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Biomedical subjects

A M Epstein

Publications and source records attributed to A M Epstein.

At least 37 records · Page 2Linked to original sources
PubMed1997

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument.

OBJECTIVES: This study developed a new acquired immunodeficiency syndrome (AIDS) severity system by including diagnostic, physiological, functional, and sociodemographic factors predictive of survival. METHODS: Three-hundred five persons with AIDS in Boston were interviewed; their medical records were reviewed and vital status ascertained. RESULTS: Overall median (+/- SD) survival for the cohort from the first interview until death was 560 +/- 14.4 days. The best model for predicting survival, the Boston AIDS Survival Score, included the Justice score (stage 2 relative hazard [RH] = 1.25, 95% confidence interval [CI] = 0.80, 1.96; stage 3 RH = 1.76, 95% CI = 1.15, 2.70), a newly developed opportunistic disease score (Boston Opportunistic Disease Survival Score; stage 2 RH = 1.35, 95% CI = 0.90, 2.02; stage 3 RH = 2.10, 95% CI = 1.38, 3.18), and measures of activities of daily living (any intermediate limitations, RH = 1.84, 95% CI = 1.05, 3.21; any basic limitations, RH = 2.60, 95% CI = 1.44, 4.69). This model had substantially greater predictive power (R2 = .17, C statistic = .68) than the Justice score alone (R2 = .09, C statistic = .61). CONCLUSIONS: Incorporating data on clinically important events and functional status into a physiologically based system can improve the prediction of survival with AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Influence of cardiac-surgery performance reports on referral practices and access to care. A survey of cardiovascular specialists.

BACKGROUND: Reports on the comparative performance of physicians are becoming increasingly common. Little is known, however, about the credibility of these reports with target audiences or their influence on the delivery of medical services. METHODS: Since 1992, Pennsylvania has published the Consumer Guide to Coronary Artery Bypass Graft Surgery, which lists annual risk-adjusted mortality rates for all hospitals and surgeons providing such surgery in the state. In 1995, we surveyed a randomly selected sample of 50 percent of Pennsylvania cardiologists and cardiac surgeons to find out whether they were aware of the guide and, if so, to determine their views on its usefulness, limitations, and influence on providers. RESULTS: Eighty-two percent of the cardiologists and all the cardiac surgeons were aware of the guide. Only 10 percent of these respondents reported that its mortality rates were "very important" in assessing the performance of a cardiothoracic surgeon. Less than 10 percent reported discussing the guide with more than 10 percent of their patients who were candidates for a coronary-artery bypass graft (CABG). Eighty-seven percent of the cardiologists reported that the guide had a minimal influence or none on their referral recommendations. For both groups, the most important limitations of the guide were the absence of indicators of quality other than mortality (cited by 78 percent), inadequate risk adjustment (79 percent), and the unreliability of data provided by hospitals and surgeons (53 percent). Fifty-nine percent of the cardiologists reported increased difficulty in finding surgeons willing to perform CABG surgery in severely ill patients who required it, and 63 percent of the cardiac surgeons reported that they were less willing to operate on such patients. CONCLUSIONS: The Consumer Guide to Coronary Artery Bypass Graft Surgery has limited credibility among cardiovascular specialists. It has little influence on referral recommendations and may introduce a barrier to care for severely ill patients. If publicly released performance reports are intended to guide the choice of providers without impeding access to medical care, a collaborative process involving physicians may enhance the credibility and usefulness of the reports.

Attitude of Health Personnel↗
PubMed1996

Cholesterol-reduction intervention study (CRIS): a randomized trial to assess effectiveness and costs in clinical practice.

BACKGROUND: The 1988 US National Cholesterol Education Program Expert Panel Report recommended initial treatment with niacin or bile acid sequestrants, followed by other agents if needed, to lower low-density lipoprotein cholesterol (LDL-C) levels in hypercholesterolemic patients who require drug therapy. It is unknown how the effectiveness and costs of such an approach ("stepped care") compare in typical clinical practice to those of initial therapy with lovastatin. PATIENTS AND METHODS: We randomly assigned 612 patients, aged 20 to 70 years, who met 1988 National Cholesterol Education Program guidelines for drug treatment of elevated LDL-C level and had not previously used cholesterol-lowering medication, to either a stepped-care regimen or initial therapy with lovastatin (both n=306). The study, conducted at Southern California Kaiser Permanente, was designed to approximate typical practice: provider compliance with treatment plans was encouraged but not enforced, and patients paid for medication as they customarily would. RESULTS: At 1 year, the decline in mean LDL-C level was significantly greater among patients assigned to initial treatment with lovastatin (22% vs 15% for stepped care; P<.001), as was the number who attained goal LDL-C level (</= 4.14 mmol/L [</= 160 mg/dL], or </= 3.36 mmol/L [</= 130 mg/dL] if coronary heart disease or two or more risk factors were present) (40% vs 24%; P<.001). The increase in mean high-density lipoprotein cholesterol levels was significantly greater in the stepped-care group, however (8% vs 1% for lovastatin; P<.001). Patients who were randomized to stepped care were more likely to report substantial bother caused by side effects (30% vs 16% for lovastatin; P<.001) and discontinuation of therapy at 1 year (28% vs 18%, respectively; P<.01). Costs of care were $333 higher per patient in the lovastatin group ($786 vs $453; P<.001). CONCLUSIONS: A stepped-care regimen beginning with niacin is less costly than initial therapy with lovastatin, but also less effective in lowering LDL-C level. While it is more effective in increasing high-density lipoprotein cholesterol levels, the tolerability of such a regimen may be a problem.

Adult↗
PubMed1996

The influence of health-related quality of life and social characteristics on hospital use by patients with AIDS in the Boston Health Study.

OBJECTIVES: The authors examine whether health-related quality of life (HRQL) and social factors were independent predictors of future hospital use for persons with acquired immunodeficiency syndrome (AIDS). METHODS: A panel of 305 patients with AIDS treated at three provider settings in the Boston, Massachusetts area were enrolled during 1990 and 1991. Data were collected at baseline study enrollment and again 4 months later. Patient interviews, hospital bills, and medical charts were used to measure hospital use (admissions and days during the 4 months after enrollment), sociodemographic characteristics (age, gender, race, education, insurance, homelessness, alcohol use, and AIDS risk factors), disease burden (patient severity and a three-level opportunistic diseases and complications score), HRQL (patient-reported symptoms, activities of daily living, neuropsychological status, and global health assessment), system of care, and use of prophylactic drugs. Logistic regression was used to estimate the odds of admission. Total days of hospital care by patients with at least one admission were analyzed using multiple linear regression. Clinical models of hospital use were developed first from the variables measuring disease burden and system of care. Models estimating the associations between hospital use and all other predictor variables measured at baseline then were estimated using stepwise techniques, controlling for variables in the core model. RESULTS: Patients were more likely than their reference groups to be hospitalized if they had serious opportunistic diseases (adjusted odds ratio [OR] = 2.7), had poorer neuropsychological status (OR = 1.9), were non-white (OR = 2.0), or were homeless (OR = 3.3) (all P < or = 0.05). Activities of daily living were associated moderately (OR = 1.3; P = 0.07). Only system of care and neuropsychological status predicted total hospital days. CONCLUSIONS: The results indicate that future hospital use by persons with AIDS may be influenced by social and other health-related factors in addition to the more clinically related characteristics that are recorded in a medical chart. It therefore may be appropriate to assess these factors when considering options for intervention or when comparing patterns of use among patient groups or settings.

Acquired Immunodeficiency Syndrome↗
PubMed1996

The role of quality measurement in a competitive marketplace.

Quality measurement is not a new idea. However, in recent years, several new trends have gained prominence: greater interest in publicly reported information on quality of care, access to care, and patient satisfaction; an increased focus on health plans and integrated systems of care rather than on institutional providers and practitioners as the unit of observation; wide adoption of the techniques of continuous quality improvement within the health care sector; increased use of clinical practice guidelines to improve care for a broad range of medical conditions; incorporation of computer technology into the clinical setting; and greater appreciation for health outcomes as a measure of quality of care. This chapter first reviews the changes in the medical landscape that have seeded these trends and the distinction between quality assurance and quality improvement. It then focuses on public policy concerns, in particular on the emergence of publicly disseminated information about quality of care, now often called "quality report cards." The major prototypes of these reports developed to date, the responses to quality reporting by different members of the delivery system, and the major criticisms of this approach are reviewed. The chapter concludes by predicting probable developments and the strategies most likely to move health care forward in a productive direction.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1995

Development and validation of a claims based index for adjusting for risk of mortality: the case of acute myocardial infarction.

We developed a comorbidity index on a cohort of 162,699 Medicare beneficiaries who had an acute myocardial infarction (AMI) in 1987 and validate it on two national cohorts: (1) a cohort of 164,427 Medicare beneficiaries who had an AMI in 1988 and (2) a cohort of 10,466 patients admitted to Veterans Administration Hospitals (VAH) for AMI in 1988-1991. The impact of each sensitivity was expressed as; (1) the risk of mortality for those with the comorbidity, (2) the adjustment to the log odds for 2 year mortality and (3) the age-based likelihood of 2 year mortality. Models were validated by calculated the area under an ROC curve obtained by fitting a logistic regression model to each validation population. The two year mortality rate for 30-day survivors was approximately 30% in each of the 3 cohorts. The 5 most prevlent comorbidities coded in the developmental cohort were heart failure (34%), chronic angina (27%), minor arrythmias (25%) and uncomplicated hypertension (18%). Cancer was the most powerful predictor of 2 year mortality, impacting mortality the same as a 18.3 year age increase. Saturation (having all secondary diagnoses in the discharge summary filled) resulted in a 9.2 year age increase. Validation in the 1988 Medicare and in the Veterans Administration Hospitals cohorts resulted in areas of 73% and 72% under the respective ROC curves. Our methods can serve as a prototype for others wishing to assess comorbidity in other targeted subgroups.

Aged↗
PubMed1995

Variations in the utilization of coronary angiography for elderly patients with an acute myocardial infarction. An analysis using hierarchical logistic regression.

This article reports a study of variations in the utilization of angiography for Medicare recipients who had an acute myocardial infarction. The study cohort consisted of 1987 Medicare beneficiaries who had a recent acute myocardial infarction. Variations were examined from three perspectives: patient characteristics, regional practice patterns, and on-site availability of the procedure. Factors associated with variation within and among states were incorporated into the analysis using hierarchical logistic regression models. The probability of angiography during the first 90 days after an acute myocardial infarction was estimated as a function of patient age, gender, race, and comorbidity for patients in 51 states (including the District of Columbia). Interstate differences were examined in relation to geographic region and on-site availability of angiography. Observed rates of angiography ranged between 13.8% and 38.3% (median, 24.7%). Variation was nearly threefold based on estimated state probabilities of angiography for a patient with characteristics set at the national average. Observed and estimated rates were lower in northeastern states than in other parts of the United States. States with more extensive onsite availability of angiography tended to have higher angiography rates after adjusting for patient characteristics and geographic region. Adjusted angiography rates were on average higher for younger patients, males, and nonblacks. There was substantial interstate variation in race differences, with states in the Southeast generally having the largest differences. The adjusted black-to-nonblack odds ratio ranged from a low of 0.41 to a high of 0.94. Interstate variation in age and gender differences was moderate. The work reported in this article illustrates the potential of hierarchical regression modeling as a framework for the analysis of variations and some methodologic issues connected with its implementation. Our results show that large variations in the utilization of procedures can exist, despite uniform insurance coverage and a relatively homogeneous patient cohort. Aggressive use of angiography was highly variable across states as was the degree of access to the procedure for blacks and nonblacks. The state rate of on-site availability of angiography facilities was an important predictor of utilization. Increased on-site availability of angiography, however, was not associated with a reduction of differences in access to the procedure.

Age Factors↗
PubMed1995

Costs of medical care and out-of-pocket expenditures for persons with AIDS in the Boston Health Study.

We examined the cost of health care and out-of-pocket medical expenditures for 189 persons with AIDS at three sites in Massachusetts: an HMO; a public hospital immunodeficiency clinic; and a group practice at a major teaching hospital. The mean cost of care during a four-month reference period was $9,093 +/- $12,683 (mean +/- standard deviation) per patient. Thirty-six percent of the cost was due to hospital care and 40% was due to home health care. Mean out-of-pocket expenditures were $429 +/- $991 (mean +/- standard deviation). Studies that focus on the cost of hospital care may seriously underestimate the medical costs of AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Physician discretion and racial variation in the use of surgical procedures.

BACKGROUND: Racial variation in the use of surgical procedures raises concern about equitable access. The goal of our study was to examine racial differences in utilization across a broad range of procedures in Massachusetts and to assess whether racial variation is related to physician discretion. METHODS: We obtained fiscal year 1988 hospital discharge data for all Massachusetts residents, identified 10 clinically important surgical procedures, and calculated age- and sex-adjusted rate ratios for white and black patients. Level of discretion was determined by using a modified Delphi technique. RESULTS: Whites had higher rates for eight procedures (abdominal aortic aneurysm repair, appendectomy, cardiac valve replacement, carotid endarterectomy, cholecystectomy, lumbar disk procedures, open reduction/internal fixation of the femur, and tonsillectomy) and lower rates for two procedures, hysterectomy and prostatectomy. Of the eight procedures for which utilization was higher among whites, four were ranked as moderate- or high-discretion procedures and four were ranked as low-discretion procedures. Hysterectomy, the only procedure for which utilization was substantially higher among blacks (white:black rate ratio < 0.90), was ranked as a high-discretion procedure. CONCLUSIONS: With the exception of hysterectomy and prostatectomy, procedure rates for whites were greater than those for blacks for a wide range of surgical procedures. Racial variation exists for low-discretion procedures as well as for those associated with moderate and high discretion. Variation among low-discretion procedures that is not explained by medical need suggests the possibility of race-related differences in access to care or in the way patients and physicians make clinical decisions.

Adult↗
PubMed1994

The impact of socioeconomic status on the intensity of ambulatory treatment and health outcomes after hospital discharge for adults with asthma.

OBJECTIVES: To examine whether differences in intensities of care by socioeconomic status and race result in worse health among adults with asthma post-hospital discharge. DESIGN: Patients were enrolled during hospitalization and recontacted three months after discharge. PATIENTS: Those aged 18-55 years, with a primary diagnosis of asthma (n = 97). MAIN OUTCOME MEASURES: Regular source of care, "intensive" therapy (use of an anti-inflammatory agent, pulmonary function testing, or an asthma specialist), and patient-reported (Intermediate Activities of Daily Living Scale [IADL] score, dyspnea) and performance-based (peak flow rate) measures of health status post-discharge. RESULTS: 28% of patients with a yearly income less than $16,000 had no regular source of care, compared with 11% of those with an income from $16,000 to $29,999 and no patient with an income of at least $30,000 (p = 0.003). Similarly, intensive therapy was received by 40%, 67%, and 81% of these groups (p = 0.005). Education had similar associations. Patients with no regular source of care or who did not receive intensive therapy had significantly worse health. Patients of lower socioeconomic status had health outcomes that were up to 25% lower than those of patients of higher socioeconomic status (p < 0.05 for differences in LADL score, dyspnea, and peak flow by educational levels and for differences in dyspnea by income levels), after adjustment for age, gender, race, insurance status, and baseline health. After further adjustment for source of care and intensity of therapy, differences in health outcomes by socioeconomic status uniformly decreased in magnitude and only the differences in LADL scores and dyspnea by educational levels remained statistically significant. Although nonwhite patients were less likely to have a regular source of care or to receive intensive therapy, there was no difference in health outcomes by race. CONCLUSIONS: Patients of lower socioeconomic status who have asthma have worse health outcomes post-hospital discharge, which appear to be due in part to less continuous and less intensive treatment.

Academic Medical Centers↗
PubMed1994

Trends in the use of drug therapies in patients with acute myocardial infarction: 1988 to 1992.

OBJECTIVES: In this study, we investigated the use of thrombolytic agents and other cardiac drugs in a national cohort of patients with acute myocardial infarction and assessed the influence of large clinical studies on types of thrombolytic therapy prescribed. BACKGROUND: Information about usage patterns for these drugs is unavailable, and little is known about the impact of large clinical trials on their use. METHODS: We conducted a retrospective cohort study of 65,011 patients who were treated for acute myocardial infarction during fiscal years 1988 to 1992 (October 1, 1987 to September 30, 1992) in hospitals participating in the SMS Corporation's on-line data pool. RESULTS: The overall thrombolysis rate for patients with acute myocardial infarction increased from 11% in fiscal year 1988 to 18% in fiscal year 1990 and has remained approximately at that level since then. In mid-1989, tissue plasminogen activator was used in 90% of the patients receiving thrombolysis, whereas streptokinase was used in only 10%. Since 1991, tissue plasminogen activator has been used in 60% of patients and streptokinase in almost 30%. Much of this change came after presentation and publication of results of the Second Gruppo Italiano per lo Studio Della Sopravvivenza nell'Infarto Miocardico (GISSI-2) and the Third International Study of Infarct Survival (ISIS-3) trials. Over these 5 years, use of beta-adrenergic blocking agents increased steadily, and use of calcium-channel blocking agents declined steadily. CONCLUSIONS: Current usage rates of thrombolytic therapy are lower than expected, but trends in usage rates for beta-blockers and calcium channel blockers reflect their increasing and decreasing approval, respectively. Presentation and publication of results from the Third International Study of Infarct Survival and the Second Gruppo Italiano per lo Studio Della Sopravvivenza nell'Infarto Miocardico trials appear to have influenced the type of thrombolytic agent prescribed.

Adrenergic beta-Antagonists↗
PubMed1994

Cost-effectiveness of ticlopidine in preventing stroke in high-risk patients.

BACKGROUND: Ticlopidine, an antiplatelet agent, when compared with aspirin has been found to reduce the risk of stroke in high-risk patients, ie, those with recent transient ischemic attack, reversible ischemic neurological deficit, amaurosis fugax, or minor stroke. Its cost-effectiveness in such use, however, is unknown. METHODS: We developed a model of primary stroke prevention in which a hypothetical cohort of 100 high-risk men and women 65 years of age was assumed to receive either ticlopidine (500 mg daily) or aspirin (1300 mg daily). Using published data, we estimated lifetime incidence of stroke, life expectancy (unadjusted and adjusted for changes in quality of life), and lifetime medical care costs associated with each therapy. RESULTS: Patients who receive ticlopidine would experience two fewer initial strokes per hundred than those treated with aspirin. Life expectancy would be extended by approximately one-half month, and lifetime medical care costs (discounted at 5%) would increase by about $2300. The cost-effectiveness of ticlopidine, compared with aspirin, is estimated to range from $31,200 to $55,500 per quality-adjusted life-year gained as the utility of life after nonfatal stroke is assumed to vary from 0.75 to 0.95. CONCLUSIONS: Ticlopidine therapy to prevent stroke in high-risk patients is cost-effective by current standards of medical practice.

Aged↗
PubMed1994

Correlates of employment after AIDS diagnosis in the Boston Health Study.

OBJECTIVES: The purpose of this study was to determine the impact of personal and job characteristics on the time to employment loss after diagnosis of the acquired immunodeficiency syndrome (AIDS) and to examine how job loss affects patients' income. METHODS: Data were collected from 305 patients with AIDS at three sites in Boston, Mass, between February 1990 and July 1991. Life-table methods were used to estimate the number of months employed after diagnosis. A Cox proportional hazards model was used to estimate the effect of risk factors on the probability of ceasing employment in a month. RESULTS: Seventy-six percent of respondents were working at the time of diagnosis; 53% still had a job at the time of the baseline interview, which averaged 16 months later, but about one in three was on sick or disability leave. Mental and physical demands of jobs significantly influenced the likelihood of employment loss. The loss of earnings reduced monthly income by 75%. CONCLUSIONS: Job characteristics affect the likelihood of employment loss, which in turn has a deleterious effect on income. Programs supporting persons with AIDS during the transition out of work or enabling them to modify their job demands may also reduce these problems.

Acquired Immunodeficiency Syndrome↗