Random practice results in more effective motor learning than either constant or blocked practice. Recent studies have investigated the effects of practice schedules at the neurophysiological level. ...This study aims to conduct a literature review of the following issues: (a) the differential involvement of premotor areas, the primary motor cortex, the dorsolateral prefrontal cortex and the posterior parietal cortex in different types of practice; (b) changes in the participation of these areas throughout practice; and (c) the degree of support that current neurophysiological findings offer to strengthen the behavioral proposition that distinct cognitive processes are generated by different practice schedules. Data from 10 studies that investigated associations between practice structures and neurobiological substrates were analyzed. The participation of the indicated areas was found to depend on practice structure and varied during the learning process. Greater cognitive engagement was associated with random practice. In conclusion, distinct neural processes are engendered by different practice conditions. The integration of behavioral and neurophysiological findings promotes a more comprehensive view of the phenomenon.
The overall goal of this book is to give the reader a state-of-the-art synopsis of the pharmacist services domain. To accomplish this goal, the authors have addressed the social, psychosocial, ...political, legal, historic, clinical, and economic factors that are associated with pharmacist services. In this book, you will gain cutting-edge insights from learning about the research of experts throughout the world. The findings have relevance for enhancing pharmacist professionalism, pharmacist practice, and the progression of pharmacist services in the future.
Innovation and its discontents Jaffe, Adam B; Jaffe, Adam B; Lerner, Josh
2008., 20110527, 2011, 2004, 2005-01-01, 20040101
eBook
The United States patent system has become sand rather than lubricant in the wheels of American progress. Such is the premise behind this provocative and timely book by two of the nation's leading ...experts on patents and economic innovation.
IMPORTANCE: Graduate medical education training may imprint young physicians with skills and experiences, but few studies have evaluated imprinting on physician spending patterns. OBJECTIVE: To ...examine the relationship between spending patterns in the region of a physician’s graduate medical education training and subsequent mean Medicare spending per beneficiary. DESIGN, SETTING, AND PARTICIPANTS: Secondary multilevel multivariable analysis of 2011 Medicare claims data (Part A hospital and Part B physician) for a random, nationally representative sample of family medicine and internal medicine physicians completing residency between 1992 and 2010 with Medicare patient panels of 40 or more patients (2851 physicians providing care to 491 948 Medicare beneficiaries). EXPOSURES: Locations of practice and residency training were matched with Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups, with approximately equal distribution of beneficiary numbers. There were 674 physicians in low-spending training and low-spending practice HRRs, 180 in average-spending training/low-spending practice, 178 in high-spending training/low-spending practice, 253 in low-spending training/average-spending practice, 417 in average-spending training/average-spending practice, 210 in high-spending training/average-spending practice, 97 in low-spending training/high-spending practice, 275 in average-spending training/high-spending practice, and 567 in high-spending training/high-spending practice. MAIN OUTCOMES AND MEASURES: Mean physician spending per Medicare beneficiary. RESULTS: For physicians practicing in high-spending regions, those trained in high-spending regions had a mean spending per beneficiary per year $1926 higher (95% CI, $889-$2963) than those trained in low-spending regions. For practice in average-spending HRRs, mean spending was $897 higher (95% CI, $71-$1723) for physicians trained in high- vs low-spending regions. For practice in low-spending HRRs, the difference across training HRR levels was not significant ($533; 95% CI, –$46 to $1112). After controlling for patient, community, and physician characteristics, there was a 7% difference (95% CI, 2%-12%) in patient expenditures between low- and high-spending training HRRs. Across all practice HRRs, this corresponded to an estimated $522 difference (95% CI, $146-$919) between low- and high-spending training regions. For physicians 1 to 7 years in practice, there was a 29% difference ($2434; 95% CI, $1004-$4111) in spending between those trained in low- and high-spending regions; however, after 16 to 19 years, there was no significant difference. CONCLUSIONS AND RELEVANCE: Among general internists and family physicians who completed residency training between 1992 and 2010, the spending patterns in the HRR in which their residency program was located were associated with expenditures for subsequent care they provided as practicing physicians for Medicare beneficiaries. Interventions during residency training may have the potential to help control future health care spending.
Background
Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link ...evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.
Objectives
To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.
Search methods
We searched the Database of s of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.
Selection criteria
Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.
Data collection and analysis
Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.
Main results
Twenty‐seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in‐hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 11.95: 95%CI 4.72 to 30.30). There was no evidence of differences in readmission to hospital or in‐hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD ‐4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta‐analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.
Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.
Authors' conclusions
Clinical pathways are associated with reduced in‐hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.
Aims and objectives
To explore the evidence‐based nursing practice (EBNP) competencies of clinical and academic nurses and their collaboration needs for supporting EBNP.
Background
Academic‐practice ...partnerships have strong potential to overcome the key barriers to EBNP. However, there is little known about the collaboration needs of clinical and academic nurses for EBNP.
Design
A cross‐sectional study.
Methods
We recruited clinical and academic nurses online during November 2021 to January 2022. Using a reliable and validated scale and adapted questionnaires, data were collected relating to demographic information, EBNP‐related resources availability, EBNP competencies and EBNP collaboration needs. These data were described using descriptive statistical methods. The t test, χ2 test and Mann–Whitney U test were used to evaluate if the different responses between clinical and academic nurses were statistically significant. This study was reported following the STROBET checklist.
Results
Two 240 clinical nurses and 232 academic nurses submitted questionnaires. There was no difference in overall EBNP competence between clinical and academic nurses. However, clinical nurses reported lower levels of competence and stronger intentions to collaborate with academic nurses when searching for, appraising, and synthesising evidence. Academic nurses reported lower levels of competence and stronger intentions to collaborate with clinical nurses for disseminating and implementing evidence.
Conclusion
Clinical and academic nurses both reported high needs for collaborating to overcome their perceived role limitations. Clinical and academic nurses have different strengths and limitations in EBNP. These role differences and intentions to collaborate for different dimensions of EBNP competence suggest that clinical and academic nursing roles could be complementary to each other, offering opportunities for synergistic collaborations to better support overall EBNP.
Relevance to clinical practice
Healthcare and academic institutions should promote academic‐practice partnerships as opportunities to gain complementary expertise on different dimensions of EBNP, and to improve nurses' competencies and confidence in EBNP overall.
Primary care medicine, as we know and remember it, is in crisis. While policymakers, government administrators, and the health insurance industry pay lip service to the personal relationship between ...physician and patient, dissatisfaction and disaffection run rampant among primary care doctors, and medical students steer clear in order to pursue more lucrative specialties. Patients feel helpless, well aware that they are losing a valued close connection as health care steadily becomes more transactional than relational. The thin-margin efficiency, rapid pace, and high volume demanded by the new health care economics do not work for primary care, an inherently slower, more personal, and uniquely tailored service.
InOut of Practice, Dr. Frederick Barken juxtaposes his personal experience with the latest research on the transformations in the medical field. He offers a cool critique of the "market model of medicine" while vividly illustrating how the seemingly inexorable trend toward specialization in the last few decades has shifted emphasis away from what was once the foundation of medical practice. Dr. Barken addresses the complexities of modern practice-overuse of diagnostic studies, fragmentation of care, increasing reliance on an array of prescription drugs, and the practice of defensive medicine. He shows how changes in medicine, the family, and society have left physicians to deal with a wide range of geriatric issues, from limited mobility to dementia, that are not addressed by health care policy and are not entirely amenable to a physician's prescription. Indeed, Dr. Barken contends, the very survival of primary care is in jeopardy at a time when its practitioners are needed more than ever.
Illustrated with case studies gleaned from more than twenty years in private practice and data from a wide range of sources,Out of Practiceis more than a jeremiad about a broken system. Throughout, Dr. Barken offers cogent suggestions for policymakers and practitioners alike, making clear that as valuable as the latest drug or medical device may be, a successful health care system depends just as much on the doctor-patient relationship embodied by primary care medicine.
Background
Educational outreach visits (EOVs) have been identified as an intervention that may improve the practice of healthcare professionals. This type of face‐to‐face visit has been referred to ...as university‐based educational detailing, academic detailing, and educational visiting.
Objectives
To assess the effects of EOVs on health professional practice or patient outcomes.
Search methods
For this update, we searched the Cochrane EPOC register to March 2007. In the original review, we searched multiple bibliographic databases including MEDLINE and CINAHL.
Selection criteria
Randomised trials of EOVs that reported an objective measure of professional performance or healthcare outcomes. An EOV was defined as a personal visit by a trained person to healthcare professionals in their own settings.
Data collection and analysis
Two reviewers independently extracted data and assessed study quality. We used bubble plots and box plots to visually inspect the data. We conducted both quantitative and qualitative analyses. We used meta‐regression to examine potential sources of heterogeneity determined a priori. We hypothesised eight factors to explain variation across effect estimates. In our primary visual and statistical analyses, we included only studies with dichotomous outcomes, with baseline data and with low or moderate risk of bias, in which the intervention included an EOV and was compared to no intervention.
Main results
We included 69 studies involving more than 15,000 health professionals. Twenty‐eight studies (34 comparisons) contributed to the calculation of the median and interquartile range for the main comparison. The median adjusted risk difference (RD) in compliance with desired practice was 5.6% (interquartile range 3.0% to 9.0%). The adjusted RDs were highly consistent for prescribing (median 4.8%, interquartile range 3.0% to 6.5% for 17 comparisons), but varied for other types of professional performance (median 6.0%, interquartile range 3.6% to 16.0% for 17 comparisons). Meta‐regression was limited by the large number of potential explanatory factors (eight) with only 31 comparisons, and did not provide any compelling explanations for the observed variation in adjusted RDs. There were 18 comparisons with continuous outcomes, with a median adjusted relative improvement of 21% (interquartile range 11% to 41%). There were eight trials (12 comparisons) in which the intervention included an EOV and was compared to another type of intervention, usually audit and feedback. Interventions that included EOVs appeared to be slightly superior to audit and feedback. Only six studies evaluated different types of visits in head‐to‐head comparisons. When individual visits were compared to group visits (three trials), the results were mixed.
Authors' conclusions
EOVs alone or when combined with other interventions have effects on prescribing that are relatively consistent and small, but potentially important. Their effects on other types of professional performance vary from small to modest improvements, and it is not possible from this review to explain that variation.
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