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Biomedical subjects

A Kazanjian

Publications and source records attributed to A Kazanjian.

At least 19 recordsLinked to original sources
PubMed2001

The quick and the dead: "managing" inpatient care in British Columbia hospitals, 1969-1995/96.

OBJECTIVE: To examine changes in hospital use in British Columbia during a decade of capacity reductions. DATA SOURCES/STUDY SETTING: The data used are all separation records for British Columbia hospitals for the years 1969, 1978, 1985/86, 1993/94, and 1995/96. Separation records include acute care, rehabilitation, extended care, and surgical day care hospital encounters in British Columbia that were concluded during the years of interest. STUDY DESIGN: Analyses were based on per capita use of services for five-year age groups of the population to ages 90+; the emphasis was on looking at changes in the use of specific types of hospital services over the 26 years of study, with a particular focus on the most recent decade. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from hospital separations files owned by the British Columbia Ministry of Health and housed at the Centre for Health Services and Policy Research. All separation records for the years of interest were included in the study. PRINCIPAL FINDINGS: Acute care use continued to fall over the last decade. The rate of decline increased during the last time period of study and affected seniors to the same degree as younger patients. At the same time, use of extended care decreased, compared to steady increases in earlier years. The result was that by 1995/96 nearly 40 percent of inpatient days were used by people who died in hospital, compared to 9 percent in 1969. These people, however, still represent a small proportion of separations. CONCLUSIONS: The "bed blocker" problem common to many hospital systems appears to have been largely alleviated in British Columbia over the decade 1985-95. The concurrent decrease in extended care use, however, makes it difficult to say where and how these people are now being cared for. Care for the dying has become a bigger issue for hospitals, but whether this is because of heroic interventions at the end of life is not clear. A "top-down," capacity-driven management approach to hospital use in British Columbia has produced effects that may seem familiar to those involved in more "bottom-up" managed care approaches in the United States.

Adolescent↗
PubMed2001

Evidence-based practice: extending the search to find material for the systematic review.

BACKGROUND: Cochrane-style systematic reviews increasingly require the participation of librarians. Guidelines on the appropriate search strategy to use for systematic reviews have been proposed. However, research evidence supporting these recommendations is limited. OBJECTIVE: This study investigates the effectiveness of various systematic search methods used to uncover randomized controlled trials (RCTs) for systematic reviews. Effectiveness is defined as the proportion of relevant material uncovered for the systematic review using extended systematic review search methods. The following extended systematic search methods are evaluated: searching subject-specific or specialized databases (including trial registries), hand searching, scanning reference lists, and communicating personally. METHODS: Two systematic review projects were prospectively monitored regarding the method used to identify items as well as the type of items retrieved. The proportion of RCTs identified by each systematic search method was calculated. RESULTS: The extended systematic search methods uncovered 29.2% of all items retrieved for the systematic reviews. The search of specialized databases was the most effective method, followed by scanning of reference lists, communicating personally, and hand searching. Although the number of items identified through hand searching was small, these unique items would otherwise have been missed. CONCLUSIONS: Extended systematic search methods are effective tools for uncovering material for the systematic review. The quality of the items uncovered has yet to be assessed and will be key in evaluating the value of the systematic search methods.

Humans↗
PubMed2000

Defensive medicine during hospital obstetrical care: a byproduct of the technological age.

This paper presents an alternative perspective on defensive medicine. Defensive medicine is usually understood as arising from the effect of law on medicine through fear of litigation. Of equal significance, however, is the complementary influence of medicine on law through technological innovation, and, more importantly, the way that medicine and law develop dialectically. Each shapes the other in establishing the standards of care central to both clinical medicine and to actual or potential legal action. Excessive testing owing to fear of litigation indicates that defensive medicine is being practised in a particular setting, but it does not explain why this is so. To understand why defensive medicine occurs and why it is so troubling to clinicians requires an understanding, not only of medical and legal developments, but of a political-economic system and the beliefs and values of a society. Defensive medicine is discussed in relation to hospital obstetrical scenarios commonly associated with fear of litigation: fetal oxygen deprivation ("distress"), which is detected using an electronic fetal monitor, and prolonged labor, known as "dystocia". The material presented is taken from a medical anthropological study of obstetrical care in rural British Columbia, Canada. Litigation fears are shown to result less from rare, albeit often devastating, allegations of malpractice than from doctors adopting a role as "fetal champions", together with the introduction of electronic monitoring technology. The paper concludes by asserting that, rather than being in an adversarial relationship, medical practice and associated litigation primarily work together to reinforce each other, and the social conditions in which defensive medicine occurs.

British Columbia↗
PubMed2000

Do clinical practice guidelines reflect research evidence?

OBJECTIVES: To examine whether existing clinical practice guidelines (CPGs) for cholesterol testing reflect research evidence and hence may control or reduce costs while maintaining or improving the quality of care. METHODS: A systematic search for published and unpublished cholesterol testing CPGs and independent critical appraisal of the CPGs by two researchers using a standard checklist. RESULTS: In four of the five CPGs analysed, the link between the research evidence and the recommendations was not maintained. The appraisal, local experience and the literature all suggest that panel composition is an important explanation, in that the greater the involvement of clinical experts in the development process of the CPGs, the less the recommendations reflected the research evidence. Even though their participation is important for CPG uptake, clinical expert panels appear to have difficulty limiting CPGs to research-based recommendations. CONCLUSIONS: Existing cholesterol testing CPGs are unlikely to improve the quality of care while controlling or reducing costs. The problem lies not with guideline implementation but with the guidelines themselves. It is unclear how best to ensure that recommendations reflect research evidence but this is likely to require significant and progressive changes to the current guideline development process, including a redefinition of the clinical experts' role.

Adult↗
PubMed1999

A systematic review of craniosacral therapy: biological plausibility, assessment reliability and clinical effectiveness.

OBJECTIVES: The objective of this research was to review critically the scientific basis of craniosacral therapy as a therapeutic intervention. DESIGN: A systematic search for and critical appraisal of research on craniosacral therapy was conducted. Medline, Embase, Healthstar, Mantis, Allied and Alternative Medicine, Scisearch and Biosis were searched from their start date to February 1999. MAIN OUTCOME MEASURES: A three-dimensional evaluative framework with related appraisal criteria: (A) craniosacral interventions and health outcomes; (B) validity of craniosacral assessment; and (C) pathophysiology of the craniosacral system. RESULTS: The available research on craniosacral treatment effectiveness constitutes low-grade evidence conducted using inadequate research protocols. One study reported negative side effects in outpatients with traumatic brain injury. Low inter-rater reliability ratings were found. CONCLUSIONS: This systematic review and critical appraisal found insufficient evidence to support craniosacral therapy. Research methods that could conclusively evaluate effectiveness have not been applied to date.

Adult↗
PubMed1999

Mortality rates after cataract extraction.

Senile cataract may be a marker of generalized tissue aging. We examined this hypothesis using population-based linked health data. We hypothesized that any such association would diminish with increased use of cataract surgery. Mortality rates of those 50-95 years of age undergoing cataract surgery in British Columbia during either 1985 or 1989 were compared with the provincial population of comparable age who did not undergo cataract surgery during the study period. The 1985 cohort included 8,262 patients undergoing surgery and a comparison population of 804,303, and the 1989 cohort included 11,952 patients and a comparison population of 839,393. Using Cox regression, for the 1985 cohort, the hazard ratios for dying during follow-up were 3.2 for males 50-54.9 years of age [95% confidence limits (CL) = 2.0, 5.0] and 3.3 for females (95% CL = 1.9, 5.7). Hazard ratios for older age groups decreased with age. We also fit an additive risk model that produced excess mortalities that were less age dependent. In the 1985 analysis, these ranged from +7.1 per 1,000 (95% CL = +0.44, +13.76) to +20.3 (95% CL = +13.24, +27.36) for males and -17.5 (95% CL = -28.28, -6.72) to +2.0 (95% CL = -2.12, +6.12) for females. Findings for the 1989 analyses were similar, indicating that the association between cataracts and generalized aging remained constant despite a large increase in the use of cataract surgery.

Age Distribution↗
PubMed1999

Bone mineral density testing in social context.

Bone mineral density (BMD) testing of healthy women continues to increase, despite widespread discrediting of this test as a valid means to predict fracture risk. To find an explanation for this expanding utilization, we turn to the literature of sociology and political science. Two interdisciplinary approaches proved particularly useful in critical examination of technologies related to women and aging: feminist analysis and cross-cultural analysis. BMD testing has grown because it is marketed in ways that draw upon and perpetuate two trends in western popular culture: a) the medical model of the aging female body; and b) the fear of aging, with its associated disability, dependency, and immobility. The feedback loop between popular and scientific knowledge has created and perpetuated the notion that the aging female body is a diseased body. The trend toward defining osteoporosis entirely on the basis of BMD diagnostic criteria has resulted in the transformation of a risk factor into a disease entity. As the onus for managing risk falls increasingly on women as individuals, and as they strive to reach the preferred ideal of normality, the area that defines normality on the continuum is shrinking, while that defining abnormality is increasing. The power relations and private interests served by this altered continuum remain largely unexamined. The effect, however, is to encourage the demand for screening and diagnostic technologies, giving rise to the rapid diffusion of such technologies, even where the research evidence does not support their use.

Absorptiometry, Photon↗
PubMed1999

Women, the media, and heart disease. For better or for worse?

OBJECTIVE: To analyze the nature and presentation of print media messages regarding cholesterol and heart disease in women. The hypothesis is that print media messages about cholesterol and heart disease may encourage and perpetuate the use of cholesterol-lowering drugs in women. METHODS: A hand-search of the "seven sisters" of American women's magazines and of two Canadian women's magazines. All print material related to cholesterol and heart disease in women was photocopied and the content analyzed qualitatively. The print media content was divided into two categories: magazine articles and drug industry-sponsored advertisements. Themes were identified and were analyzed for the messages they contained about heart disease, cholesterol, and the use of cholesterol-lowering drugs in women. RESULTS: From the magazine articles, three main messages were identified. First, heart disease is the number one killer of women. Second, women must demand recognition of their hig risk of heart disease and demand equal access to prevention and treatment services for heart disease. Third, lifestyles changes are not enough. Cholesterol-lowering drugs should be considered. Drug advertisements also emphasize that postmenopausal women are at high risk of heart disease and that lifestyle changes are inadequate or insufficient to lower this risk. In both cases, high blood cholesterol is considered not as a risk factor for heart disease but as the disease itself. CONCLUSIONS: Magazine articles and drug advertisements act synergistically and may encourage and promote the use of cholesterol-lowering drugs in women. Postmenopausal women not on hormone therapy are particularly targeted.

Advertising↗
PubMed1998

Socioeconomic status, mortality, and the development of cataract at a young age.

It has been hypothesized that senile cataract may serve as a marker for generalised tissue aging, since structural changes occurring in the proteins of the lens during cataract formation are similar to those which occur elsewhere as part of the aging process. An earlier analysis we carried out to test this hypothesis revealed a strong age-dependent relationship between undergoing cataract surgery and subsequent mortality. Relative risks for dying over 9 yr of follow-up were particularly increased for individuals who had developed cataract requiring operation between the ages of 50-65. This finding prompted us to test the hypothesis that younger patients undergoing surgery for cataract (those in which surgery was undertaken at 50-65 yr of age) would tend disproportionately to be resident in areas of generally lower socioeconomic status. A population-based linked health data resource containing data on all hospital separations in the province of British Columbia was used to examine this hypothesis. Linkage to Canadian census data was used to assign a socioeconomic decile to the area of residence for all individuals in British Columbia who either did, or did not, undergo cataract surgery over a 3 yr period, and were aged 50-95. Relative to those who resided in the highest socioeconomic areas, odds ratios for undergoing cataract surgery between 50 and 65 yr of age were significantly greater than 1 for the four lowest socioeconomic deciles. This association was observed despite a conservative bias in our setting that favoured those of higher socioeconomic status tending to receive earlier treatment. The results of this ecologic study prompt consideration of whether factors which have the dual attributes of being correlates of socioeconomic status and implicated in the development of cataract may play a role in mediating the processes involved in the well known association of socioeconomic status and mortality.

Age Factors↗
PubMed1997

Anticoagulation in chronic nonvalvular atrial fibrillation: a critical appraisal and meta-analysis.

OBJECTIVE: To assess the outcomes associated with warfarin treatment of patients with chronic nonvalvular atrial fibrillation (CNVAF) for prevention of primary stroke. DATA SOURCES: MEDLINE was searched for literature published from 1987 to August 1996. Search terms used were 'atrial fibrillation' and 'anticoagulants'. STUDY SELECTION: Five published randomized controlled trials concerning primary stroke prevention. DATA EXTRACTION: Data were pooled across trials to estimate the magnitude of the effect for each of nine reported end-points. The annual probability of occurrence of each outcome was calculated, including standard errors and Mantel-Haenszel significance tests with 95% CIs. DATA SYNTHESIS: In view of the lack of blinded assessment and documented low inter-rater reliability of soft neurological end-points, the analysis was limited to the relatively objective end-points of major strokes, fatal strokes, major bleeding and fatal bleeding. Warfarin did not reduce the incidence of fatal strokes to a statistically significant extent, nor was incidence of fatal bleeding increased significantly. Warfarin reduced the absolute annual incidence of major strokes in patients with CNVAF by 0.89%, while at the same time it increased the absolute annual risk of major bleeding incidents by 1.8%. Though small, these differences were statistically significant. CONCLUSIONS: On balance, the margin between expected benefit and harm for warfarin prophylaxis in patients with CNVAF is uncomfortably thin. These results and conclusions differ from those of a previously published meta-analysis of these same studies.

Anticoagulants↗
PubMed1993

Health care managers in British Columbia, Part I: Who manages our system?

Part I of this article provides, for the first time, the supply side overview of middle- and high-level managers in the B.C. health care system. It presents findings from two province-wide surveys and describes the sociodemographic characteristics and the employment experiences of the population of interest. Part II presents a detailed analysis of management tasks and management roles, and of competency requirements for future managerial roles.

Administrative Personnel↗
PubMed1993

Defusing technology. Technology diffusion in British Columbia.

In order to explore the diffusion of the selected technologies in one Canadian province (British Columbia), two administrative data sets were analyzed. The data included over 40 million payment records for each fiscal year on medical services provided to British Columbia residents (2,968,769 in 1988) and information on physical facilities, services, and personnel from 138 hospitals in the province. Three specific time periods were examined in each data set, starting with 1979-80 and ending with the most current data available at the time. The detailed retrospective analysis of laboratory and imaging technologies provides historical data in three areas of interest: (a) patterns of diffusion and volume of utilization, (b) institutional profile, and (c) provider profile. The framework for the analysis focused, where possible, on the examination of determinants of diffusion that may be amenable to policy influence.

British Columbia↗