. The theory and application of SDT have mainly been developed and published in the fields of mathematics, statistics, operations research, and other decision sciences, but have had limited exposure in ecology. Thus, we provide an introduction to SDT for ecologists and describe its utility for linking the conventionally separate tasks of statistical investigation and decision making in a single framework. We describe the basic framework of both Bayesian and frequentist SDT, its traditional use in statistics, and discuss its application to decision problems that occur in ecology. We demonstrate SDT with two types of decisions: Bayesian point estimation and an applied management problem of selecting a prescribed fire rotation for managing a grassland bird species. Central to SDT, and decision theory in general, are loss functions. Thus, we also provide basic guidance and references for constructing loss functions for an SDT problem. © 2016 by the Ecological Society of America.

Physician Guide to Appropriate Opioid Prescribing for Noncancer Pain

PubMed Central

Munzing, Timothy

2017-01-01

Prescription opioid use for relief of noncancer pain has risen dramatically in the last 15 years, contributing to a quadrupling of opioid overdoses and prescription opioid-related deaths. This crisis is resulting in heightened attention by health care professionals and organizations, law enforcement, and the government. In this article, I highlight key topics in the management of patients using opioids (or potentially needing opioids) in outpatient clinical practice; federal and state law enforcement actions regarding physicians’ illegal prescribing of opioids; multimodal approaches to pain control; nonmedication management of pain; response strategies when suspecting a patient of diverting or misusing opioids; and warning signs for abuse or diversion. For those patients for whom opioids are appropriate, I describe key elements for prescribing, including documentation of a detailed history and examination, appropriate evaluation to arrive at a specific diagnosis, individualizing management, and ongoing monitoring (including the use of urine drug screening and a prescription drug monitoring program). In addition to individual action, when possible, the initiation of systemwide and clinicwide safe prescribing practices supports the physician and patient such that the patient’s well-being is at the heart of all pain management decisions. Physicians are encouraged to further educate themselves to treat pain safely and effectively; to screen patients for opioid use disorder and, when diagnosed, to connect them with evidence-based treatment; and to follow Centers for Disease Control and Prevention guidelines whenever possible. PMID:28488993

Physician Guide to Appropriate Opioid Prescribing for Noncancer Pain.

PubMed

Munzing, Timothy

2017-01-01

Prescription opioid use for relief of noncancer pain has risen dramatically in the last 15 years, contributing to a quadrupling of opioid overdoses and prescription opioid-related deaths. This crisis is resulting in heightened attention by health care professionals and organizations, law enforcement, and the government. In this article, I highlight key topics in the management of patients using opioids (or potentially needing opioids) in outpatient clinical practice; federal and state law enforcement actions regarding physicians' illegal prescribing of opioids; multimodal approaches to pain control; nonmedication management of pain; response strategies when suspecting a patient of diverting or misusing opioids; and warning signs for abuse or diversion. For those patients for whom opioids are appropriate, I describe key elements for prescribing, including documentation of a detailed history and examination, appropriate evaluation to arrive at a specific diagnosis, individualizing management, and ongoing monitoring (including the use of urine drug screening and a prescription drug monitoring program). In addition to individual action, when possible, the initiation of systemwide and clinicwide safe prescribing practices supports the physician and patient such that the patient's well-being is at the heart of all pain management decisions. Physicians are encouraged to further educate themselves to treat pain safely and effectively; to screen patients for opioid use disorder and, when diagnosed, to connect them with evidence-based treatment; and to follow Centers for Disease Control and Prevention guidelines whenever possible.

The role of perceived impact on relationship quality in pharmacists' willingness to influence indication-based off-label prescribing decisions.

PubMed

Basak, Ramsankar; Bentley, John P; McCaffrey, David J; Bouldin, Alicia S; Banahan, Benjamin F

2015-05-01

Little is known about factors that affect pharmacists' roles in off-label prescribing. This study examined the effect of perceived impact on relationship quality (IRQ) on hospital pharmacists' willingness to influence a physician's decision regarding an indication-based off-label medication order (WTIP) (i.e., beyond FDA-approved indications) and the moderating roles of the appropriateness of the medication order and the relative expert power of the pharmacist. Pharmacists practicing in U.S. hospitals, recruited from membership rolls of state affiliates of the American Society of Health-System Pharmacists, were sent an electronic link to a questionnaire via their respective affiliates. A cross-sectional, randomized, 2 × 2 experimental design was used; participants were assigned to one of the indication-based off-label medication order scenarios. Relative expert power (i.e., power differential between the pharmacist and the physician) and appropriateness of the prescription were manipulated. Perceived IRQ was measured with multiple items. Pharmacists' WTIP in the scenario was the outcome variable. A total of 243 responses were included in multiple linear regression analyses. After controlling for dependence power, information power, communication effectiveness, perceived responsibility, and attitude, pharmacists' WTIP was negatively affected by perceived IRQ (estimate = -0.309, P < 0.05). This effect was more pronounced in groups exposed to the scenario where the pharmacist had lower relative expert power (estimate = -0.438, P < 0.05) and where the medication was less appropriate (estimate = -0.503, P < 0.05). Although willing to ensure rationality of off-label prescribing, pharmacists' WTIP was affected by a complex array of factors - the perceived impact of influence attempts on relationship quality between the pharmacist and the prescriber, the pharmacist's relative expert power, and the appropriateness of the off-label prescription. Increasing pharmacists' expert power and collaboration with physicians and promoting pharmacists' multifaceted contribution, collaborative or independent, to patient care may facilitate pharmacist services in off-label pharmaceutical care. Published by Elsevier Ltd.

Herpetic stomatitis

MedlinePlus

... Fever, often as high as 104°F (40°C), which may occur 1 to 2 days before blisters and ulcers appear Irritability Mouth pain Swollen gums Symptoms may be so uncomfortable that your child doesn't want to eat or drink. Exams and Tests Your child's health care provider can ...

Uncomfortable Experience: Lessons Lost in the Apache War

DTIC Science & Technology

2015-03-01

wife Dos- teh -seh (daughter of Mangus Coloradas), and two of their children.20 Most accounts indicate his sons Naiche and Taza attended. However, in...May - September 1886. Edited with an introduction and epilogue by Jack C. Lane. 1970. Reprint, Lincoln NE: University of Nebraska Press, 2009

Teaching Social Class

ERIC Educational Resources Information Center

Tablante, Courtney B.; Fiske, Susan T.

2015-01-01

Discussing socioeconomic status in college classes can be challenging. Both teachers and students feel uncomfortable, yet social class matters more than ever. This is especially true, given increased income inequality in the United States and indications that higher education does not reduce this inequality as much as many people hope. Resources…

On Film

ERIC Educational Resources Information Center

Watts, Marty

2006-01-01

In this article, the author discusses the role of window films in enhancing indoor air quality in schools. Historically, window film has been used to reduce temperatures in buildings prone to overheating. Too much solar energy entering through windows makes occupants uncomfortable and air conditioning more costly. Film has been a simple solution…