Integrative approach to the treatment of postherpetic neuralgia: a case series.

OBJECTIVE: To determine if the addition of alternative therapy to conventional medicine enhances the treatment of pain in postherpetic neuralgia (PHN). METHODOLOGY: A review of literature from 1988-1998 was conducted on the MEDLINE database, searching for information on the current treatment of PHN. The literature review found that although many medications have been used to reduce the pain of PHN, no treatments have been completely successful in decreasing pain. Data on pain reduction in PHN following treatment with a multifaceted alternative therapy combined with conventional treatment were compiled from a group of patients in the principal investigator's family medicine practice. RESULTS: The alternative therapy employed in this study, combined with selected medications, showed an average pain reduction of 72.1 percent. There was a 77-percent average pain reduction in patients with herpes zoster (HZ) onset of more than one year and a 68-percent reduction in patients with HZ onset between one month and one year. Almost two-thirds of the 56 PHN patients reported pain reductions of between 75 and 100 percent. CONCLUSION: These preliminary data suggest the combination of alternative therapy and selected conventional medications provides good pain relief for most patients presenting with PHN. Randomized trials with appropriate control groups are needed to validate the effectiveness of this therapy in the treatment of PHN.

Surgical rates in subprovincial areas across Canada: rankings of 39 procedures in order of variation.

OBJECTIVE: To rank 39 surgical procedures in order of variation of inpatient surgical rates, according to a new index of variation and to test the hypothesis that there is greater variation for primarily discretionary operations than for primarily non-discretionary operations. DESIGN: A population-based retrospective cohort study. SETTING: Nine provinces (99.19% of Canada's population). PARTICIPANTS: All hospital inpatients who underwent any of 39 types of surgery and were separated from hospital between Apr. 1, 1988 and Mar. 31, 1990 (the most recent time period for which Canada-wide data were available at the subprovincial level analysed). MAIN OUTCOME MEASURE: Rankings of the 39 procedures according to the index of variation, calculated from inpatient surgery rates in 255 census divisions across Canada. RESULTS: The 13 procedures with the greatest variation were all primarily discretionary. Thirteen of the 14 procedures with the lowest variation were primarily non-discretionary. All but one of the procedures whose degree of discretion was deemed intermediate were in the middle third of the rankings. CONCLUSIONS: The greatest variation is found in primarily discretionary operations. Further investigation should be focused on identified geographical locations where rates for operations that are primarily discretionary are unusually high or low, and particularly on those operations for which there is disagreement regarding the indications for surgery.

Medicine and the Canadian state: from the politics of conflict to the politics of accommodation?

This paper analyzes data from three large-scale surveys of Canadian physicians conducted over the past decade to examine the politics of a cohort of recently established family physicians in Ontario, and to assess the extent to which these politics represent a "softening" of professional resistance to government health insurance. Politically, this is an important cohort because the physicians in it have grown up without any firsthand knowledge of the pre-Medicare period, and because they are among the first to establish practices in the wake of the month-long 1986 Ontario physicians' strike, a high point of profession-government conflict. Factors which may have contributed to a moderation of medical politics include the progressive entry of women into medicine. Our data suggest that professional opposition to Medicare is declining and that fewer physicians support a return to voluntary and commercial control of the health system, a shift which could assist in breaking the historical cycle of profession-government conflict and moving to the politics of accommodation. In the conclusions we discuss implications for medical politics in Canada and other countries such as the United States.

Physicians in health care management: 5. Payment of physicians and organization of medical services.

The financing, payment and organization of medical services are closely related. Canada's health care system is financed publicly, from tax revenue, and administered in each province by a single government payer. Although the chief method of payment to physicians is fee for service (FFS), the need to control costs and organize practice more efficiently has led to increased interest in FFS variants, such as capping payments at a certain level or fixing a budget, and alternative payment methods such as capitation-based payment, salary and combinations of these methods. Although solo practice is reportedly still the chief method of practice organization, it is being steadily replaced by arrangements in which physicians share expenses or calls, and by formal partnerships and group and team practices. As medical practice in Canada continues to shift from solo to group and team practice alternative payment methods that facilitate these models will become more common.

High and low surgical procedure rates in census divisions across Canada.

This paper identifies outliers (unusually high or low values) among rates of 39 surgical procedures in 255 Canadian census divisions. Surgery rates for the two-year period from April 1988 through March 1990 were standardized for age and sex, and then "normalized" to adjust for differences in census division population sizes. Among the 39 procedures, a total of 402 outlying census division rates were found, of which 48 were deemed to be very high, 254 high, 79 low, and 21 very low. The results are presented for individual procedures, by province, and for the 16 census divisions in which medical schools and their associated teaching hospitals are located.

Women in medicine: toward a conceptual understanding of the potential for change.

In 1959 only 6% of Canadian medical school graduates were women, but by 1989 44% of graduating classes were female. Recent data indicate that women are more likely than men to work as general practitioners, in groups, in urban settings, and on salary; to work fewer hours per week and to see fewer patients. In this paper we address the ongoing discussion of the impact of women's progressive entry into medicine. We suggest that a shortcoming of the discussion thus far has been its preoccupation with a descriptive examination of women physicians' professional characteristics and practices; sufficient attention has yet to be paid to the development of a clearer conceptual understanding of the nature of gender differences and the potential for change they imply. Using data from quantitative and qualitative phases of a national study of Canadian physicians, we address the relationship between gender differences in practice and underlying attitudes and values and identify alternative hypotheses about the potential for change created as more women enter medicine. We suggest that this potential goes beyond professional demographics and workloads to the doctor-patient relationship, but that the extent of change will be mediated by the socializing impact of medical school and the extent to which women physicians are included in or excluded from positions of power within the profession. We suggest also, that to meaningfully understand and document change, greater attention must be given to arguments that women and men view the world in qualitatively different ways.

Opinion leaders vs audit and feedback to implement practice guidelines. Delivery after previous cesarean section.

A randomized controlled trial with 76 physicians in 16 community hospitals evaluated audit and feedback and local opinion leader education as methods of encouraging compliance with a guideline for the management of women with a previous cesarean section. The guideline recommended clinical actions to increase trial of labor and vaginal birth rates. Charts for all 3552 cases in the study groups were audited. After 24 months the trial of labor and vaginal birth rates in the audit and feedback group were no different from those in the control group, but rates were 46% and 85% higher, respectively, among physicians educated by an opinion leader. Duration of hospital stay was lower in the opinion leader education group than in the other two groups. The overall cesarean section rate was reduced only in the opinion leader education group. There were no adverse clinical outcomes attributable to the interventions. The use of opinion leaders improved the quality of care.

Obstetrical attitudes and practices before and after the Canadian Consensus Conference Statement on Cesarean Birth.

This paper describes one aspect of a research program aimed at reducing the incidence of cesarean section in Ontario for women with a previous cesarean section or a breech presentation. Using data from multiple sources--surveys of obstetricians, and hospital administrators, and hospital record statistics, the authors attempt to assess the response of obstetricians to pressure to change their practice. This pressure comes principally from the Canadian Consensus Conference Statement on Cesarean Birth, released in June 1986 and subsequently endorsed by a number of professional organizations. The Statement provides clear guidelines for the management of labour in women with previous cesarean section or a breech presentation. The findings present a number of interpretive challenges. Based on their response to hypothetical cases obstetricians are favourably disposed to considering a trial of labour for women with previous cesarean section and breech presentation. However, both their reported practices, as well as hospital statistics indicate the continued high prevalence of cesarean section, though there is a small decline in cesareans for previous cesarean section. There was no evidence that hospitals lacked appropriate facilities for a trial of labour or had unduly restricted formal policies. Furthermore, although awareness of and agreement with the Consensus Statement recommendations was high, when questioned on the actual details of the recommendations, obstetrician's recall was surprisingly low. Respondents tended to err in the direction of choosing more conservative measures than those recommended by the Statement.(ABSTRACT TRUNCATED AT 250 WORDS)

A typology of medical practice organization in Canada. Data from a national survey of physicians.

Different modes of practice organization may result in advantages for physicians and their patients. Compared with solo practice, group practice may produce economies of scale, efficiencies in health care delivery, and improvements in the quality of care. However, in Canada assessment of the implications of differences in practice organization have been impeded by a lack of relevant data and a tendency to treat practice type as a dichotomous variable. Conventional solo/group distinctions fail to address the significance of the growing number of medical practices that are neither solo nor group, but combinations of both, and they obscure the policy implications of the growing number of physicians in institutional as opposed to private practice. This paper develops and applies a theoretically based typology of practice organization to data collected as part of a national survey of 2,398 Canadian physicians conducted in late 1986 and early 1987. The analysis identifies six practice types, describes their distribution and operating characteristics, and identifies the characteristics of physicians working in them.

Women in medicine: practice patterns and attitudes.

Increasing numbers of women are entering medicine in Canada. In 1959 women accounted for 6% of the medical school graduates, but by 1989 they accounted for 44%. Although there has been little systematic investigation of the impact of this increase on Canada's health care system, there are grounds for believing that female physicians bring with them distinctive values and interests, which may be reflected in the way they conduct their professional practices. We used data from a recent national survey of 2398 Canadian physicians to examine differences between women and men in their practices and their attitudes toward health care issues. Significant differences were found in the organization and management of the practices. Women preferred group over solo practice and were overrepresented in community health centres, health service organizations and centres locaux de services communautaires in Quebec. One-third of the women, as compared with half of the men, were in specialties. Even after adjusting for differences in workloads the incomes of the women were significantly lower than those of the men. Only minor differences were observed in the assessment of the health care system and alternative modes of organizing health care services. We believe that the differences were due to the double workload of women as professionals and family caregivers and the powerful socialization effects of medical education. As women overcome their minority status in the medical profession, differences between the sexes may become more apparent. Thus, the extent and effects of the progressive increase in the number of women in Canadian medicine should be assessed on an ongoing basis.

The reproduction of physician autonomy in Ontario medical group practice.

A belief exists about the advantages of group medical practice over solo practitioners. The paper through a survey of 105 group practices examines a number of organisational and operational factors. The results suggest that practices are not always organised in a way to maximise the benefits of group operation but are still characterised by an individualistic approach.

Cesarean section in Ontario: practice patterns and responses to hypothetical cases.

A 40% random sample of Ontario's obstetricians were asked to respond to hypothetical scenarios for previous cesarean section, breech presentation and dystocia, and to describe their practice patterns. Their responses confirmed findings from other studies, which reported differences between physicians' responses to hypothetical cases and their actual practice. In this study, 18% chose a cesarean section for the hypothetical case of a patient who had previously undergone cesarean section and 2% chose a cesarean section for the hypothetical case of breech presentation. However, in practice, the obstetricians reported that they do cesarean section on 71% of their previous section patients and on 57% of their breech patients. Physicians in teaching hospitals were less likely than those in community hospitals to choose cesarean section for a woman who had previously undergone cesarean section both hypothetically and in practice. For breech presentation, no difference was found. The discrepancy between responses to the hypothetical cases and practice patterns could not be attributed to the absence of anesthesia services or to restrictive hospital policies.

Characteristics of established group practices in Ontario.

Established group practices in Ontario were surveyed to determine their structure, characteristics and attitudes toward government assistance in the development of group practice. The degree of organization of the groups surveyed was related to size and less than that reported in surveys of United States group practices. Group size and years of operation were strongly associated. Night, weekend and vacation coverage, the use of a unit patient record and the employment of non-physician administrators were reported frequently, and were more common in older and larger groups. As well, fringe benefits, except for professional organization dues, were not commonly provided.

Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians.

Guidelines for medical practice can contribute to improved care only if they succeed in moving actual practice closer to the behaviors the guidelines recommend. To assess the effect of such guidelines, we surveyed hospitals and obstetricians in Ontario before and after the release of a widely distributed and nationally endorsed consensus statement recommending decreases in the use of cesarean sections. These surveys, along with discharge data from hospitals reflecting actual practice, revealed that most obstetricians (87 to 94 percent) were aware of the guidelines and that most (82.5 to 85 percent) agreed with them. Attitudes toward the use of cesarean section were congruent with the recommendations even before their release. One third of the hospitals and obstetricians reported changing their practice as a consequence of the guidelines, and obstetricians reported rates of cesarean section in women with a previous cesarean section that were significantly reduced, in keeping with the recommendations (from 72.2 percent to 61.1 percent; P less than 0.01). The surveys also showed, however, that knowledge of the content of the recommendations was poor (67 percent correct responses). Furthermore, data on actual practice after the publication of the guidelines showed that the rates of cesarean section were 15 to 49 percent higher than the rates reported by obstetricians, and they showed only a slight change from the previous upward trend. We conclude that guidelines for practice may predispose physicians to consider changing their behavior, but that unless there are other incentives or the removal of disincentives, guidelines may be unlikely to effect rapid change in actual practice. We believe that incentives should operate at the local level, although they may include system-wide economic changes.

Private practice in the United Kingdom: a growing concern.

During the past decade private medical insurance in the United Kingdom grew first rapidly and then steadily. Once almost entirely non-profit, half the private beds and 10% of the private insurance market are now in the for-profit sector. Apart from abortions, cold or elective surgery is the chief private sector service. Average annual consultant income from private practice is now approximately 19,000 pounds sterling. Recent growth of the private sector has been fanned by the present Conservative government's support of privatization generally, by limited levels of National Health Service (NHS) funding, and by vigorous advertising by private insurance companies which plays on the concerns of British consumers. The private medical sector is largely unregulated. Present government policies make its reduction or elimination unlikely. To make it possible for the public sector to compete more equally, a strategy which requires the same levels of regulations, quality assurance, accountability and public scrutiny for the private sector and the NHS is proposed.

The role of evidence in the consensus process. Results from a Canadian consensus exercise.

As part of a consensus conference on cesarean birth, the ten-member consensus panel rated 224 clinical scenarios on their appropriateness for a cesarean section. Ratings were obtained before and immediately after the consensus conference. The level of agreement (consensus) among panelists was assessed separately for scenarios with good research evidence (evidence scenarios) and for those with conflicting, poor, or no evidence (nonevidence scenarios). For each scenario, consensus between panelists was measured as total agreement, partial agreement, or disagreement on the appropriateness of a cesarean section. Before the conference, total or partial agreement existed for a larger percentage of evidence than nonevidence scenarios (85% vs 30%), with the pattern reversed for disagreements (15% vs 70%). After the conference, possible improvement in the level of consensus actually occurred for 71% of the evidence and only 24% of the nonevidence scenarios. Thus, the consensus process, as structured here, was sensitive to the availability of good evidence and suggests that aspects of both expert and public processes can successfully be combined. However, an improvement could be made in the process by grading final recommendations according to the availability of rigorous research evidence.