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Biomedical subjects

A S Ash

Publications and source records attributed to A S Ash.

At least 37 records · Page 2Linked to original sources
PubMed1998

Relation of family responsibilities and gender to the productivity and career satisfaction of medical faculty.

BACKGROUND: Studies have found that female faculty publish less, have slower career progress, and generally have a more difficult time in academic careers than male faculty. The relation of family (dependent) responsibilities to gender and academic productivity is unclear. OBJECTIVE: To describe dependent responsibilities by gender and to identify their relation to the aspirations, goals, rate of progress, academic productivity, and career satisfaction of male and female medical school faculty. DESIGN: 177-item survey questionnaire. SETTING: 24 randomly selected medical schools in the contiguous United States. PARTICIPANTS: 1979 respondents from a probability sample of full-time academic medical school faculty. MEASUREMENTS: The main end point for measuring academic productivity was the total number of publications in refereed journals. Perceived career progress and career satisfaction were assessed by using Likert scales. RESULTS: For both male and female faculty, more than 90% of time devoted to family responsibilities was spent on child care. Among faculty with children, women had greater obstacles to academic careers and less institutional support, including research funding from their institutions (46% compared with 57%; P < 0.001) and secretarial support (0.68 full-time equivalents compared with 0.83 full-time equivalents; P = 0.003), than men. Compared with men with children, women with children had fewer publications (18.3 compared with 29.3; P < 0.001), slower self-perceived career progress (2.6 compared with 3.1; P < 0.001), and lower career satisfaction (5.9 compared with 6.6; P < 0.001). However, no significant differences between the sexes were seen for faculty without children. CONCLUSIONS: Compared with female faculty without children and compared with men, female faculty with children face major obstacles in academic careers. Some of these obstacles can be easily modified (for example, by eliminating after-hours meetings and creating part-time career tracks). Medical schools should address these obstacles and provide support for faculty with children.

Adult↗
PubMed1998

Minority faculty and academic rank in medicine.

CONTEXT: Previous studies have found that fewer minority medical school faculty hold senior professorial ranks than do majority faculty and may not be promoted as rapidly. OBJECTIVE: To determine whether minority faculty were as likely as majority faculty to have attained senior rank (associate professor or full professor) after adjusting for other factors that typically influence promotion. DESIGN: A self-administered mailed survey of US medical school faculty using the Association of American Medical Colleges database. The sample was stratified by department, graduation cohort, and sex. PARTICIPANTS: A stratified random sample of 3013 full-time faculty at 24 representative US medical schools. All underrepresented minority faculty at these schools were sampled. MAIN OUTCOME MEASURE: Attainment of senior academic rank (associate professor or full professor). RESULTS: Of 3013 faculty surveyed, 1807 (60.0%) responded, including 1463 white (81.0%), 154 black (8.5%), 136 Asian (7.5%), and 54 Hispanic (3.0%). Overall, 980 faculty (54%) had attained senior academic rank, including 47 (30.5%) of 154 black faculty, 59 (43.4%) of 136 Asian faculty, 22 (40.8%) of 54 Hispanic faculty, and 852 (58.3%) of 1463 white faculty. White faculty had significantly more first-authored and total peer-reviewed publications than the other groups. After adjusting for the medical school, department, years as medical school faculty, number of peer-reviewed publications, receipt of research grant funding, proportion of time in clinical activities, sex, and tenure status, we found that the odds ratios of holding senior rank relative to white faculty were 0.33 (95% confidence interval [CI], 0.17-0.63) for black faculty, 0.36 (95% CI, 0.12-1.08) for Hispanic faculty, and 0.58 (95% CI, 0.30-1.12) for Asian faculty. CONCLUSIONS: Minority faculty were less likely than white faculty to hold senior academic rank. This finding was not explained by potential confounders such as years as a faculty member or measures of academic productivity.

Career Mobility↗
PubMed1998

Junior faculty members' mentoring relationships and their professional development in U.S. medical schools.

PURPOSE: To determine (1) the prevalence of mentoring relationships for U.S. medical school junior faculty; (2) the quality of these mentoring relationships; (3) any variation by gender or race; and (4) the relationship between mentoring and junior faculty members' perceptions of institutional professional support; research-, teaching-, and clinical-skills development; allocation of time to professional activities; and career satisfaction. METHOD: In 1995 a 177-item survey was mailed to 3,013 full-time faculty at 24 randomly selected U.S. medical schools stratified on an area of medical specialization, graduation cohort, and gender. Mentoring was defined as "dynamic reciprocal relationship between an advanced career incumbent (the mentor) and a junior faculty member (the protégé) aimed at fostering the development of the junior person/protégé." Because mentoring is most crucial for junior faculty, the study focused on mentoring relationships within the previous three years ("recent mentoring") for faculty who were not full professors. Chisquare tests, analysis of variance, and principal-components analysis were used to analyze the data. RESULTS: In all, 1,808 (60%) of the 3,013 faculty surveyed, of whom 72% were junior faculty, returned completed questionaires. Fifty-four percent of the junior faculty had had a recent mentoring relationship. There was no significant difference between the men and the women faculty or between majority and minority faculty in the prevalence and quality of the mentoring relationships. The faculty with mentors rated their research preparation and research skills higher than did the faculty without mentors. Most of the women faculty (80%) and the minority faculty (86%) who had had mentors reported that it was not important to have a mentor of the same gender or minority group. CONCLUSION: Mentoring relationships are prevalent in academic medicine and should be promoted to support the career growth of junior faculty.

Faculty, Medical↗
PubMed1998

Predicting in-hospital deaths from coronary artery bypass graft surgery. Do different severity measures give different predictions?

OBJECTIVES: Severity-adjusted death rates for coronary artery bypass graft (CABG) surgery by provider are published throughout the country. Whether five severity measures rated severity differently for identical patients was examined in this study. METHODS: Two severity measures rate patients using clinical data taken from the first two hospital days (MedisGroups, physiology scores); three use diagnoses and other information coded on standard, computerized hospital discharge abstracts (Disease Staging, Patient Management Categories, all patient refined diagnosis related groups). The database contained 7,764 coronary artery bypass graft patients from 38 hospitals with 3.2% in-hospital deaths. Logistic regression was performed to predict deaths from age, age squared, sex, and severity scores, and c statistics from these regressions were used to indicate model discrimination. Odds ratios of death predicted by different severity measures were compared. RESULTS: Code-based measures had better c statistics than clinical measures: all patient refined diagnosis related groups, c = 0.83 (95% C.I. 0.81, 0.86) versus MedisGroups, c = 0.73 (95% C.I. 0.70, 0.76). Code-based measures predicted very different odds of dying than clinical measures for more than 30% of patients. Diagnosis codes indicting postoperative, life-threatening conditions may contribute to the superior predictive power of code-based measures. CONCLUSIONS: Clinical and code-based severity measures predicted different odds of dying for many coronary artery bypass graft patients. Although code-based measures had better statistical performance, this may reflect their reliance on diagnosis codes for life-threatening conditions occurring late in the hospitalization, possibly as complications of care. This compromises their utility for drawing inferences about quality of care based on severity-adjusted coronary artery bypass graft death rates.

Coronary Artery Bypass↗
PubMed1998

Reducing random variation in reported rates of pressure ulcer development.

OBJECTIVES: The authors evaluated methods of reporting on rates of pressure ulcer development in long-term care to identify approaches that lead to more stable estimates of actual performance. METHODS: Performance measures for facilities that adequately adjust for both random variation and casemix should be relatively stable from one time period to the next. The authors calculated facility rates of pressure ulcer development over eight consecutive time periods and correlated measures over time using different reporting methods including z-scores, combining rates from several time periods, and limiting analyses to large facilities. Results were compared with a Monte Carlo simulation. RESULTS: Observed facility rates of pressure ulcer development varied considerably over time. The average correlation coefficient across seven time comparisons for observed rates was 0.17. Reporting performance as a z-score or limiting the analyses to large facilities increased the correlation. Combining two time periods was effective only when used with one of these other approaches. The correlation coefficient based on a simulation using only large facilities was 0.51. CONCLUSIONS: Random variation affects reported rates of pressure ulcer development. Using only large facilities and combining two time periods limits the effects of random variation and results in more stable estimates of performance. When describing performance, management must consider tradeoffs between having more accurate data, the frequency with which data are provided, and whether it is given to all providers.

Bias↗
PubMed1998

Profiling outcomes of ambulatory care: casemix affects perceived performance.

OBJECTIVES: The authors explored the role of casemix adjustment when profiling outcomes of ambulatory care. METHODS: The authors reviewed the medical records of 656 patients with hypertension, diabetes, or chronic obstructive pulmonary disease (COPD) receiving care at one of three Department of Veterans Affairs medical centers. Outcomes included measures of physiological control for hypertension and diabetes, and of exacerbations for COPD. Predictors of poor outcomes, including physical examination findings, symptoms, and comorbidities, were identified and entered into regression models. Observed minus expected performance was described for each site, both before and after casemix adjustment. RESULTS: Risk-adjustment models were developed that were clinically plausible and had good performance properties. Differences existed among the three sites in the severity of the patients being cared for. For example, the percentage of patients expected to have poor blood pressure control were 35% at site 1, 37% at site 2, and 44% at site 3 (P < 0.01). Casemix-adjusted measures of performance were different from unadjusted measures. Sites that were outliers (P < 0.05) with one approach had observed performance no different from expected with another approach. CONCLUSIONS: Casemix adjustment models can be developed for outpatient medical conditions. Sites differ in the severity of patients they treat, and adjusting for these differences can alter judgments of site performance. Casemix adjustment is necessary when profiling outpatient medical conditions.

Aged↗
PubMed1998

Evaluation of complication rates after coronary artery bypass surgery using administrative data.

Our objectives were (1) to determine if studying hospital complication rates after coronary artery bypass graft (CABG) surgery provides information not available when only mortality is studied, and (2) to reexplore the utility of ICD-9-CM administrative data for CABG outcomes assessment. Using data from Massachusetts, we identified CABG cohorts from 1990 and 1992 to respectively develop and validate multivariate risk adjustment models predicting in-hospital mortality and complications. The resulting models had good discrimination and calibration. In 1992, adjusted hospital complication rates ranged widely from 13.0% to 57.6%, while mortality rates ranged from 1.4% to 6.1%. Hospitals with high complication rates tended to have high mortality (r = 0.74, p = 0.006), but 2 of the 12 hospitals studied ranked quite differently when judged by complications rather than mortality. We conclude that (1) complications after CABG occur frequently and may provide information about hospital quality beyond that obtained from hospital mortality rates, and that (2) administrative data continue to be a promising resource for outcomes research.

Aged↗
PubMed1997

Hospital cost of complications associated with coronary artery bypass graft surgery.

We identified 6,791 coronary artery bypass grafting (CABG) cases using the Massachusetts hospital discharge data to quantify the contribution of complications to the cost of a hospitalization for CABG. After adjusting for in-hospital mortality and baseline clinical severity as other contributors to cost, the additional costs associated with complications were substantial.

Aged↗
PubMed1997

Statewide quality improvement initiatives and mortality after cardiac surgery.

BACKGROUND: Recent reports from New York and northern New England claim that statewide quality improvement initiatives and outcome reporting are leading to decreased mortality following coronary artery bypass graft (CABG) surgery. OBJECTIVE: To compare trends in mortality after CABG surgery in Massachusetts (a state that has not instituted statewide outcome reporting) with the decreases reported from New York and northern New England. DESIGN: Surgical cohorts from 1990, 1992, and 1994 were used to evaluate the risk-adjusted mortality trend for Massachusetts. We present this trend along with the published trends from New York and northern New England. For comparison, we also present unadjusted Medicare mortality trends from Massachusetts, New York, northern New England, and the entire United States. SETTING: All 12 Massachusetts hospitals performing cardiac surgery (excluding a Veterans Affairs hospital). PATIENTS AND DATA SETS: Massachusetts administrative data were used to identify all patients undergoing isolated CABG surgery in 1990, 1992, and 1994. MAIN OUTCOME MEASURES: Observed and risk-adjusted in-hospital mortality. RESULTS: Observed mortality rates in Massachusetts decreased from 4.7% in 1990 to 3.5% in 1992 and to 3.3% in 1994. The corresponding risk-adjusted mortality reductions for 1992 and 1994 (relative to 1990) were 35% and 42%, respectively. The mortality reduction seen in Massachusetts is comparable to the reductions seen in New York and northern New England over similar periods. Unadjusted Medicare mortality trends were generally similar in the states under study, and in the United States as a whole. CONCLUSIONS: In-hospital mortality after CABG surgery has decreased in Massachusetts despite the absence of statewide outcome reporting. Direct program evaluations are needed to better characterize the efficacy of the ongoing statewide outcome studies in New York and northern New England.

Aged↗
PubMed1997

Differences in procedure use, in-hospital mortality, and illness severity by gender for acute myocardial infarction patients: are answers affected by data source and severity measure?

OBJECTIVES: According to some studies, women with heart disease receive fewer procedures and have higher in-hospital death rates than men. These studies vary by data source (hospital discharge abstract versus detailed clinical information) and severity measurement methods. The authors examined whether evaluations of gender differences for acute myocardial infarction patients vary by data source and severity measure. METHODS: The authors considered 10 severity measures: four using clinical medical record data and six using discharge abstracts (diagnosis and procedure codes). The authors studied all 14,083 patients admitted in 1991 for acute myocardial infarction to 100 hospitals nationwide, examining in-hospital death and use of coronary angiography, coronary artery bypass graft surgery (CABG), and percutaneous transluminal coronary angioplasty (PTCA). Logistic regression was used to calculate odds ratios for death and procedure use for women compared with men, controlling for age and each of the severity scores. RESULTS: After adjusting only for age, women were significantly more likely than men to die and less likely to receive CABG and coronary angiography. Severity measures provided different assessments of whether women were sicker than men; for all cases, clinical data-based MedisGroups rated women's severity compared with men's, whereas four code-based severity measures viewed women as sicker. After adjusting for severity and age, women were significantly more likely than men to die in-hospital and less likely to receive coronary angiography and CABG; women and men had relatively equal adjusted odds ratios of receiving PTCA. Odds ratios reflecting gender differences in procedure use and death rates were similar across severity measures. CONCLUSIONS: Comparisons of severity-adjusted in-hospital death rates and invasive procedure use between men and women yielded similar findings regardless of data source and severity measure.

Angioplasty, Balloon, Coronary↗
PubMed1996

As mammography use increases, are some providers omitting clinical breast examination?

OBJECTIVE: To explore use of clinical breast examination (CBE) among women receiving mammography. METHODS: A retrospective cohort analysis of 100 women aged 50 years or older with at least one bilateral mammogram. Chart review documented demographic information, severity of illness, and performance of CBE (from 1 year prior to 18 months after the mammogram). RESULTS: The mean age of the 100 women was 63 years. They were predominantly unmarried (60%), nonwhite (58%), and not currently employed (57%). Three quarters (76%) had mammography and CBE (comprehensive screening), while the remaining 24% had mammography only. Sociodemographic factors did not differ for women with and without comprehensive screening (P>.1). However, patients of female providers were more likely to receive comprehensive screening than patients of male providers. Specifically, 95% of women seen by female attending physicians or fellows had comprehensive screening vs 67% for male attending physicians or fellows and 61% for residents (P=.008). CONCLUSIONS: Mammography may be replacing CBE especially among patients of male providers. Interventions targeted to these providers could help improve the use of CBE and mammography.

Aged↗
PubMed1996

Rating long-term care facilities on pressure ulcer development: importance of case-mix adjustment.

OBJECTIVE: To determine the importance of case-mix adjustment in interpreting differences in rates of pressure ulcer development in Department of Veterans Affairs long- term care facilities. DESIGN: A sample assembled from the Patient Assessment File, a Veterans Affairs administrative database, was used to derive predictors of pressure ulcer development; the resulting model was validated in a separate sample. Facility-level rates of pressure ulcer development, both unadjusted and adjusted for case mix using the predictive model, were compared. SETTING: Department of Veterans Affairs long-term care facilities. PATIENTS: The derivation sample consisted of 31 150 intermediate medicine and nursing home residents who were initially free of pressure ulcers and were institutionalized between October 1991 and April 1993. The validation sample consisted of 17 946 residents institutionalized from April 1993 to October 1993. MEASUREMENT: Development of a stage 2 or greater pressure ulcer. RESULTS: 11 factors predicted pressure ulcer development. Validated performance properties of the resulting model were good. Model-predicted rates of pressure ulcer development at individual long-term care facilities varied from 1.9% to 6.3%, and observed rates ranged from 0% to 10.9%. Case-mix-adjusted rates and ranks of facilities differed considerably from unadjusted ratings. For example, among five facilities that were identified as high outliers on the basis of unadjusted rates, two remained as outliers after adjustment for case mix. CONCLUSIONS: Long-term care facilities differ in case mix. Adjustments for case mix result in different judgments about facility performance and should be used when facility incidence rates are compared.

Aged↗
PubMed1996

Variations in the management of acute myocardial infarction. Importance of clinical measures of disease severity.

OBJECTIVE: To determine the extent to which resource use for patients hospitalized with acute myocardial infarction varies with clinical status, and to see if an observed difference in resource use between two states can be explained by clinically detailed risk adjustment. DESIGN: Retrospective review of the clinical characteristics and resource use of 342 patients hospitalised in two states with acute myocardial infarction. DATA SOURCES: Merged data from three sources: a large, existing research database used in developing the Medicare Mortality Predictor Score, clinical data abstracted from medical charts specifically for this study, and Medicare Parts A and B claims records. PATIENTS: A probability sample of Medicare patients hospitalized in 1986 with a diagnosis of acute myocardial infarction and residing in either Wisconsin or Washington state; patients dying within 30 days are oversampled. MEASUREMENTS AND MAIN RESULTS: Although patients were clinically similar in the two states, there were systematic differences in resource use. Patients in Wisconsin spent more than one extra day in the intensive care unit (ICU) (2.8 vs 1.7) as well as more than one extra non-ICU day in the hospital (8.0 vs 6.5) than patients in Washington. Patients in Wisconsin were also more likely to receive an echocardiogram (35.6% vs 15.8%), nuclear ventriculogram (12.8% vs 4.1%), exercise tolerance test (21.5% vs 3.4), and Holter monitoring (5.4% vs 0%). (All p < .01.) Differences in utilization were greater for patients at lower risk of dying. The average cost of care was 20.8% higher in Wisconsin (p = .01); risk adjustment for clinical and other factors reduced this difference to 11.8%, but did not eliminate it (p = .04). CONCLUSIONS: Patients with acute myocardial infarction vary in resource use as a function of clinical factors present at admission and occurring during the hospital stay; comparisons that do not take account of these factors may not discriminate well between providers who care for sicker patients and those who are inefficient. The greater use of resources for patients in Wisconsin is at least partially explained by differences in clinical characteristics that are not presently captured in administrative data.

Aged↗
PubMed1996

Using severity measures to predict the likelihood of death for pneumonia inpatients.

OBJECTIVE: To see whether predictions of patients, likelihood of dying in-hospital differed among severity methods. DESIGN: Retrospective cohort. PATIENTS: 18,016 persons 18 years of age and older managed medically for pneumonia; 1,732 (9.6%) in-hospital deaths. METHODS: Probability of death was calculated for each patient using logistic regression with age, age squared, sex, and each of five severity measures as the independent variables: 1) admission MedisGroups probability of death scores; 2) scores based on 17 admission physiologic variables; 3) Disease Staging's probability of mortality model; the Severity Score of Patient Management Categories (PMCs); 4) and the All Patient Refined Diagnosis-Related Groups (APR-DRGs). Patients were ranked by calculated probability of death; 5) rankings were compared across severity methods. Frequencies of 14 clinical findings considered poor prognostic indicators in pneumonia were examined for patients ranked differently by different methods. RESULTS: MedisGroups and the physiology score predicted a similar likelihood of death for 89.2% of patients. In contrast, the three code-based severity methods rated over 25% of patients differently by predicted likelihood of death when compared with the rankings of the two clinical data-based methods [MedisGroups and the physiology score]. MedisGroups and the physiology score demonstrated better clinical credibility than the three severity methods based on discharge abstract data. CONCLUSIONS: Some pairs of severity measures ranked over 25% of patients very differently by predicted probability of death. Results of outcomes studies may vary depending on which severity method is used for risk adjustment.

Adolescent↗
PubMed1996

Evaluating pressure ulcer occurrence in long-term care: pitfalls in interpreting administrative data.

Administrative databases for long-term care frequently collect information on fixed dates of the calendar year, rather than for entire episodes of care. Patients discharged or dying prior to an evaluation date are lost to follow-up. We used one such database, the VA Patient Assessment File, to examine pressure ulcer occurrence in long-term care. Clinical studies have established that most pressure ulcers develop during the first several weeks following admission. In these data, however, pressure ulcer development was less common in patients assessed within 2 months following admission, as compared to those examined at 3 to 6 months. This finding appears to be related to the selective discharge of patients, which makes these patient populations noncomparable. These results highlight that care must be exercised when interpreting results obtained from such administrative data.

Aged↗
PubMed1996

Searching for an improved clinical comorbidity index for use with ICD-9-CM administrative data.

We studied approaches to comorbidity risk adjustment by comparing two ICD-9-CM adaptations (Deyo, Dartmouth-Manitoba) of the Charlson comorbidity index applied to Massachusetts coronary artery bypass surgery data. We also developed a new comorbidity index by assigning study-specific weights to the original Charlson comorbidity variables. The 2 ICD-9-CM coding adaptations assigned identical Charlson comorbidity scores to 90% of cases, and specific comorbidities were largely found in the same cases (kappa values of 0.72-1.0 for 15 of 16 comorbidities). Meanwhile, the study-specific comorbidity index identified a 10% subset of patients with 15% mortality, whereas the 5% highest-risk patients according to the Charlson index had only 8% mortality (p = 0.01). A model using the new index to predict mortality had better validated performance than a model based on the original Charlson index (c = 0.74 vs. 0.70). Thus, in our population, the ICD-9-CM adaptation used to create the Charlson score mattered little, but using study-specific weights with the Charlson variables substantially improved the power of these data to predict mortality.

Aged↗