The use of pure and impure placebo interventions in primary care - a qualitative approach

Background: Placebos play an important role in clinical trials and several surveys have shown that they are also common in daily practice. Previous research focused primarily on the frequency of placebo use in outpatient care. Our aim was to explore physicians' views on the use of placebos in daily practice, whereby distinction was made between pure placebos (substances with no pharmacological effect, e.g. sugar pills) and impure placebos (substances with pharmacological effect but not on the condition being treated, e.g. antibiotics in viral infections or vitamins). Methods: We performed semi-structured interviews with a sample of twelve primary care physicians (PCPs). The interview addressed individual definitions of a placebo, attitudes towards placebos and the participants' reasons for prescribing them. The interviews were transcribed and analysed using qualitative content analysis. Results: The definition of a placebo given by the majority of the PCPs in our study was one which actually only describes pure placebos. This definition, combined with the fact that most impure placebos were not regarded as placebos at all, means that most of the participating PCPs were not aware of the extent to which placebos are used in daily practice. The PCPs stated that they use placebos (both pure and impure) mainly in the case of non-severe diseases for which there was often no satisfactory somatic explanation. According to the PCPs, cases like this are often treated by complementary and alternative therapies and these, too, are associated with placebo effects. However, all PCPs felt that the ethical aspects of such treatment were unclear and they were unsure as to how to communicate the use of placebos to their patients. Most of them would appreciate ethical guidelines on how to deal with this issue. Conclusions: Many PCPs seem to be unaware that some of the drugs they prescribe are classified as impure placebos. Perceptions of effectiveness and doubts about the legal and ethical aspects of the use of placebos by PCPs may discourage their application. Dissemination of guidelines and consensus papers may be one approach, but it has to be acknowledged that the topic itself is in conflict with the PCPs' perception of themselves as professional and reliable physicians

Parenteral provision of micronutrients to adult patients: an expert consensus paper

Background:Micronutrients, an umbrella term used to collectively describe vitamins and trace elements, are essential componentsof nutrition. Those requiring alternative forms of nutrition support are dependent on the prescribed nutrition regimen for theirmicronutrient provision. The purpose of this paper is to assist clinicians to bridge the gap between the available guidelines’recommendations and their practical application in the provision of micronutrients via the parenteral route to adult patients.Methods:Based on the available evidenced-based literature and existing guidelines, a panel of multidisciplinary healthcareprofessionals with significant experience in the provision of parenteral nutrition (PN) and intravenous micronutrients developedthis international consensus paper.Results:The paper addresses 14 clinically relevant questions regarding the importance and use ofmicronutrients in various clinical conditions. Practical orientation on how micronutrients should be prescribed, administered, andmonitored is provided.Conclusion:Micronutrients are a critical component to nutrition provision and PN provided without thempose a considerable risk to nutrition status. Obstacles to their daily provision—including voluntary omission, partial provision, andsupply issues—must be overcome to allow safe and responsible nutrition practice

From Pabst to Pepsi: The Deinstitutionalization of Social Practices and the Creation of Entrepreneurial Opportunities

In this paper, we examine the dual role that social movement organizations can play in altering organizational landscapes by undermining existing organizations and creating opportunities for the growth of new types of organizations. Empirically, we investigate the impact of a variety of tactics employed by the Woman’s Christian Temperance Union (WCTU), the leading organizational representative of the American temperance movement, on two sets of organizations: breweries and soft drink producers. By delegitimating alcohol consumption, altering attitudes and beliefs about drinking, and promoting temperance legislation, the WCTU contributed to brewery failures. These social changes, in turn, created opportunities for entrepreneurs to found organizations producing new kinds of beverages by creating demand for alternative beverages, providing rationales for entrepreneurial action, and increasing the availability of necessary resources.Tolbert13_From_Pabst_to_Pepsi.pdf: 3878 downloads, before Oct. 1, 2020

Politics ahead of patients: The battle between medical and chiropractic professional associations over the inclusion of chiropractic in the American Medicare System

Health care professions struggling for legitimacy, recognition, and market share can become disoriented to their priorities. Health care practitioners are expected to put the interests of patients first. Professional associations represent the interests of their members. So when a professional association is composed of health care practitioners, its interests may differ from those of patients, creating a conflict for members. In addition, sometimes practitioners’ perspectives may be altered by indoctrination in a belief system, or misinformation, so that a practitioner could be confused about the reality of patient needs. Politicians, in attempting to find an expedient compromise, can value a “win” in the legislative arena over the effects of that legislation. These forces all figure into the events that led to the acceptance of chiropractic into the American Medicare system. Two health care systems in a political fight lost sight of their main purpose: to provide care to patients without doing harm. Dans leur recherche de légitimité, de reconnaissance et d’une juste part sur le marché de la santé, les professionnels de la santé peuvent perdre de vue leurs priorités. Ces praticiens doivent donner préséance aux intérêts des patients tandis que les associations professionnelles représentent ceux de leurs membres. Lorsqu’une association professionnelle regroupe des praticiens de la santé cependant, ses intérêts s’opposent parfois à ceux des patients, créant ainsi un conflit pour les membres. De plus, les praticiens peuvent être endoctrinés par un système de valeurs ou mal informés, au point de se tromper dans l’évaluation des besoins réels des patients. De leur côté, les politiciens peuvent préférer une « victoire » dans l’arène législative à une juste appréciation des impacts d’une loi. Ces forces ont toutes participé aux évènements qui ont mené à l’acceptation de la chiropraxie par le système américain Medicare. Dans cette bataille politique, deux systèmes de santé ont négligé leur principal objectif : soigner des patients sans leur nuire

Assessment of Preferences for Classification Detail in Medical Information: Is Uniformity Better?

The growing acceptance of evidence-based decision making in healthcare organizations has resulted in recognition of information classification and retrieval as a key area of both strategic and operational management. In the emerging information-intensive healthcare environment, healthcare managers are beginning to understand the increased need for formal, continuous information classification and coding in health services, creating a need for enhanced information retrieval, delivery of services and quality management. Variation in classification preferences across practice settings poses healthcare quality management problems for evidence-based medicine in such an environment. This paper reports results from a major national study into the perceived variation reported by health information managers related to the relevance-efficiency trade-offs of information classification across regions and practice settings. This study provides: (1) a benchmark of the degree of such variation, examining how classification preferences vary across organization types, regions, and management indicators, and (2) the extent to which managers prefer more descriptive classification systems, despite nationwide mandates to adopt greater non-descriptive categorization of information. Findings suggest that due to major regional variation, stringent national information standards may be counterproductive for some healthcare practice settings and geographic locations. Implications for healthcare information classification and retrieval are further examined and discussed