Fibromyalgia syndrome (FMS) is a chronic pain condition with significant societal and personal burdens of illness. Chronic opioid therapy in the treatment of chronic nonmalignant pain has increased drastically over the past decade. This is a worrisome trend in general, but specifically, given the pathophysiologic characteristics seen in fibromyalgia syndrome patients, the use of this class of medication deserves special scrutiny. Although the theoretical case against this therapy choice is strong, little empirical evidence exists. In order to supplement this literature, retrospective analysis methods are utilized to examine the association of state-, provider-, and patient level characteristics with the prevalence of chronic opioid use in this disease state. Data gathered through this analysis is then used to develop a propensity index for the identification of an appropriate control group for fibromyalgia patients, a task that has proven difficult in the literature to date. Using propensity stratification and matching techniques analysis of the impact of fibromyalgia, chronic opioid use, and the interaction of these two variables are undertaken. Several key findings and updates to the understanding of chronic opioid use and fibromyalgia syndrome are reported. Wide geographic variation in chronic opioid utilization between states is seen. The role of diagnosing provider type in the rate of chronic opioid prescribing is significant and can be aggregated at various levels. Demographic characteristics, comorbid conditions, and concurrent medication use are all important associates of chronic opioid use in fibromyalgia syndrome. Additionally, chronic opioid use in fibromyalgia patients, independent of propensity to receive that therapy choice is a significant correlate with healthcare costs. A diagnosis of fibromyalgia is a statistically significant source of healthcare costs, though the clinical significance of its impact when compared to a closely matched control group is minimized. Despite the minimization of the role of this diagnosis the impact of the interaction of chronic opioid use with fibromyalgia, despite control for myriad regressors, is significant both statistically and clinically.

This thesis examines the construction of forensic medical evidence in penetrative sexual assault cases and the procedures that Forensic Medical Examiners (FMEs) employ in order to ensure the authority of that evidence. Drawing upon interviews and on the texts and artefacts that FMEs use in their work, the thesis employs the concept of “meaning finitism” to analyse how FMEs perform forensic examinations for evidential purposes. The thesis starts with an exploration of how medical practitioners are taught to identify and classify injuries of medico-legal significance, culminating in their being judged “safe” to provide expert testimony by other members of the clinical forensic medical community. The thesis next addresses the construction of what I call the “morphological account”: a set of judgements about the nature of a case based upon a combination of the observed injuries, the FME’s training and their previous experience of cases. While there is considerable agreement amongst practitioners about how to interpret injuries (a result of their training), because the morphological account involves personal judgement, there is also scope for differences of opinion. The thesis therefore explores the methods that FMEs employ to limit the risk of being seen to disagree with one another during trials. The thesis also examines the role that guidelines play in the forensic medical examination. The thesis argues that standardised medical kits and associated guidance documents were originally introduced in the early 1980s in response to sustained criticism of FMEs’ practices, and further developed in the late 1990s and early 2000s with the rise of Evidence-Based Medicine. Kits and guidance documents provide a means for FMEs to legitimate and explain their work to others, particularly during trials: they codify collective practice and provide FMEs with an aide memoire of the requisite procedures, without overly determining or constraining practice. Finally, I will argue that FMEs’ concern to ensure the authority of their evidence may sometimes limit the value of that evidence. Caution over drawing inferences that might be challenged in court, and a concern not to be seen as “prosecution-minded”, commonly leads FME to compose so-called “Neutral Reports” which neither confirm nor deny the complainer’s allegations. As Scottish Procedural Law makes provision for non-contentious evidence to be removed from trial, such neutral reports are likely to be dismissed from consideration.

This thesis explores the statement that the health information needs and behaviour of the general public, namely health information consumers are comparable with those of academics, health and social care professionals. The research has been conducted in the broad Interpretist tradition, seeking to understand rather than merely explain human behaviour. A model depicting the health information and knowledge environment has been developed to show the how the infonnation behaviour of the various populations in the research are interpreted and where they are placed. The provision, access and use of health information by consumers is the focus of the inner core of the model and is the first theme of the thesis. Several discrete groups of the information poor are investigated to explore their information needs and behaviour. The middle layer of the model depicts the second theme of this thesis focusing on the attitudes of academics, health and social care professionals in their use and access of health information and IT in everyday practice. The information behaviour of the health information and library professional is the focus of the third theme of the thesis and is represented by the outer layer of the model. This theme explores the detail and the contribution of the role to the clinical team, the use of Evidence Based Medicine and Clinical Governance. Conclusions support the opening statement that the health information needs and behaviour of the general public, namely health information consumers are comparable with those of academics, health and social care professionals. Recommendations are made to promote better and more frequent use of health information and health information professionals in the everyday practice of health and social care; to improve the access and provision of health information for consumers.

The aim of this study was to determine the information-seeking behaviour, needs and preferences of doctors, specifically with reference to Evidence Based Medicine (EBM) in the UK. This is particularly relevant during the current IT and resource development currently being undertaken in the NHS. Mixed methods research techniques were utilised to gather and analyse the data collected to meet the aims and objectives of this study. Three data collection methods have been utilised. The first utilised Clinical Librarians to count the information needs (questions) of doctors (Clinical Librarians Logs). The second data collection method gathered clinical questions from clinical librarians (specialists), medical librarians (generalists) and from websites hosting clinical questions (such as http://www.attract.wales.nhs.uk). These were analysed using the taxonomy developed by Ely et al. 2000. Finally an online questionnaire was used to gather data on doctors' awareness and use of electronic EBM resources. The major finding is that research undertaken on the information needs in the healthcare sector in the USA cannot be readily utilised in the NHS. This research utilised a unique data collection technique, the Clinical Librarian as a data collector. This enabled the quantification of doctors unperceived information needs. This research identified that doctors in the UK asked roughly one question for every four patients seen. Despite the advances and ease of use of electronic resources, the preferred information source was colleagues. Time continues to be the major barrier for accessinge lectronici nformation to aid clinical decision making.

Coronary heart disease is the leading cause of premature death in the UK. Chest pain, the most common symptoms associated with this disease, accounts for 1% of all primary care consultations, 5% of visits to emergency departments, and up to 40% of emergency admissions to hospital. When people experience acute coronary symptoms such as chest pain, or other symptoms such as pain in the arms, back or shoulder pain and pain in the jaw and neck, we know that prompt diagnosis and treatment of heart disease can significantly reduce mortality. However, we also know that when people experience these symptoms they can wait sometime before seeking medical help. Part of the problem may be that people do not attribute their symptoms a serious problem such as heart disease. Whilst several campaigns have been aimed at the general population there is no information resource targeted at people who may be at risk of heart disease to help them understand and evaluate their symptoms and take prompt action. The overall aim of this thesis is to fill this gap by producing a piloted draft information resource which aims to help people to respond effectively to symptoms that might be attributable to heart disease for people at high risk of heart disease. Using focus group discussions and individual interviews with people who had experienced symptoms that might be attributable to heart disease or might be at high risk of heart disease experiential data about their response to symptoms were gathered. Participants were also asked their views on what an information resource should be like and their experiences and views formed the basis of the content of the first draft of the information resource. In making sense of their symptom the participants drew upon a range of past experiences and the experiences of others to help them; participants who experienced severe symptoms sought help quickly; those whose symptoms were mild or transient waited, in some cases a considerable time, before seeking help. Previous personal experience may be the factor that helped those who acted quickly. Whereas the experience of others, evident in many of the accounts of those who waited, may not be sufficient to help people interpret and make sense of their own symptom experiences. The information resource incorporated the experiences of people with symptoms that ended up being attributable to heart disease and included examples of the range of symptoms that can be encountered to illustrate the different ways in which heart disease can be manifested as well as information drawn from best practice resources in the management of heart disease. Participants in the original focus group discussions and interviews were asked to be involved in the development of the resource and seventeen agreed. The information resource went through three drafts; at each stage changes were made to incorporate respondent views; at the penultimate draft health professionals’ views were also sought and used to inform the final draft which is now ready for further evaluation.

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Tort laws aim to deter risky medical practices and increase accountability for harm. This research examines their effects on deterrence of a high-risk obstetric practice in the United States: elective early-term (37-38 weeks gestation) induction of labor. Using birth certificate data from the Natality Detail Files and state-level data from publicly available sources, this study analyzes the effects of tort laws on labor induction with multilevel models (MLM) of 665,491 early-term births nested in states. Results reveal that caps on damages are associated with significantly higher odds of early-term induction and Proportionate Liability (PL) is associated with significantly lower odds compared to Joint and Several Liability (JSL). The findings suggest that clinicians are more likely to engage in practices that defy professional guidelines in tort environments with lower legal burdens. I discuss the implications of the findings for patient safety and the deterrence of high-risk practices.

D.Litt. et Phil. / The practice of medicine changes constantly and rapidly. Consequently, it is difficult for clinicians to learn about innovations, given the vast quantity of information available. Evidence-based medicine (EBM) is the process by which practitioners turn clinical problems into questions, and then systematically integrate personal clinical expertise with the best available external evidence as the basis for clinical decisions. To practice EBM, the practitioner is required to search the literature for relevant material, and then to synthesise knowledge and apply findings to each patient. Clinicians require fast and specific access to multiple data sources, but the availability of electronic full text documents has substantially exacerbated the lack of time to read the clinical literature owing to the demands of clinical practice, and is further compounded by the fact that the Web contains much health-related misinformation. Clinicians therefore require a means of searching the literature that will enhance the retrieval of accurate and evaluated clinical data from ranked resources, whereby the most relevant information is retrieved first from the most likely source. Strong correlations exist between four primary steps in EBM, and the formula commonly used in search strategy design in the field of information seeking. The similarities inherent in these steps suggest that an evidence-based approach to information seeking might enable endusers in the health professions to enhance their searching skills and to translate the clinical question into an appropriate information-seeking strategy. A main problem and two sub-problems were investigated, namely whether: · a Web-based EBM information-seeking model could be designed to enhance the information-seeking skills of healthcare practitioners · it was possible to design an information-seeking model more closely aligned with the clinical decision-making model familiar to healthcare practitioners · it was possible to design such a model in a manner that could further enhance the translation of the clinical question into an appropriate information-seeking strategy. Various models in medicine and the domain of information seeking were investigated. It was found that the model of the clinical decision-making process accorded with all six phases of the information-seeking process (ISP), whereas other information-seeking models only addressed the ISP from the formulation of the problem onwards, thus ignoring prior stages of initiation, selection and exploration in the ISP. A Web-based EBM information-seeking model (Model C) was devised and tested for compatibility against a general Web-based information-seeking model, and was found to be valid. Model C was further empirically assessed against a Web site design methodology, and was again found to be compatible. A unique approach to EBM information seeking is thus offered by Model C, which incorporates all aspects of the clinical-decision-making metaphor, as well as the “PICO” EBM filters (Patient/Problem, Intervention, Comparative Intervention and Outcome), into a facet analysis template for the design of a clinical search strategy. Prior to selection of the EBM information resource, Model C further allows for the ranking of each resource and for the design of individual browsing and/or analytical search strategies, as appropriate, so as to enhance EBM information seeking amongst healthcare practitioners.

Use of the Internet can increase patients' understanding about their medical conditions and offers opportunities to strengthen the patient-physician relationship, increase patient satisfaction, and improve health outcomes. However, physicians vary widely in the extent to which they accept patient online medical information seeking and make it part of the patient-physician relationship. This paper explores factors impacting the extent to which physicians advocate (encourage, speak in favor, or are supportive of) patient internet use. Specifically, using social cognitive theory as a theoretical base, this study develops a model of the determinants of physician advocation of patient use of the internet for information about medical conditions and treatments. Survey data collected from a random sample of 179 physicians licensed to practice medicine in Florida is used to test the proposed model. Proxy efficacy for patient internet use, social efficacy for enlisting patient internet use, performance outcomes expectations, and personal outcome expectations are shown to be significant determinants of physician professional advocation of patient internet use. In addition to its direct impact, proxy efficacy is shown to influence intention to advocate patient internet use indirectly thru social efficacy and outcome expectations, demonstrating the key role of this construct in the proxy agency model. Self-efficacy, in contrast, is not found to be a significant factor. Overall, the results support the proposed model of technology use. / by Neil Morton. / Thesis (Ph.D.)--Florida Atlantic University, 2009. / Includes bibliography. / Electronic reproduction. Boca Raton, Fla., 2009. Mode of access: World Wide Web.

Delivering good quality care is a complex endeavor that is highly dependent on patient information and medical knowledge. When decisions about the care of a patient are made, they must, as far as possible, be based on research-derived evidence rather than on clinical skills and experience alone. Evidence based medicine (EBM) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise as well as patient values and preferences to guide healthcare decisions. Following the principles of EBM, healthcare practitioners are required to formulate questions based on patients’ current clinical status, medical history, values and preferences, search the literature for answers, evaluate the evidence for its validity and usefulness, and finally apply the information to the patient. Information systems play a crucial role in the practice of evidence based medicine, by allowing healthcare practitioners to access clinical evidence and information about the patients’ health as they formulate their patient-care strategies. However, current information systems solutions are far from this perspective for various reasons. One of these reasons is that existing information systems do not support a seamless flow of patient information along the patient process. Due to interoperability issues, healthcare practitioners cannot easily exchange patient information from one information system to another and from one healthcare practitioner to another. Consequently, vital information that is stored in separate information systems and which could present a clear and complete picture of the patient cannot be easily accessed. All too often, units have to operate without knowledge of the problems addressed by other healthcare practitioners from other units, the services provided, medications prescribed, or preferences expressed in those previous situations. The practice of EBM is further complicated by current information systems that do not support practitioners in their search and evaluation of current evidence in everyday clinical care. Based on a qualitative approach, this work aims to find solutions for how future healthcare information systems can support the practice of EBM. By combining existing research on process orientation, knowledge management and evidence based medicine with empirical data, a number of recommendations have been initiated. These recommendations aim to support healthcare managers, IT–managers and system developers in the development of future healthcare information systems, from a process-oriented and knowledge management perspective. By following these recommendations, it is possible to develop information systems that facilitate the practice of evidence based medicine, and improve patient engagement.