Trust and the Ethics of Health Care Institutions

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90594/1/3527779.pd

Discussions about Limiting Treatment in a Geriatric Clinic

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111239/1/j.1532-5415.1993.tb06705.x.pd

How do doctors use information in real-time? A qualitative study of internal medicine resident precepting

Background  Despite the importance of evidence-based medicine in medical education, little observational research exists on how doctors-in-training seek and use evidence from information resources in ambulatory care. Objective  To describe information exchange behaviour by internal medicine residents and attendings in ambulatory resident clinic precepting rooms. Design  We observed resident behaviour and audiotaped resident–attending doctor interactions during precepting sessions. Participants  Participating residents included 70 of an eligible 89 residents and 28 of 34 eligible attendings from one large academic internal medicine residency programme in the Midwestern USA. Residents were observed during 95 separate precepting interactions at four ambulatory sites. Approach  Using a qualitative approach, we analysed transcripts and field notes of observed behaviours and interactions looking for themes of information exchange. Coders discussed themes which were refined using feedback from an interdisciplinary panel. Results  Four themes of information exchange behaviour emerged: (i) questioning behaviours that were used as part of the communication process in which the resident and attending doctor could reason together; (ii) searching behaviour of non-human knowledge sources occurred in a minority of precepting interations; (iii) unsolicited knowledge offering and (iv) answering behaviours were important means of exchanging information. Conclusions  Most clinic interactions between resident and attending doctors relied heavily on spoken deliberation without resorting to the scientific literature or other published information resources. These observations suggest a range of factors that may moderate information exchange behaviour in the precepting context including relationships, space and efficiency. Future research should aim to more readily adapt information resources to the relationships and practice context of precepting.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72879/1/j.1365-2753.2006.00752.x.pd

Do we practice what we preach? A qualitative assessment of resident–preceptor interactions for adherence to evidence‐based practice

Background  Evidence‐based medicine (EBM) is important in training doctors for high‐quality care. Yet little is known about whether ambulatory precepting incorporates the concepts and principles of EBM. Methods  The authors observed and audiotaped 95 internal medicine residency precepting interactions and rated interactions using a qualitative analytic template consisting of three criteria: (1) presence of clinical questions; (2) presence of an evidence‐based process; and (3) resident ability to articulate a clinical question. Results  Sixty‐seven of 95 audio tapes (71%) were of acceptable quality to allow template analysis. Thirty (45%) contained explicit clinical questions; 11 (16%) included an evidence‐based process. Resident ability to articulate a clinical question when prompted was rated as at least ‘fair’ in 59 of 67 interactions (88%). Conclusions  EBM was not optimally implemented in these clinics. Future research could explore more systematically what factors facilitate or impair the use of EBM in the real‐time ambulatory training context.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99027/1/j.1365-2753.2008.00966.x.pd

Priorities for Patient‐Centered Outcomes Research: The Views of Minority and Underserved Communities

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136533/1/hesr12505_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136533/2/hesr12505.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136533/3/hesr12505-sup-0001-AppendixSA1.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136533/4/hesr12505-sup-0002-AppendixSA2.pd

Members of Minority and Underserved Communities Set Priorities for Health Research

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146820/1/milq12354.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146820/2/milq12354_am.pd

Primary care provider perceptions and use of a novel medication reconciliation technology

Background Although medication reconciliation (MR) can reduce medication discrepancies, it is challenging to operationalise. Consequently, we developed a health information technology (HIT) to collect a patient medication history and make it available to the primary care (PC) provider. We deployed a self-service kiosk in a PC clinic that permits patients to indicate a medication adherence history. Patient responses are immediately viewable in the legacy electronic health record. This paper describes a survey developed to assess PC provider perceptions of our HIT and HIT implementation effectiveness. Methods We developed and administered a survey to all PC providers to assess technology implementation effectiveness. The survey included scales measuring (1) user attitudes towards MR, (2) perceptions of our HIT and (3) the local organisational climate for implementation. We also assessed the consistency and quality of tool use. Results Nearly 90% of PC providers responded to the survey and 58% indicated that they were familiar with the technology and had seen the tool output. Most providers believed that MR represented an important safety intervention, although 43% did not believe that they had the necessary resources to manage discrepancies. Composite scale scores for the 58% of respondents familiar with the HIT indicate that the majority favoured our tool over usual care. However, composite scale scores suggest that the climate for implementation at our facility was suboptimal. Overall, the quality and consistency of tool use among providers was very heterogeneous. Conclusions A patient self-service kiosk offers an efficientmechanismto collect amedication adherence history; provider survey responses indicate that they appreciated and used the MR kiosk output. Nonetheless, opportunities exist to improve data displays and embed decision support to facilitate discrepancy management

Bacterial Pneumonias during an Influenza Pandemic: How Will We Allocate Antibiotics?

We are currently in the midst of the 2009 H1N1 pandemic, and a second wave of flu in the fall and winter could lead to more hospitalizations for pneumonia. Recent pathologic and historic data from the 1918 influenza pandemic confirms that many, if not most, of the deaths in that pandemic were a result of secondary bacterial pneumonias. This means that a second wave of 2009 H1N1 pandemic influenza could result in a widespread shortage of antibiotics, making these medications a scarce resource. Recently, our University of Michigan Health System (UMHS) Scarce Resource Allocation Committee (SRAC) added antibiotics to a list of resources (including ventilators, antivirals, vaccines) that might become scarce during an influenza pandemic. In this article, we summarize the data on bacterial pneumonias during the 1918 influenza pandemic, discuss the possible impact of a pandemic on the University of Michigan Health System, and summarize our committee's guiding principles for allocating antibiotics during a pandemic.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78141/1/bsp.2009.0019.pd

Norms of Presentational Force

This is the author's accepted manuscript, made available with permission of the American Forensic Association.Can style or presentational devices reasonably compel us to believe, agree, act? I submit that they can, and that the normative pragmatic project explains how. After describing a normative pragmatic approach to presentational force, I analyze and evaluate presentational force in Susan B. Anthony's "Is it a Crime for a U. S. Citizen to Vote" as it apparently proceeds from logic, emotion, and style. I conclude with reflections on the compatibility of the normative pragmatic approach with the recently-developed pragma-dialectical treatment of presentational devices

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND: Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. METHODS: The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. RESULTS: One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. CONCLUSIONS: Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. TRIAL REGISTRATION: Prospero registration number: 42016037725