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Biomedical subjects

A M Fendrick

Publications and source records attributed to A M Fendrick.

At least 91 records · Page 5Linked to original sources
PubMed1996

Specialist and generalist physicians' adoption of antibiotic therapy to eradicate Helicobacter pylori infection.

OBJECTIVES: The authors examine how specialist and generalist physicians adapted their practice patterns to emerging information on the role of Helicobacter pylori in peptic ulcer disease (PUD). METHODS: Data were collected via a mail survey sent to national random samples of gastroenterologists, family practitioners, and general internists in April 1994. A Cox proportional hazards regression was used to evaluate the determinants of the timing of adoption of antibiotic therapy for suspected or confirmed PUD. RESULTS: Most respondents (99.1% of specialists and 64.6% of generalists) had prescribed antibiotic therapy to eradicate Helicobacter pylori at least once. The median specialist adopted 21 months before the medical generalist. Timing of adoption also was related to gender, board certification, PUD case load, and practice setting. CONCLUSIONS: Gastroenterologists were more likely than primary care physicians to adopt antibiotic therapy for PUD, even before the evidence of this therapy's effectiveness was conclusive. Primary care physicians remained less likely to adopt after efficacy was established. The slower adoption by primary care physicians appeared to be related both to having less information than specialists about the new therapy and to more conservative practice styles. Measures to facilitate the flow of information about new technologies to primary care physicians may be warranted. Research on interspecialty differences in adoption of new therapies can contribute to understanding the consequences of the current shift from specialist- to generalist-driven care.

Adult↗
PubMed1996

Differences between generalist and specialist physicians regarding Helicobacter pylori and peptic ulcer disease.

OBJECTIVES: To assess differences between gastroenterologists and primary care physicians in the United States in their attitudes, timing of adoption, and practice patterns concerning the use of Helicobacter pylori eradication therapy in peptic ulcer disease (PUD) patients. METHODS: We surveyed a random sample of 4500 gastroenterologists, family practitioners, and general internists shortly after a National Institutes of Health Consensus Conference recommended eradication of H. pylori in PUD patients. RESULTS: The survey response rate was 30%. Bivariate comparisons revealed significant differences between primary care physicians and gastroenterologists in sources of information about H. pylori, beliefs about the strength of the evidence supporting the relationship between H. pylori and PUD, adoption of H. pylori eradication therapy and timing of first use, and patients likely to receive eradication therapy. Although adoption of H. pylori eradication therapy was nearly universal among gastroenterologists by April 1994 (99%), approximately one-third of primary care providers had never prescribed H. pylori eradication therapy. Practice patterns of physicians using eradication therapy also varied significantly by specialty group. CONCLUSIONS: Gastroenterologists were more aware of the relationship of H. pylori to PUD and adapted their practices more quickly to this emerging information than did primary care providers. Specialty differences in attitudes and adoption patterns of medical innovation existed, even when the new intervention did not require specialized training or equipment. These findings have important clinical implications as the role of primary care physicians expands and managed care delivery systems decrease the use of specialist services.

Adult↗
PubMed1995

Alternative management strategies for patients with suspected peptic ulcer disease.

OBJECTIVE: To estimate the clinical and economic effects of available invasive and noninvasive management strategies for peptic ulcer and Helicobacter pylori in persons with symptoms suggesting peptic ulcer disease. DESIGN: Cost-effectiveness analysis using a decision analytic model. INTERVENTION: 2 immediate endoscopy and 3 noninvasive diagnostic and treatment strategies were evaluated: 1) immediate endoscopy for peptic ulcer and biopsy for H. pylori; 2) immediate endoscopy without biopsy; 3) serologic test for H. pylori; 4) empiric treatment with antisecretory therapy; and 5) empiric treatment with antisecretory therapy and antibiotic agents to eradicate H. pylori. MEASUREMENTS: Cost per ulcer cured and cost per patient treated. RESULTS: The estimated costs per ulcer cured by strategy were as follows: 1) endoscopy and biopsy for H. pylori, $8045; 2) endoscopy without biopsy, $6984; 3) serologic test for H. pylori, $4541; 4) empiric antisecretory therapy, $4835; and 5) empiric antisecretory and antibiotic therapy, $4155. The predicted costs per patient treated were as follows: 1) endoscopy and biopsy for H. pylori, $1584; 2) endoscopy without biopsy, $1375; 3) serologic test for H. pylori, $894; 4) empiric antisecretory therapy, $952; and 5) empiric antisecretory and antibiotic therapy, $818. The cost-effectiveness advantage of the noninvasive strategies diminished as the cost of endoscopy decreased or as the probability of recurrent symptoms increased in patients initially managed without endoscopy. CONCLUSION: Endoscopy, although costly, precisely guided diagnosis and treatment and thus potentially reduced the number of patients inappropriately treated. However, the safety and effectiveness of less expensive, less invasive diagnostic and treatment strategies strongly support initial noninvasive care of symptomatic persons thought to have peptic ulcer disease.

Anti-Bacterial Agents↗
PubMed1995

The effectiveness initiative. I. Medical practice guidelines.

We examined the impact of the "effectiveness initiative" and medical practice guidelines on the practice of ophthalmology. The effectiveness initiative asserts that much of current medical practice is unnecessary or harmful, too costly, and unresponsive to patient desires. It promotes more critical review of the medical literature, research on outcomes, and stringent practice guidelines. Whereas current practice guidelines are helpful in codifying accepted procedures, they tend to sanction interventions of unproved value. Future guidelines will probably reject unproved interventions, especially if they are expensive. Although such guidelines may limit physicians' freedom of choice, they may protect them against capricious malpractice claims and unreasonable patient expectations.

Health Planning↗
PubMed1995

The effectiveness initiative. II: The spectrum of effectiveness research.

Effectiveness research aims to base medical decision making more on rigorous evidence than on intuition and anecdote. The methods used to generate new data include, in order of decreasing rigor, clinical trials, observational studies, claims data analysis, and anecdotal studies. The methods that synthesize existing data include unstructured literature reviews, consensus development, meta-analysis, and decision modeling. Cost minimization, cost-effectiveness, and cost-benefit analyses are formal methods of incorporating the economic impact of alternative medical interventions.

Clinical Trials as Topic↗
PubMed1994

Improved health benefits of increased use of thrombolytic therapy.

BACKGROUND: To quantify population health consequences of increased use of thrombolytic therapy for acute myocardial infarction in the United States. METHODS: A decision analytic model was constructed to evaluate treatment-related outcomes for two myocardial infarction treatment strategies: standard therapy and standard therapy plus combination aspirin-thrombolytic therapy. Patients were entered into the model by age, electrocardiographic presentation, and time to medical evaluation. Estimated mortality changes associated with increased use of thrombolytic therapy were calculated both for populations for which thrombolytic therapy is recommended and for specific patient populations for which thrombolytic therapy is not recommended under current guidelines. Sensitivity analyses tested the robustness of results when input variables were altered. RESULTS: If every patient with acute myocardial infarction for whom thrombolytic therapy is recommended under current guidelines were treated with aspirin and a thrombolytic agent, more than 4000 additional lives would be saved annually in the United States. The model projected that approximately 8000 additional lives could be saved if use of thrombolytic therapy were expanded to include the following patient groups: age greater than 75 years (approximately 4500 lives saved), left bundle-branch block on electrocardiogram (approximately 2500 lives saved), and presentation 6 to 12 hours after the onset of chest pain (approximately 2000 lives saved). Sensitivity analysis demonstrated a mortality advantage attributable to the use of thrombolytic therapy in each clinical scenario tested. CONCLUSIONS: Providing thrombolytic therapy more aggressively could prevent over 12,000 deaths from acute myocardial infarction each year in the United States.

Aged↗
PubMed1993

A reappraisal of hepatitis B virus vaccination strategies using cost-effectiveness analysis.

OBJECTIVE: To determine clinical and economic consequences of alternative vaccination strategies for preventing hepatitis B virus infection (HBV). METHODS: Decision analysis was used to evaluate costs, outcomes, and cost-effectiveness of three HBV management strategies ("no vaccination," "universal vaccination," and "screen and vaccinate") in four populations (newborns, 10-year-old adolescents, a high-risk adult population, and the general adult U.S. population). Information on HBV incidence and prevalence, clinical course, and management of acute illness and chronic sequelae was obtained from the literature and a panel of experts. Actual payments (costs) were obtained from Blue Cross/Blue Shield and local pharmacies. Incremental cost-effectiveness was calculated from the perspective of the payer of medical care and subjected to sensitivity analysis. RESULTS: Vaccination (with or without screening) prevents more disease at somewhat increased cost than no vaccination for the neonatal, adolescent, and adult populations. Vaccination (with or without screening) is a dominant strategy in adult high-risk populations (lower cost and greater benefit than no vaccination). Optimal cost-effectiveness, with nonmonetary benefits not discounted, results if all pregnant women are screened for active HBV infection, and HBV vaccine and hepatitis B immune globulin are administered to babies born to mothers with positive screening tests. Then HBV vaccine is administered to all children at age 10 and again 10 years later (incremental cost-per-year-of-life-saved relative to the "no vaccination" strategy is $375). A strategy of universal newborn vaccination alone leads to an incremental cost-per-year-of-life saved of $3332. If adolescents are vaccinated at age 10, incremental cost-per-year-of-life saved is $13,938; for the general adult population, the incremental cost-per-year-of-life saved of universal vaccination is $54,524. Discounting benefits will increase cost-per-year-of-life saved 7 to 12 times for all strategies. CONCLUSIONS: HBV vaccine is most cost-effective when a strategy of screening newborns is combined with routine administration to 10-year-old children. The means to achieve substantial improvements in the health of the public in a cost-effective fashion are now available and should be pursued aggressively.

Adolescent↗
PubMed1993

Asymptomatic gallstones revisited. Is there a role for laparoscopic cholecystectomy?

OBJECTIVE: To compare the mortality effects of prophylactic laparoscopic cholecystectomy with that of expectant management in persons with asymptomatic gallstones. DESIGN: Decision analytic models of the two clinical strategies using input data from a review of the published medical literature pertaining to the epidemiology, natural history, and treatment outcomes related to gallstone disease. PATIENTS: Cohorts of men and women aged 30 and 50 years with asymptomatic gallstones. INTERVENTION: Prophylactic laparoscopic cholecystectomy performed at the time of diagnosis of asymptomatic gallstones or expectant management, defined as therapeutic intervention delayed until gallstone symptoms or complications spontaneously develop. MAIN OUTCOME MEASURES: Gallstone-related deaths and gallstone-related life-years lost for each age and gender cohort, by strategy. Models were subjected to rigorous sensitivity analysis to test the robustness of the results to changes in individual input variables. Outcomes were calculated with and without discounting nonfinancial benefits. RESULTS: The prophylactic laparoscopic cholecystectomy strategy led to fewer gallstone-related deaths than the expectant management strategy, but all of the deaths in the prophylactic laparoscopic cholecystectomy group occurred earlier in life. In cohorts older than age 30 years, the expectant management strategy resulted in fewer undiscounted gallstone life-years lost than the prophylactic laparoscopic cholecystectomy strategy. Discounting favored expectant management further because life-years lost were delayed compared with prophylactic surgery. Sensitivity analysis demonstrated the superiority of expectant management over a wide range of input assumptions. CONCLUSIONS: Prophylactic laparoscopic cholecystectomy should not be routinely recommended for individuals with asymptomatic gallstones.

Adult↗
PubMed1993

The dynamics of innovation in minimally invasive therapy.

The emergence of minimally invasive therapy (MIT), which provides alternatives to major open-surgery procedures, is affecting all aspects of medical care delivery. In the present environment of resource and cost constraint in health services, an uncommon consensus among patients, physicians, providers, and payers has evolved regarding the rapid acceptance of this area of medical intervention, an acceptance that, in turn, is stimulating further innovation. This paper discusses the dynamics of medical innovation and analyzes these forces in the context of three minimally invasive therapies: percutaneous transluminal coronary angioplasty, extracorporeal shock wave lithotripsy, and laparoscopic cholecystectomy. The different experiences of the United States and Europe are used to illustrate how scientific, medical, economic, and regulatory factors affect both the rate and direction of technological change in minimally invasive therapy.

Angioplasty, Balloon, Coronary↗
PubMed1992

Cost-effectiveness of the screening and treatment of diabetic retinopathy. What are the costs of underutilization?

Diabetic retinal disease remains a leading cause of visual disability among those of working age. Controlled trials have demonstrated that timely diagnosis and photocoagulation treatment can reduce significantly the likelihood of visual impairment in affected diabetic patients. Using a prospective simulation model, we show that an annual screening and treatment program saves thousands of years of vision and reduces medical expenditures over the lifetime of a cohort of Swedish Type I diabetic patients.

Cohort Studies↗
PubMed1992

Treatment of symptomatic cholelithiasis in France. A decision analysis comparing cholecystectomy and biliary lithotripsy.

To determine the potential role of extracorporeal shock wave lithotripsy (ESWL) in the treatment of symptomatic gallstone patients in France, a simulation model evaluated the health and economic effects of three different treatment strategies. Decision analysis of conventional cholecystectomy alone and either of two strategies using a combination of biliary lithotripsy and conventional cholecystectomy reveals that a strategy employing biliary ESWL results in a significant number of successfully treated patients, thus avoiding the risks and costs of abdominal surgery. Moreover, cost analysis shows that expanding the use of lithotripsy to all patients for whom the procedure is indicated increases the average cost per successfully treated patient, but, more importantly, decreases the overall costs incurred by the cohort. From a societal viewpoint, a policy using biliary ESWL in appropriate patients is superior to one of cholecystectomy alone, from both clinical and economic perspectives.

Adolescent↗