Physicians' Initial Management of Acute Low Back Pain Versus Evidence-Based Guidelines: Influence of Sciatica

BACKGROUND: Little information is available on physician characteristics and patient presentations that may influence compliance with evidence-based guidelines for acute low back pain. OBJECTIVE: To assess whether physicians' management decisions are consistent with the Agency for Health Research Quality's guideline and whether responses varied with the presentation of sciatica or by physician characteristics. DESIGN: Cross-sectional study using a mailed survey. PARTICIPANTS: Participants were randomly selected from internal medicine, family practice, general practice, emergency medicine, and occupational medicine specialties. MEASUREMENTS: A questionnaire asked for recommendations for 2 case scenarios, representing patients without and with sciatica, respectively. RESULTS: Seven hundred and twenty surveys were completed (response rate=25%). In cases 1 (without sciatica) and 2 (with sciatica), 26.9% and 4.3% of physicians fully complied with the guideline, respectively. For each year in practice, the odds of guideline noncompliance increased 1.03 times (95% confidence interval [CI]=1.01 to 1.05) for case 1. With occupational medicine as the referent specialty, general practice had the greatest odds of noncompliance (3.60, 95% CI=1.75 to 7.40) in case 1, followed by internal medicine and emergency medicine. Results for case 2 reflected the influence of sciatica with internal medicine having substantially higher odds (vs case 1) and the greatest odds of noncompliance of any specialty (6.93, 95% CI=1.47 to 32.78), followed by family practice and emergency medicine. CONCLUSIONS: A majority of primary care physicians continue to be noncompliant with evidence-based back pain guidelines. Sciatica dramatically influenced clinical decision-making, increasing the extent of noncompliance, particularly for internal medicine and family practice. Physicians' misunderstanding of sciatica's natural history and belief that more intensive initial management is indicated may be factors underlying the observed influence of sciatica

Rethinking the Emergence of Relationship Marketing

In this article, the history of relationship marketing (RM) is challenged. Similar to discussions of the marketing concept, the debates surrounding RM are largely ahistorical. This is despite numerous scholars indicating that RM has a far longer history than is currently appreciated. In contrast to received wisdom that RM emerged in the late 1970s, it is demonstrated that RM themes have been present in the marketing literature for longer than is recognized by the contemporary scholars

Patients' perceptions of safety and quality of maternity clinical handover

<p>Abstract</p> <p>Background</p> <p>Maternity clinical handover serves to address the gaps in knowledge existing when transitions between individuals or groups of clinicians occur throughout the antenatal, intra-partum and postnatal period. There are limited published studies on maternity handover and a paucity of information about patients' perceptions of the same. This paper reports postnatal patients' perceptions of how maternity handover contributes to the quality and safety of maternity care.</p> <p>Methods</p> <p>This paper reports on a mixed-methods study consisting of qualitative interviews and quantitative medical record analysis. Thirty English-speaking postnatal patients who gave birth at an Australian tertiary maternity hospital participated in a semi-structured interview prior to discharge from hospital. Interview data were coded thematically using the constant comparative method and managed via NVivo software; this data set was supplemented by medical record data analysed using STATA.</p> <p>Results</p> <p>Almost half of the women were aware of a handover process. Clinician awareness of patient information was seen as evidence that handover had taken place and was seen as representing positive aspects of teamwork, care and communication by participants, all important factors in the perception of quality health care. Collaborative cross-checking, including the use of cognitive artefacts such as hand held antenatal records and patient-authored birth plans, and the involvement of patients and their support people in handover were behaviours described by participants to be protective mechanisms that enhanced quality and safety of care. These human factors also facilitated team situational awareness (TSA), shared decision making and patient motivation in labour.</p> <p>Conclusions</p> <p>This study illustrates that many patients are aware of handover processes. For some patients, evidence of handover, through clinician awareness of information, represented positive aspects of teamwork, care and communication.</p> <p>Cross-checking and cognitive artefacts were observed to support handover. Patient-authored birth plans were described by some to enhance the quality and safety of the handover by providing a 'voice' to the patient in this process. This was a novel and potentially important perspective.</p> <p>Future research involving patients and their support people in supporting and evaluating handover should be considered.</p