Payers are demanding that US health care become more accountable and integrated, posing new demands for physicians and the organizations that partner with them. We conducted focus groups with 30 physicians in a large integrated delivery system who had previous experience practicing in less integrated settings and asked about skills they need to succeed in this environment. Physicians identified 3 primary skills: orienting to teams and systems, engaging patients as individuals and as a panel, and integrating cost awareness into practice. Physicians also expressed a high level of trust that the system was designed to help them provide better care. This belief appeared to make the new demands and mental shifts tolerable, even welcome, standing in contrast to research showing widespread physician distrust of their institutional settings. Physicians' new skills and the system features that promote trust are described in the article and should be a focus for systems transitioning to a more integrated, accountable model. Keywords organization and delivery of care, integrated delivery systems, physician culture, physician competencies, physicians' experience Original Research IntroductionPublic and private payers are demanding that health care organizations in the United States become more accountable for quality and total costs of care. Many stakeholders have set goals around the proportion of health care payments that should be "value-based" in the near future. [1][2][3] Nearly all types of value-based payment programs-including capitation, bundling, shared savings, pay-for-performance, and so onencourage greater collaboration among providers than generally exists today. At the same time, physicians are increasingly choosing employment in larger, more organized settings, as opposed to solo or small-group practices. This is due in part to hospitals purchasing physician practices, 4 and in part to physicians choosing the stability and work-life balance that larger employers can provide. [5][6][7] If these trends continue, health care organizations will increasingly resemble integrated delivery systems, defined as "network [s] of organizations that provide . . . a coordinated continuum of services to a defined population and [that are] willing to be held clinically and fiscally accountable for the outcomes and the health status of the population served" 8 (see also Suter et al 9 for a more detailed definition of the properties of integrated care and Valentijn et al 10 for a proposed taxonomy of levels of integration). Such a shift will likely pose new demands for physicians and for organizations that educate, certify, employ, or partner with them. 11We can learn from existing integrated delivery systemssuch as Kaiser Permanente, the Mayo Clinic Health System, and Geisinger Health System-about how physicians adapt to working in these settings. In this study, we asked physicians about their transitions from a less integrated to a more integrated setting. Physicians' accounts of such transitions may reveal specific...
18% 'medium' and 3% 'critical' interventions. The main pharmaceutical problem was out of the formulary discharge proposal which represented 54% of PIs (796/1483). Dosage adaptation was recommended in 12% of cases; 9% of PIs were for stopping the treatment and other interventions were about the choice of route of administration, adding a treatment, therapeutic monitoring and optimization of administration. In total, 58% of PIs were accepted, the physician was not informed of 23% and 19% were not accepted; but 11% of the PIs accepted were not implemented. 135 PIs were discussed in pharmaceutical meetings. Among the subjects that arose, 3 were particularly highlighted: re-evaluation of renal failure and metformin, interaction between beta blockers and flecainide and recommendations on allergies. We have studied out of the formulary discharge proposal discrepancies about cardiology medicines (angiotensin converting enzyme inhibitors and angiotensin receptor antagonists). Conclusions Feedback on PIs is a key element to improve their relevance. Finally, a weekly pharmaceutical meeting can highlight recurrent prescription problems in order to propose and implement corrective measures. It is moreover a working base for our hospital to improve the quality of medical care.No conflict of interest. Background Forty to 50% of hospitalised patients with an acute medical illness have risk factors for venous thromboembolism (VTE) and it has been shown that thromboprophylaxis reduces the incidence of VTE events in these patients [1]. However, a large multinational survey, the ENDORSE study, showed that only 37% of medical patients with VTE risk factors currently received thromboprophylaxis [2]. Purpose To evaluate the impact over time of pharmacist-driven interventions aiming at increasing the appropriate use of thromboprophylaxis in acutely ill medical patients hospitalised in an urban academic tertiary care hospital. Materials and Methods First, medical and nurse reports of hospitalised medical patients were reviewed to evaluate the proportion of patients who were on prophylaxis according to clinical practise guidelines. Second, interventions were conducted and included unit-specific physician and nurse education, dissemination of educational tools summarising VTE prophylaxis guidelines, and reminders. Third, the effect of the interventions on the proportion of patients receiving appropriate thromboprophylaxis was evaluated after three and six months. Results The baseline evaluation showed that 36% (26/72) of the patients at risk of VTE received appropriate thromboprophylaxis. Three and six months after the interventions, 68% (55/81), and 72% (58/81) of the patients at risk of VTE received appropriate thromboprophylaxis. Pharmacist-Driven interventions imProve thromboProPhylaxis in acutely illOf the patients not at risk of VTE, 15% (21/141), 8% (24/290), and 8% (27/330) respectively at baseline evaluation, three and six months after the interventions, received thromboprophylaxis. Conclusions Pharmacist-driven interventions imp...
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