Search PubMed⌕ Search

Biomedical subjects

A M Fendrick

Publications and source records attributed to A M Fendrick.

At least 37 records · Page 2Linked to original sources
PubMed2001

Coronary artery bypass grafting in Native Americans: a higher risk of death compared to other ethnic groups?

BACKGROUND: While the efficacy and safety of coronary artery bypass grafting (CABG) has been established in several clinical trials, little is known about its outcomes in Native Americans. MEASUREMENTS AND MAIN RESULTS: We assessed clinical outcomes associated with CABG in 155 Native Americans using a national database of 18,061 patients from 25 nongovernmental, not-for-profit U.S. health care facilities. Patients were classified into five groups: 1) Native American, 2) white, 3) African American, 4) Hispanic, and 5) Asian. We evaluated for ethnic differences in in-hospital mortality and length of stay, and after adjusting for age, gender, surgical priority, case-mix severity, insurance status, and facility characteristics (volume, location, and teaching status). Overall, we found the adjusted risk for in-hospital death to be higher in Native Americans when compared to whites (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.5 to 9.8), African Americans (OR, 3.4; 95% CI, 1.1 to 9.9), Hispanics (OR, 7.1; 95% CI, 2.5 to 20.3), and Asians (OR, 2.8; 95% CI, 1.1 to 7.0). No significant differences were found in length of stay after adjustment across ethnic groups. CONCLUSIONS: The risk of in-hospital death following CABG may be higher in Native Americans than in other ethnic groups. Given the small number of Native Americans in the database (n = 155), however, further research will be needed to confirm these findings.

Black or African American↗
PubMed2001

The role of economic evaluation in infection control.

Given the rise in health care-related expenditures, decision-makers are increasingly relying on both clinical effectiveness and economic efficiency when making health care decisions. The field of infection control is not immune to this rise in cost-consciousness among health care managers. This article clarifies the role of economic evaluation within infection control for both the user and producer of economic evaluations in this field. The strengths and drawbacks of the several different types of economic analysis--cost minimization, cost-effectiveness, cost-benefit, and cost utility analysis--will be discussed. Additionally, the important features of two specific methods used for economic evaluation-decision analytic modeling and economic analysis alongside a clinical trial-will be outlined. Finally, the criteria by which economic analyses should be judged will be provided. As economic evaluation and health services research continue to play an increasingly important role in health care, it will be vital for infection control advocates to partner with individuals from diverse fields to give decision-makers the type of information they need to make choices.

Clinical Trials as Topic↗
PubMed2001

National estimates of the quantity and cost of informal caregiving for the elderly with dementia.

OBJECTIVE: Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia. DESIGN: Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people age 70 years or older (N = 7,443). SETTING: National population-based sample of the community-dwelling elderly. MAIN OUTCOME MEASURES: Incremental weekly hours of informal caregiving and incremental cost of caregiver time for those with mild dementia, moderate dementia, and severe dementia, as compared to elderly individuals with normal cognition. Dementia severity was defined using the Telephone Interview for Cognitive Status. RESULTS: After adjusting for sociodemographics, comorbidities, and potential caregiving network, those with normal cognition received an average of 4.6 hours per week of informal care. Those with mild dementia received an additional 8.5 hours per week of informal care compared to those with normal cognition (P < .001), while those with moderate and severe dementia received an additional 17.4 and 41.5 hours (P < .001), respectively. The associated additional yearly cost of informal care per case was 3,630 dollars for mild dementia, 7,420 dollars for moderate dementia, and 17,700 dollars for severe dementia. This represents a national annual cost of more than 18 billion dollars. CONCLUSION: The quantity and associated economic cost of informal caregiving for the elderly with dementia are substantial and increase sharply as cognitive impairment worsens. Physicians caring for elderly individuals with dementia should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

Aged↗
PubMed2001

Initial validation of a diagnostic questionnaire for gastroesophageal reflux disease.

OBJECTIVES: Brief, reliable, and valid self-administered questionnaires could facilitate the diagnosis of gastroesophageal reflux disease in primary care. We report the development and validation of such an instrument. METHODS: Content validity was informed by literature review, expert opinion, and cognitive interviewing of 50 patients resulting in a 22-item survey. For psychometric analyses, primary care patients completed the new questionnaire at enrollment and at intervals ranging from 3 days to 3 wk. Multitrait scaling, test-retest reliability, and responsiveness were assessed. Predictive validity analyses of all scales and items used specialty physician diagnosis as the "gold standard." RESULTS: Iterative factor analyses yielded three scales of four items each including heartburn, acid regurgitation, and dyspepsia. Multitrait scaling criteria including internal consistency, item interval consistency, and item discrimination were 100% satisfied. Test-retest reliability was high in those reporting stable symptoms. Scale scores significantly changed in those reporting a global change. Regressing specialty physician diagnosis on the three scales revealed significant effects for two scales (heartburn and regurgitation). Combining the two significant scales enhanced the strength of the model. Symptom response to self-directed treatment with nonprescription antisecretory medications was highly predictive of the diagnosis also, although the item demonstrated poor validity and reliability. CONCLUSIONS: A brief, simple 12-item questionnaire demonstrated validity and reliability and seemed to be responsive to change for reflux and dyspeptic symptoms.

Adult↗
PubMed2001

Quality of life measurement clarifies the cost-effectiveness of Helicobacter pylori eradication in peptic ulcer disease and uninvestigated dyspepsia.

OBJECTIVES: Previous economic studies of Helicobacter pylori eradication in dyspepsia and peptic ulcer disease have not measured quality of life using utilities (preference probabilities), which are needed to compare the cost-effectiveness of such treatment to other health care interventions. The goals of this study were to measure quality of life in patients with dyspepsia or peptic ulcer and apply these measurements to published models of disease management to determine cost-effectiveness in dollars per quality-adjusted life year (QALY) gained. METHODS: Utilities for dyspepsia and peptic ulcer disease were measured in adult patients (n = 73) on chronic acid suppression for peptic ulcer or ulcer-like dyspepsia. Median utility values were applied to the results of published cost-effectiveness analyses and a previously validated dyspepsia model. Cost-utility ratios for early H. pylori eradication in uninvestigated dyspepsia and peptic ulcer disease were then computed. RESULTS: The total disutility, or lost quality of life, for an ulcer was 0.11 QALY, of which 0.09 QALY was attributed to dyspeptic symptoms. After these results were incorporated into published studies, cost-utility ratios for ulcer treatment varied from $3,100 to $12,500 per QALY gained, whereas estimates for uninvestigated dyspepsia management ranged from $26,800 to $59,400 per QALY. Sensitivity analyses indicated a range of $1,300 to $27,300 per QALY for management of duodenal ulcer and $15,000 to $129,700 per QALY for dyspepsia. CONCLUSIONS: Strategies that emphasize early H. pylori eradication were cost-effective for patients with peptic ulcer and possibly cost-effective for patients with uninvestigated dyspepsia, relative to other medical interventions. Dyspeptic symptoms cause significant disutility that should be incorporated in future cost-effectiveness analyses of treatment strategies.

California↗
PubMed2001

Self-reported effectiveness and physician consultation rate in users of over-the-counter histamine-2 receptor antagonists.

OBJECTIVE: Decreased physician visits for dyspepsia were predicted with the histamine-2 receptor antagonists (H2RA) release to over-the-counter (OTC) status. The aim of this study was to examine the presentation frequency for dyspeptic complaints before and after the OTC release of the H2RA and the self-reported effectiveness of OTC H2RA. METHODS: Two cross-sectional surveys were used in a community sample. The patients comprised a random age- and sex-stratified sample of 1600 ambulatory adults in 1993 and 1800 in 1997. Self-report, valid mail surveys gathered information on healthcare seeking and gastrointestinal symptoms in 1993 and 1997 and antisecretory use in 1997. RESULTS: Presentation frequency for dyspepsia was 22% in 1993 versus 23.5% in 1997. Only 16% of chronic users of the OTC H2RA obtained complete relief of symptomatic episodes. Use of an OTC H2RA was highly associated with presentation to a physician in the past year. CONCLUSIONS: OTC H2RA infrequently provided the complete relief desired by patients. Presentation frequency to physicians for dyspeptic complaints did not change with availability of H2RA OTC.

Adult↗
PubMed2001

Outcomes of initial noninvasive Helicobacter pylori testing in U.S. primary care patients with uninvestigated dyspepsia.

OBJECTIVE: Recent European trials demonstrate that testing and treatment for Helicobacter pylori (H. pylori) is an effective alternative to prompt endoscopy in uninvestigated dyspepsia. The eventual endoscopy rate after H. pylori testing, which is a key determinant of cost-effectiveness, is unknown in the United States. Our aim was to determine the endoscopy rate after H. pylori testing in primary care practice in the United States and to compare outcomes among seropositive and seronegative patients. METHODS: We performed a retrospective review with mean 13 month follow-up of primary care patients with dyspeptic symptoms tested with office-based H. pylori serology. RESULTS: Of 268 adults tested (37+/-11 yr, 58% women), 57 (21%) were seropositive and 49/57 (86%) received eradication therapy. Endoscopy or contrast radiography was performed on 19% of seropositive and 19% of seronegative patients (p = 0.97). Annualized median disease-related expenditures were similar among seropositive and seronegative patients ($228 [$93-$654] vs $366 [$107-$1268], p = 0.19). However, aggregate expenditures were substantially lower than the cost of endoscopy alone ($816 [$296-$970]). On follow-up, seropositive and seronegative patients had similar numbers of primary care visits (2.9+/-3.2 vs 3.5+/-3.6, p = 0.23), prolonged antisecretory medication use (25 vs 33%, p = 0.27), and specialist referrals (23 vs 24%, p = 0.83). CONCLUSION: In a United States center, 81% of primary care patients tested for H. pylori did not undergo endoscopy, and patients incurred significantly lower median expenditures after noninvasive H. pylori testing than the cost of endoscopy alone. Seropositive and seronegative patients experienced comparable outcomes after H. pylori testing.

Adult↗
PubMed2001

Influenza. Cost of illness and considerations in the economic evaluation of new and emerging therapies.

Influenza infection has been a burden to humans for thousands of years. Despite the fact that epidemics could be predicted with regularity, the lack of available prevention or treatment measures left humankind vulnerable to the harmful effects of this ubiquitous virus. While the pandemics of 1918 and 1957 are recent examples of the devastation that influenza may inflict, even in a typical year influenza infection and related complications cause significant morbidity and mortality. The development of an influenza vaccine during the 1940s marked a major turning point in the management of this disease. Vaccination of the elderly and other high risk patients has been shown to reduce morbidity and mortality and to be a worthwhile investment from an economic perspective. Despite these benefits, vaccine use in this group remains suboptimal. The role of annual vaccination for individuals at lower risk for influenza-related complications remains controversial. While prevention by vaccination is relatively straightforward, the treatment of symptomatic influenza-like illness with medication is more complicated. Differentiating symptoms caused by the influenza viruses from those caused by other common viruses is difficult. Currently available tests to document influenza as the cause of illness are either too expensive, too inaccurate or too time consuming to impact treatment. Symptom-based diagnosis remains the most commonly used strategy in clinical practice. The approval of the neuraminidase inhibitors (NIs)--zanamivir and oseltamivir--remind healthcare providers of the difficulties in diagnosing and treating influenza. NIs have been shown to reduce the duration of symptoms of individuals infected with influenza when prescribed within the first 2 days of symptoms. Whether these innovative agents are cost effective, however, requires a more detailed understanding of the benefits that these agents may offer above and beyond existing therapies. In this review, we examine the burden of influenza infection, diagnostic challenges and the clinical and economic impact of available interventions. Clinical controversies and potential areas for further investigation are also explored.

Cost of Illness↗
PubMed2001

The spectrum of acute bronchitis. Using baseline factors to guide empirical therapy.

The optimal therapy for acute bronchitis depends on the causative pathogen and the presence or absence of underlying lung disease. Because there is no fast, reliable way to identify the pathogen, physicians have to rely on clinical judgment and epidemiologic characteristics. In this article, Drs Flaherty, Saint, Fendrick, and Martinez discuss how an evidence-based approach to treatment may help ensure that efficacious therapy is available in the future.

Acute Disease↗
PubMed2001

Decomposing pharmaceutical cost growth in different types of health plans.

OBJECTIVE: To decompose pharmaceutical spending growth into price and quantity components and to compare growth across different types of health plans. STUDY DESIGN: Retrospective analysis of pharmaceutical claims for active employees of a large national employer from 1996 to 1998, who were enrolled in traditional fee-for-service plans, health maintenance organizations (HMOs), and preferred provider organizations. OUTCOME MEASURES: Outcomes measures included total cost growth, price growth, and quantity growth. Quantity growth was divided into growth in use of existing products and in use of newly introduced products. For existing products, quantity growth was further decomposed into growth in the number of prescriptions and change in the mix of prescriptions. RESULTS: During the study period, HMOs had the greatest cost growth. This differential cost growth was largely attributable to changes in utilization as opposed to changes in prices, which were similar among types of health plans. Introduction of new products contributed 15 to 20 percentage points to cost growth in each setting. Differences in cost growth were largely attributed to differences in the growth rate of spending on existing products. For existing products, the impact of increases in the number of prescriptions was much greater in the HMOs, while the impact of changes in the mix of prescriptions was only mildly greater in the HMOs. CONCLUSIONS: Pharmaceutical cost growth was largely attributable to changes in utilization as opposed to changes in prices. Changes in utilization patterns were complex and differed across types of health plans.

Adolescent↗
PubMed2001

A benefit-based copay for prescription drugs: patient contribution based on total benefits, not drug acquisition cost.

Several managerial mechanisms have been used by managed care organizations to affect prescription drug utilization and related expenditures. Some efforts have focused on monitoring clinical conditions, drug use, and compliance, whereas other efforts have focused on consumer cost sharing and changing product-mix. Efforts focusing on improving quality of care by identifying untreated patients or by enhancing compliance can lead to appropriately increased drug costs, although perhaps with reduced overall medical expenditures. In contrast, the mechanisms implemented to constrain drug costs raise concerns regarding missed opportunities to enhance clinical outcomes, and the possibility of higher medical expenditures. Cost sharing plays a critical role in defining the pharmaceutical benefit. To balance the demands for access to pharmaceuticals with pressures to constrain costs, levels of cost sharing must be set in a manner that achieves appropriate clinical and financial outcomes. Modern multitier systems often base patient contributions on drug acquisition cost, and often do not consider medical necessity as a coverage criterion. Using an alternative approach, the benefit-based copay, patient contributions are based on the potential for clinical benefit, taking into consideration the patient's clinical condition. For any given drug, patients with a high potential benefit would have lower copays than patients with a low potential benefit. Implementation of such a system would provide a financial incentive for individuals to prioritize their out-of-pocket drug expenditures based on the value of their medications, not their price.

Cost Control↗
PubMed2001

Endoscopic outcomes analysis.

Endoscopic outcomes analysis has become an increasingly important topic as attempts to measure outcomes, define costs, and compare the relative costs and benefits of different diagnostic and therapeutic procedures have become a major focus of the health care community. This article (1) defines the potential benefits and medical effects of endoscopy; (2) reviews the economic and social pressures fostering the increased focus on health care outcomes research; (3) explores the basic principles, approaches, and paradigms used in health care outcomes analysis; and (4) illustrates how health care outcomes research can help to guide therapeutic approaches, such as endoscopy, in patients with abdominal pain or inflammatory bowel disease.

Child↗
PubMed2000

The potential clinical and economic benefits of silver alloy urinary catheters in preventing urinary tract infection.

BACKGROUND: Catheter-associated urinary tract infection (UTI) is associated with increased morbidity, mortality, and costs. A recent meta-analysis concluded that silver alloy catheters reduce the incidence of UTI by 3-fold; however, clinicians must decide whether the efficacy of such catheters is worth the extra per unit cost of $5.30. OBJECTIVE: To assess the clinical and economic impact of using silver alloy urinary catheters in hospitalized patients. METHODS: The decision model, performed from the health care payer's perspective, evaluated a simulated cohort of 1000 hospitalized patients on general medical, surgical, urologic, and intensive care services requiring short-term urethral catheterization (2-10 days). We compared 2 catheterization strategies: silver alloy catheters and standard (noncoated) urinary catheters. Outcomes included the incidence of symptomatic UTI and bacteremia and direct medical costs. RESULTS: In the base-case analysis, use of silver-coated catheters led to a 47% relative decrease in the incidence of symptomatic UTI from 30 to 16 cases per 1000 patients (number needed to treat = 74) and a 44% relative decrease in the incidence of bacteremia from 4.5 to 2.5 cases per 1000 patients (number needed to treat = 500) compared with standard catheters. Use of silver alloy catheters resulted in estimated cost savings of $4.09 per patient compared with standard catheter use ($20.87 vs $16.78). In a multivariate sensitivity analysis using Monte Carlo simulation, silver-coated catheters provided clinical benefits over standard catheters in all cases and cost savings in 84% of cases. CONCLUSIONS: Using silver alloy catheters in hospitalized patients requiring short-term urinary catheterization reduces the incidence of symptomatic UTI and bacteremia, and is likely to produce cost savings compared with standard catheters.

Alloys↗
PubMed2000

Helicobacter pylori-related disease: guidelines for testing and treatment.

OBJECTIVE: To develop practical guidelines for the treatment of patients with suspected and documented Helicobacter pylori-related gastroduodenal diseases. METHODS: A panel of physicians with expertise in H. pylori reviewed, critically appraised, and synthesized the literature on assigned topics and presented their overviews to the panel. Consensus was obtained in controversial areas through discussion. RESULTS AND CONCLUSIONS: The panel recommended testing for H. pylori in patients with active ulcers, a history of ulcers, or gastric mucosa-associated lymphoid tissue lymphomas. Young, otherwise healthy patients with ulcerlike dyspepsia and those with a family history or fear of gastric cancer may also undergo H pylori testing. Non-endoscopic methods are preferred for H. pylori diagnosis. Dual medication regimens should not be used for therapy; twice-daily triple therapy with a proton pump inhibitor or ranitidine bismuth citrate, clarithromycin, and amoxicillin for 10 to 14 days is an appropriate therapy. Posttreatment assessment of H. pylori status using urea breath testing should be considered in patients with a documented history of ulcer disease or with persistent symptoms.

Adenocarcinoma↗
PubMed2000

Surgeon predictions on growth of minimal invasive therapy: the difficulty of estimating technologic diffusion.

OBJECTIVE: To compare five-year predictions made in 1992 by academic surgeon leaders in UK, US and Canada, with actual experiences in 1997, of increased rates of minimal invasive therapy (MIT) for surgical operations. METHOD: We compared 1992 predictions of percent of operations done by minimal invasive therapy and length of stay in the US with actual 1997 percents found by literature searches. RESULTS: We found sufficient data on 12 operations done by MIT in 1997 of the original 34 operations predicted in 1992 by surgeon experts to be to be amenable to this technique. These 12 operations were among the top 20 most commonly performed procedures in 1992 and 1997. Of these 12 operations, ten had 40-60% lower 1997 percentages than predicted, one had about 10% lower rate, and two had 18% and 100% higher rates of MIT than predicted. Overall mean length of stay (LOS) for all 34 study operations fell from 6.8 days in 1992 to 5.2 days in 1997. Mean LOS in 1997 was 2.5 days by MIT and 6.7 days by open technique (OT). CONCLUSION: Most of the predictions made in 1992 by surgical leaders in Canada, US and UK were incorrect when examined 5 years later. The rate of MIT diffusion and its effect on length of stay were overestimated for most operations, while for two procedures the predictions underestimated extent of diffusion. Also, much of the declines of LOS for surgical care paralleled declines in length of stay for all care, supplemented by the individual contributions of MIT specifically. Relying on expert opinion alone to predict the acceptability, rapidity, scope and extent of technological change is fraught with uncertainty. Unexpected consequences occur when one or a few parts of complex systems are changed. This is a particular problem when predictions are a main basis for informed decision making in the absence of any supporting data from appropriately designed empirical or controlled study.

Attitude of Health Personnel↗
PubMed2000

The role of economic evaluation in the diagnosis and treatment of Helicobacter pylori infection.

The unfolding of the H. pylori story coupled with the high prevalence and economic burden associated with upper gastrointestinal symptoms makes H. pylori-associated disorders an ideal candidate for economic evaluation. As a result of the high quality and quantity of data emerging, H. pylori eradication is cost-effective in individuals with either newly diagnosed or past PUD. The role of eradication in other areas, for example, patients with nonulcer dyspepsia and screening to prevent gastric cancer, may never be worked out to some clinicians' satisfaction. Conflicting reports and the lack of definitive clinical trials have frustrated clinicians. H. pylori diagnosis and treatment have not been integrated into everyday clinical practice. As a result, the enormous potential benefits associated with H. pylori eradication have not been achieved. Economic evaluation is not a panacea to the problems confronting medical services delivery. Assessments of medical practice are methodologically challenging, time-consuming, and expensive. Once the answers are in, it remains difficult to alter an individual provider's patterns of care and integrate the research findings into everyday practice. Further research into physician decision making is necessary to complement the advances being made in determining the value of medical interventions. The fruits of these efforts will be the more efficient delivery of health care services, which, it is hoped, ultimately will improve the health of patients. There is no reason to believe, however, that more attention to effectiveness research would lead to a reduction in health care expenditures. Increasing demands for accountability of medical interventions will propel effectiveness movements. Economic analyses, performed in concert with carefully designed clinical studies, will spur more critical review of health care resource allocation decisions. Despite the limitations, the findings generated from effectiveness research will have a major impact on physician practices, guideline development, and reimbursement decisions. The tendency of clinicians not to pay attention to economic evaluations may lead to missed clinical benefits and unnecessary expenditures. Physicians who have been reluctant to appreciate the information provided by economic evaluation must understand what other stakeholders in health care delivery already have accepted: that the rational basis for cost-effectiveness analysis is the overall improvement in the quality of health care services--not simply a tool to reduce health care costs.

Cost-Benefit Analysis↗
PubMed2000

Patient, physician, and payer perceptions and misperceptions of willingness to pay for diagnostic certainty.

Little is known about the value patients, physicians, and payers place on intangible attributes of care. Differences in valuations among these groups and misperceptions of value of intangible attributes to other groups can contribute to conflicts about treatment recommendations or coverage decisions. We surveyed patients, physicians, and managed care executives to assess their willingness to pay (WTP) for diagnostic certainty for peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD). To determine if patients, physicians, and payers accurately perceive each other's valuations of diagnostic certainty, participants were also asked to estimate the WTP of each of the other types of respondents. Patients were most likely, and executives least likely, to value diagnostic certainty. For PUD, 84% of patients, 61% of physicians, and 43% of executives expressed a positive WTP. Median WTP was low for all three groups ($1-9 for patients and physicians; $0 for payers). Physicians and executives both correctly predicted patient WTP. For GERD, 87% of patients, 52% of physicians, and 29% of executives expressed a positive WTP. Executives underestimated patient WTP. For both diseases, physicians' WTP was overestimated by patients and underestimated by executives. The inconsistency in the value that patients, physicians, and managed care executives place on diagnostic certainty indicates the potential for conflict over practice guidelines or access to services. WTP surveys can provide information to aid in anticipating and addressing areas of disagreement.

Cost-Benefit Analysis↗