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Biomedical subjects

A Fink

Publications and source records attributed to A Fink.

At least 55 records · Page 3Linked to original sources
PubMed1995

Helping practices reach primary care goals. Lessons from the literature.

We reviewed rigorous evaluations of programs to enhance the quality and economy of primary care. We identified 36 evaluations published from 1980 through 1992. We abstracted data on objectives, setting(s), patients and processes, outcomes, and costs of care. We identified successful programs, as well as significant gaps in our knowledge of how to improve aspects of care. In specific, computer reminders and social influence-based methods fostered preventive and economic care. Nurse implementation of prevention protocols increased their performance. Multidisciplinary teams improved access and economy. Regional organization of practices or telephone management improved access; regionalization also reduced emergency care. Improvements were not found in continuity, comprehensiveness, humanistic process, physical environment, or health outcomes. Primary care practices can implement several programs to continuously improve prevention and access, and to reduce costs and use of unnecessary services. Research documenting how to accomplish other major goals, including health outcome changes, in different practice types is needed.

Evaluation Studies as Topic↗
PubMed1995

The cost effectiveness of preoperative autologous blood donations.

BACKGROUND: Since the recognition that human immunodeficiency virus is transmissible by blood transfusion there has been increasing public and professional support for autologous blood donations before elective surgery. Autologous blood donation is, however, a more expensive process than the donation of allogeneic blood by community volunteers. Furthermore, there have been recent improvements in the safety of the volunteer blood supply. METHODS: We used a decision-analysis model to assess the cost effectiveness of donating autologous blood for four surgical procedures. Cost data were collected from the observation of transfusion practice at the University of California, Los Angeles, in 1992. Estimates of the risks of transfusion-associated diseases and the costs of treating them came from the medical literature. Cost effectiveness was expressed in dollars per quality-adjusted year of life saved. We performed sensitivity analyses of the variables in our model and examined the effect of strategies suggested to reduce costs. RESULTS: Substituting autologous for allogeneic blood resulted in little expected health benefit (0.0002 to 0.00044 quality-adjusted year of life saved) at considerable additional cost ($68 to $4,783 per unit of blood). The additional cost of autologous blood was primarily a function of the discarding of units that were donated but not transfused and of a more labor-intensive donation process. The cost-effectiveness ratios ranged from $235,000 to over $23 million per quality-adjusted year of life saved. CONCLUSIONS: Given the improved safety of allogeneic transfusions today, the increased protection afforded by donating autologous blood is limited and may not justify the increased cost.

Blood Transfusion↗
PubMed1995

Quality-of-life outcomes in men treated for localized prostate cancer.

OBJECTIVE: To assess health-related quality of life (HRQOL) in men treated for clinically localized prostate cancer. DESIGN: A cross-sectional analysis of HRQOL after treatment with radical prostatectomy, pelvic irradiation, or observation alone for clinically localized prostatic adenocarcinoma, and in age-matched comparison patients. SETTING: A large managed care population in California. SUBJECTS: A total of 528 men, including 214 treated for clinically localized prostate cancer (41 with evidence of metastatic disease were excluded from this analysis) and 273 age-matched, ZIP code-matched comparison patients without prostate cancer. Cancer patients were analyzed in three treatment groups: radical prostatectomy (n = 98), primary pelvic irradiation (n = 56), and observation alone (n = 60). MAIN OUTCOME MEASURES: General HRQOL was measured with the RAND 36-Item Health Survey 1.0. Cancer-specific HRQOL was measured with the CAncer Rehabilitation Evaluation System-Short Form and the Functional Assessment of Cancer Therapy-General form. Disease-targeted quality of life was measured with a new instrument assessing function and bother in three organ systems: sexual, urinary, and bowel. RESULTS: No differences among treatment groups were seen in comparisons of general HRQOL: Significant differences among treatment groups were seen in both function and bother in the prostate-targeted measures of sexual, urinary, and bowel domains. When cancer patients were compared with men of similar age without prostate cancer, differences were seen in the sexual, urinary, and bowel function and bother but not in general HRQOL measures. Although cancer-free men were found not to have full potency or continence, prostate cancer patients treated with surgery or radiation reported significantly worse sexual, urinary, and bowel function than men without cancer. Men who had undergone nerve-sparing prostatectomy did not differ from those who had undergone standard prostatectomy, but the power to detect a difference was low. CONCLUSIONS: Although no differences were seen in general HRQOL, three disease-targeted domains were found to differ significantly among the treatment groups and comparison patients. Even after controlling for the sexual and urinary dysfunction experienced by older men without cancer, those receiving therapeutic interventions for their prostate cancer were found to have poorer disease-targeted HRQOL: We conclude that in addition to general HRQOL, disease-targeted measures must be used to assess outcomes of care in men treated for localized prostate cancer.

Adenocarcinoma↗
PubMed1995

Urinary organ specific neoantigen. A potentially diagnostic test for colorectal cancer.

Urinary organ-specific neoantigen from colorectal cancer patients has been used to make a monoclonal antibody, BAC 18.1. In this study we assessed the potential of this antibody for the diagnosis of colorectal cancer. We evaluated binding in both urine and effluent samples and compared it with effluent carcinoembryonic antigen standardized for both volume (nanograms per milliliter) and protein. Urinary organ-specific antigen as detected by BAC 18.1 was significantly greater in 29 cancer patients (A405: 0.717 +/- 0.500) vs 27 controls [0.121 +/- 0.273 (P < 0.05)]. Considerable overlap of binding of BAC 18.1 was observed in the colonic effluent of patients with CRC (N = 13), adenomas (N = 26), inflammatory bowel disease (N = 8), or having a normal colonoscopic examination (N = 24). CEA levels (nanograms per milliliter) were significantly elevated in the effluent samples of patients with a past history of colorectal cancer, as compared to that of normal individuals (P < 0.05). The presence of the M(r) 30,000 organ-specific neoantigen in colonic effluent was also demonstrated by western blot. Organ-specific neoantigen originates in the colon and is excreted into the urine, so the BAC 18.1 binding levels in the urine may be a diagnostic aid for CRC.

Adult↗
PubMed1995

Increasing the impact of quality improvement on health: an expert panel method for setting institutional priorities.

BACKGROUND: Successful implementation of modern ongoing quality improvement (QI) methods requires investment of institutional resources, but can produce significant improvements in medical care. A health care organization's goals and objectives for improving care are expressed in strategic plan documents, which could provide a framework for planning quality improvement initiatives. However, institutional strategic planning processes are often not well linked to QI staff and resources. We developed the Quality Action Program (QAP) to connect QI to strategic planning. HISTORY: In 1991, Sepulveda VHAMC implemented a major primary care initiative, documented in a comprehensive strategic plan. The QAP was developed to enable the initiative to be evaluated within a QI context. THREE-ROUND EXPERT PANEL PROCESS: To carry out the QAP, members of an institution's quality council engage in a structured consensus process. The first round involves reading educational materials and filling out a quality action survey the second round includes participation in an expert panel meeting, and the third round involves making final priority rankings. EIGHT-STEP QAP IMPLEMENTATION PLAN: QI staff carry out activities to prepare for and carry out the three-round expert panel process. RESULTS: QAP induced significant institutional QI activity directed toward achieving the top-ranked QI criterion--ensuring continuity of care. Continuity of care improved significantly over time between the pre- and post-QAP periods. CONCLUSIONS: Expert panel methods can be used to link strategic plan goals and objectives to QI efforts.

California↗
PubMed1995

A comprehensive transfusion medicine curriculum for medical students. Transfusion Medicine Academic Award Group.

BACKGROUND: The Transfusion Medicine Academic Awards (TMAA) program, sponsored by the National Heart, Lung, and Blood Institute, has provided grants to medical schools to help them develop comprehensive curricula in transfusion medicine. In 1989, the TMAA Group published a set of comprehensive curricular goals for teaching transfusion medicine. The medical student portion of this curriculum has now been revised to reflect new developments in transfusion medicine and recent trends in medical school education. STUDY DESIGN AND METHODS: Two medical schools independently revised the 1989 curriculum for their students. Because significant similarities were noted between curricula of the two institutions, the two revisions were combined and submitted to all TMAA institutions for comment. As a result, a revised medical school curriculum was developed and approved by the TMAA Group. RESULTS: The revised curriculum consists of 28 objectives in six major areas of transfusion medicine. It is presented in its entirety in this article. CONCLUSION: The TMAA transfusion medicine curriculum should provide to medical schools a valuable resource for evaluating their teaching of transfusion medicine and should provide to medical school deans and curriculum committees an authoritative source of transfusion medicine expertise.

Autoimmunity↗
PubMed1994

Evaluating generalist education programs: a conceptual framework. Generalist program evaluation working group.

This paper provides and applies a conceptual framework and a list of guiding principles for evaluation of generalist education programs. Programs are systematic efforts to achieve specified objectives. Evaluations gather data in order to improve or appraise programs and have a continuum of purposes and methods. Descriptive evaluations characterize the structures, processes, and outcomes of programs; research evaluations definitively assess the effectiveness of a program in terms of outcomes. Intermediate outcomes are changes in knowledge, attitudes, and skills of program participants; conclusive outcomes reflect the quality of performance of graduates in actual clinical situations. Outcomes are affected by inputs--the qualities of students entering the program. Guiding principles of program evaluation ensure that data gathered are useful. The authors illustrate the guiding principles with an actual pilot study that determined that expert pediatricians, general internists, and family practitioners could agree on key generalist competencies and that explores evaluation design based on these competencies. Finally, they consider the implications of undertaking generalist education evaluation.

Adult↗
PubMed1994

Functional disability screening of ambulatory patients: a randomized controlled trial in a hospital-based group practice.

The authors conducted a randomized controlled trial of functional disability screening in a hospital-based internal medicine group practice. They assigned 60 physicians and 497 of their patients to either an experimental or a control group. Every four months the patients in both groups completed a self-administered questionnaire measuring physical, psychological, and social function. The experimental group physicians received reports summarizing their patients' responses; the control group physicians received no report. At the end of one year the authors found no significant difference between the patients of the experimental and control group physicians on any measure of functional status. Functional disability screening alone does not improve patient function.

Activities of Daily Living↗
PubMed1994

Insulin and glucose status, tissue and plasma lipids in patients with tumours of the ovary or endometrium: possible dietary implications.

The relationship between tumour growth, insulin status, blood lipids and adipose linoleic acid (LA, reflecting long-term LA intake) was studied in 19 Jewish women suffering from early and advanced stages (ES and AS) of ovarian and endometrial tumours. Blood insulin in patients with ES tumours was four times higher than the control value in cancer-free subjects, but fell to normal levels at AS and after ES surgery (PES). Tumours and abdominal adipose tissue (AAT) had 4-6 and 1.4-1.7 times as much insulin as non-cancerous control organs. Serum total cholesterol (CHOL) and LDL-cholesterol were high at ES, dropped below normal at AS, but normalised at PES, while HDL-cholesterol increased after ES surgery. Linoleic acid in subcutaneous adipose tissue (SAT) was high in controls (26.4 + 1.5% of total fatty acids), but lower in cancer patients (20.5 + 3.7%, P < 0.05), while palmitic acid showed the opposite change. The results suggest mobilisation of glucose, cholesterol and linoleic acid for the supply of energy and structural lipids to rapidly multiplying tumour cells and possibly for prostaglandin synthesis. They also raise the question of whether the high linoleic acid intake by the Jewish population in Israel predisposes individuals to tumour development.

Adipose Tissue↗
PubMed1994

Detection and prevention of treatable visual failure in general practice: room for improvement?

An ageing population, the introduction of sight test charges and a problem that has never been adequately addressed since the inception of the National Health Service presents general practitioners with the increasing burden of detecting and preventing visual failure which they feel poorly equipped to deal with. Ophthalmology in general practice is a fundamental requirement for the reduction of avoidable visual failure and this is probably especially true for elderly patients and diabetic patients. A postal survey of general practitioners in Brent and Harrow suggests that there is potential for major improvements in the delivery of eye care by general practitioners, often without much additional expenditure (the equipment is there but it is not used) and with minimal training requirements. Simple changes in already existing screening programmes could potentially have an immediate effect on the visual well-being of the community.

Aged↗
PubMed1993

The leukocyte adherence inhibition test (LAI) in preoperative diagnosis of epithelial ovarian cancer.

One hundred two women admitted for evaluation of an adnexal mass were tested prior to surgery by the computerized tube leukocyte adherence inhibition (LAI) assay. The test was positive in 24/35 (69%) patients, diagnosed after surgery as epithelial ovarian cancer while 50/67 (75%) of those diagnosed as benign masses were negative. Only 2/38 (5%) of normal control subjects showed a false-positive result. The LAI test described in this report showed a sensitivity of 88% and a specificity of 75% in stage I ovarian cancer; thus it may be useful for early diagnosis of ovarian malignancy.

Adnexal Diseases↗
PubMed1993

The critical shortage of geriatrics faculty.

To estimate the adequacy of current and future supply of geriatrics faculty, we conducted a national survey to determine the current supply of geriatrics faculty in five specialties and compared these estimates to standards for optimal faculty supply in geriatrics. Finally, we generated a model to project future faculty supply based on both current training capacity and differing assumptions regarding future training capacity. Our findings indicate that the current supply of geriatrics physician faculty is less than half the number needed in each specialty. (Existing numbers range from a high of 909 faculty in internal medicine to a low of 86 in physical medicine.) Moreover, given the current capacity for training, there will be a net loss of such faculty each year in each specialty. We conclude that the number of geriatrics faculty currently available is insufficient to provide an appropriate "core" level of geriatrics training for all undergraduate medical students and residents in relevant residency programs. In addition, the current training capacity for geriatrics faculty cannot even sustain the current level of faculty over the next 10 years. To correct the current and future deficit, substantial increases in both geriatrics fellowship positions and mid-career training positions will be necessary.

Career Mobility↗
PubMed1993

How many physicians will be needed to provide medical care for older persons? Physician manpower needs for the twenty-first century.

To estimate the number of full-time-equivalent (FTE) physicians and geriatricians needed to provide medical care in the years 2000 to 2030, we developed utilization-based models of need for non-surgical physicians and need for geriatricians. Based on projected utilization, the number of FTE physicians required to care for the elderly will increase two- or threefold over the next 40 years. Alternate economic scenarios have very little effect on estimates of FTE physicians needed but exert large effects on the projected number of FTE geriatricians needed. We conclude that during the years 2000 to 2030, population growth will be the major factor determining the number of physicians needed to provide medicare care; economic forces will have a greater influence on the number of geriatricians needed.

Activities of Daily Living↗