Search PubMed⌕ Search

Biomedical subjects

B Burnand

Publications and source records attributed to B Burnand.

At least 73 records · Page 4Linked to original sources
PubMed1999

The assessment of appropriate indications for laminectomy.

We have developed criteria to determine the appropriate indications for lumbar laminectomy, using the standard procedure developed at the RAND corporation and the University of California at Los Angeles (RAND-UCLA). A panel of five surgeons and four physicians individually assessed 1000 hypothetical cases of sciatica, back pain only, symptoms of spinal stenosis, spondylolisthesis, miscellaneous indications or the need for repeat laminectomy. For the first round each member of the panel used a scale ranging from 1 (extremely inappropriate) to 9 (extremely appropriate). After discussion and condensation of the results into three categories laminectomy was considered appropriate in 11% of the 1000 theoretical scenarios, equivocal in 26% and inappropriate in 63%. There was some variation between the six categories of malalignment, but full agreement in 64% of the hypothetical cases. We applied these criteria retrospectively to the records of 196 patients who had had surgical treatment for herniated discs in one Swiss University hospital. We found that 48% of the operations were for appropriate indications, 29% for equivocal reasons and that 23% were inappropriate. The RAND-UCLA method is a feasible, useful and coherent approach to the study of the indications for laminectomy and related procedures, providing a number of important insights. Our conclusions now require validation by carefully designed prospective clinical trials, such as those which are used for new medical techniques.

Back Pain↗
PubMed1998

Performance of panel-based criteria to evaluate the appropriateness of colonoscopy: a prospective study.

BACKGROUND: Prospective data describing the appropriateness of use of colonoscopy based on detailed panel-based clinical criteria are not available. METHODS: In a cohort of 553 consecutive patients referred for colonoscopy to two university-based Swiss outpatient clinics, the percentage of patients who underwent colonoscopy for appropriate, equivocal, and inappropriate indications and the relationship between appropriateness of use and the presence of relevant endoscopic lesions was prospectively assessed. This assessment was based on criteria of the American Society for Gastrointestinal Endoscopy and explicit American and Swiss criteria developed in 1994 by a formal panel process using the RAND/UCLA appropriateness method. RESULTS: The procedures were rated appropriate or equivocal in 72.2% by criteria of the American Society for Gastrointestinal Endoscopy, in 68.5% by explicit American criteria, and in 74.4% by explicit Swiss criteria (not statistically significant, NS). Inappropriate use (overuse) of colonoscopy was found in 27.8%, 31.5%, and 25.6%, respectively (NS). The proportion of appropriate procedures was higher with increasing age. Almost all reasons for using colonoscopy could be assessed by the two explicit criteria sets, whereas 28.4% of reasons for using colonoscopy could not be evaluated by the criteria of the American Society for Gastrointestinal Endoscopy (p < 0.0001). The probability of finding a relevant endoscopic lesion was distinctly higher in the procedures rated appropriate or equivocal than in procedures judged inappropriate. CONCLUSIONS: The rate of inappropriate use of colonoscopy is substantial in Switzerland. Explicit criteria allow assessment of almost all indications encountered in clinical practice. In this study, all sets of appropriateness criteria significantly enhanced the probability of finding a relevant endoscopic lesion during colonoscopy.

Algorithms↗
PubMed1998

Reliability of panel-based guidelines for colonoscopy: an international comparison.

BACKGROUND: This study examined the reliability of explicit guidelines developed using the RAND-UCLA appropriateness method. METHODS: The appropriateness of over 400 indications for colonoscopy was rated by two multispecialty expert panels (United States and Switzerland). A nine-point scale was used, which was consolidated into three categories of appropriateness: appropriate, uncertain, inappropriate. The distribution of appropriateness ratings between the two panels and the intrapanel and interpanel agreement for categories of appropriateness were calculated for all possible indications. Similar statistics were calculated for a series of 577 primary care patients referred for colonoscopy in Switzerland. RESULTS: Over 80% of all indications (348) could be directly compared. The proportions of indications classified as appropriate, uncertain, or inappropriate were 28.4%, 24.7%, 46.6% and 33.0%, 23.0%, 44.0% for the U.S. and the Swiss panels, respectively. Interpanel agreement was excellent for all the possible indications (kappa value: 0.75) and lower for actual cases (kappa value: 0.51) because of lower agreement for the most frequently encountered indications. CONCLUSIONS: Good agreement between the two sets of criteria was found, pointing to the reliability of the method. Partial disagreement occurred essentially for a few, albeit frequently encountered, indications for use of colonoscopy in cases of uncomplicated lower abdominal pain or constipation.

Colonoscopy↗
PubMed1998

MOS-SF-36 in evaluating health-related quality of life in alcohol-dependent patients.

Health-related quality of life (HRQoL) was evaluated in a sample of alcohol-dependent patients with the 36-item Medical Outcome Study Short-Form Health Survey (MOS-SF-36). The instrument was administered to 147 patients (77% males), aged 26-78, with a DSM-III-R diagnosis of alcohol dependence. The Hamilton Depression Scale (HDS), the Severity of Alcohol Dependence Questionnaire (SADQ), and the Addiction Severity Index (ASI) were also administered to the first 100 patients included in the study. The reliability and validity of the MOS-SF-36 were evaluated. Test-retest intraclass coefficients for a 10-day interval were in the range .65 to .79, whereas the Cronbach alpha coefficient indicated good internal consistency (range .70 to .89). Compared to scores observed in the general population, MOS-SF-36 scores for alcohol-dependent patients were relatively low (indicating worse perception of HRQoL), especially in the psychological and role dimensions (range 52/100 to 55/100), but were closer to populational values in the physical and functional dimensions (range 61/100 to 75/100)). The highest correlation between MOS-SF-36 dimensions and HDS was found in the MOS-SF-36 "mental health" dimension (r=-.56, p < .001); this dimension was also correlated highly with the psychiatric dimension of the ASI (r=-.73, p < .001). The eight dimensions of the MOS-SF-36 were 21% to 127% lower in patients with HDS greater than or equal to 16 (major depression) compared to those with HDS less than or equal to 7 (absence of depression). The MOS-SF-36 dimensions were 10% to 141% lower in patients with high "ASI alcohol" scores, indicating worse HRQoL profiles with a higher severity of alcohol dependence. The MOS-SF-36 presents good criteria for reliability and validity in alcohol-dependent patients. The results suggested that alcohol-dependent patients perceived their problems more as psychological than physical. The severity of alcohol dependence and depression seemed to influence the perception of HRQoL negatively.

Adult↗
PubMed1998

[Percutaneous versus surgical revascularization of isolated lesions of the proximal anterior interventricular artery. Five-year follow-up of a prospective randomized study].

The authors report the results of 5 years follow-up of 134 patients who benefited from percutaneous transluminal coronary angioplasty 5PTCA) or surgical intervention with implantation of the internal mammary artery as treatment of an isolated lesions of the proximal left anterior descending artery with normal left ventricular function. Sixty-eight patients underwent PTCA (group 1) and 66 had surgical bypass (group 2). The demographic data of the two groups was comparable. The incidence of the following events was analysed: death, myocardial infarction, indication for further revascularisation and functional class. At 5 years, the global mortality was 6% (8% in group 1 and 2% in group 2) but cardiac mortality was only 1% (1 patient in each group). The cumulative incidence of myocardial infarction was higher after angioplasty (15% vs 5%) but was mainly related to acute occlusions or acute coronary syndromes during angioplasty. However, the incidence of Q wave infarction was similar in the two groups. During follow-up, 32 patients (26 in group 1 and 6 in group 2) required one or more additional revascularisation procedures of the left anterior descending or of another artery. The proportion of asymptomatic patients at 5 years was high and similar in both groups. Finally, the proportion of patients without events during follow-up was 56% in group 1 and 86% in group 2. Despite the risk of restenosis and reoperation associated with angioplasty, this technique is an acceptable therapeutic alternative to surgical revascularisation in patients with isolated stenosis of the left anterior descending artery. Therefore, the therapeutic decision depends on the individual case, the availability of treatment and the patient's preference during consultation.

Angioplasty, Balloon, Coronary↗
PubMed1997

Appropriateness of indications for surgery of lumbar disc hernia and spinal stenosis.

STUDY DESIGN: This prospective study examines the appropriateness of indications for surgery of herniated intervertebral disc and spinal stenosis in patients undergoing surgery in a university hospital setting. OBJECTIVE: To evaluate the appropriateness of surgery using explicit criteria developed by an expert panel in the United States. SUMMARY OF BACKGROUND DATA: The use of surgery for herniated intervertebral disc and spinal stenosis varies widely within and among countries. It has been postulated that the main reason for treatment failure is poor selection of candidates for the procedure. METHODS: The authors prospectively evaluated appropriateness of surgical indications for herniated lumbar intervertebral disc or spinal stenosis in 328 consecutive patients undergoing the operation in two university neurosurgery departments. Outcome was measured 1 year after surgery by a standardized interview. RESULTS: Indications for surgery were considered to be appropriate or equivocal in 202 (62%) patients and inappropriate in 126 (38%). Among the 126 inappropriate procedures, 66 were so rated because of insufficient activity restriction before the procedure. One year after surgery, 74% of the patients perceived the results of the operation as good or very good. CONCLUSIONS: Appropriateness as measured by the criteria established by the American panel identified a large percentage of day-to-day practice in the two surgical units as inappropriate. However, use of criteria that include new findings about lack of efficacy of bed rest probably would lower this percentage. Criteria of appropriateness of medical and surgical procedures, developed through the panel process, need to be updated regularly.

Adolescent↗
PubMed1997

Importance of albumin, 25(OH)-vitamin D and IGFBP-3 as risk factors in elderly women and men with hip fracture.

The relative importance of vitamin D deficiency, secondary hyperparathyroidism, nutritional deficiency and low bone mineral density (BMD) as risk factors for hip fracture is not definitely established. In the framework of a case-control study of risk factors for hip fractures, biochemical markers of bone metabolism and nutrition and femoral BMD data were compared in 136 female and 43 male hip fracture patients, 136 female and 44 male age-matched hospitalized controls, and 47 healthy elderly women (8 men). Patients with hip fracture had lower albumin (-10%) and 25(OH)-vitamin D (25(OH)D; -19%) compared with hospitalized controls, and lower albumin (-28%) and 25(OH)D levels (-52%) compared with the elderly controls. Serum values of IGFBP-3 were also significantly lower (-33%) in hip fracture patients than in community controls. BMD of femoral neck was lower (p < 0.001) in patients than in hospitalized and community controls. In hip fracture patients, parathyroid hormone (PTH) correlated weakly with BMD (neck: r = -0.19, trochanter: r = -0.17; both p < 0.05). When all women were pooled (n = 233), albumin correlated significantly (age-adjusted) with BMD at all sites (neck: r = 0.27, trochanter: r = 0.25; all p < 0.001). Albumin, but not 25(OH)D, also correlated with skinfold thickness (r = 0.19, p < 0.0025) and with body mass index (BMI) (r = 0.14, p < 0.05). Male patients with hip fracture had lower BMD and albumin (both p < 0.001), 25(OH)D (p = 0.02) and IGFBP-3 levels (p < 0.005) compared with the controls. When male patients and controls were pooled together, albumin, skinfold thickness and BMI were significantly correlated with each other, but not with BMD. IGFBP-3 was highly correlated with albumin (p < 0.0001), 25(OH)D (p < 0.005) and, less significantly, with PTH (p < 0.05), but not with BMI or skinfold thickness. IGFBP-3 was significantly correlated with BMD at all sites (neck: r = 0.27, p < 0.05; trochanter: r = 0.40, p < 0.0005). In conclusion, low albumin and low BMD were both important risk factors for hip fracture. Low serum albumin was the strongest independent variable correlated with hip fractures. In men. IGFBP-3 was correlated with BMD. The femoral BMD depended only weakly on PTH and 25(OH)D, but was correlated at all sites with albumin, a non-specific parameter of nutrition and general health.

Aged↗
PubMed1997

Underutilization of upper gastrointestinal endoscopy.

BACKGROUND & AIMS: Efforts to reduce costs in health care may raise concerns about underuse of medical procedures. This study prospectively assessed underuse of upper gastrointestinal endoscopy in a cohort of patients in whom we have recently published data on overuse of endoscopy. METHODS: Underuse was identified by formal necessity criteria for endoscopy, obtained by an explicit panel process. Outpatients were consecutively included in two clinical settings. Setting A consisted of 20 primary care physicians and 7215 patient visits that occurred within 1 month. Setting B consisted of 920 visits that occurred during 3 weeks at an outpatient clinic. RESULTS: During these 8135 visits, 611 patients complained of upper digestive symptoms; 63 of them underwent endoscopy. Underuse was identified in 72 patients (11.8%). The two clinical situations mainly responsible for underuse of endoscopy were uninvestigated peptic symptoms resistant to treatment and dysphagia. At first follow-up, 29 of the patients with initial underuse still fulfilled criteria of necessity (underuse rate, 4.7%). One-year follow-up showed underuse of endoscopy in 5 patients. CONCLUSIONS: This prospective evidence shows that underuse of a medical procedure exists. The estimated overuse and underuse of endoscopy in this cohort were approximately equal (5%). Improving quality of care will require reductions of both overuse and underuse of medical procedures.

Adolescent↗
PubMed1997

Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care.

BACKGROUND: This prospective observational study was aimed at evaluating the appropriateness of use of upper gastrointestinal endoscopy (UGE) in primary care in a country with open access to and high availability of the procedure. METHODS: Outpatients were consecutively included in two clinical settings: Setting A (20 primary care physicians during 4 weeks) and B (university-based outpatient clinic during 3 weeks). In patients undergoing UGE, appropriateness of referral was judged by explicit Swiss criteria developed by the RAND/UCLA panel method. RESULTS: Patient visits (8135) were assessed. Six hundred eleven patients complained of upper gastrointestinal symptoms. Physicians decided to perform UGE in 63 of these patients. Twenty-five (40%) of the endoscopies were rated appropriate, 7 (11%) equivocal, and 31 (49%) inappropriate. Overuse of UGE occurred in 5.1% (setting A: 4.7%; setting B:6.5%; p = 0.39) of the patients who presented with upper gastrointestinal symptoms. The decision to perform UGE in previously untreated dyspeptic patients was the most common clinical situation resulting in overuse. CONCLUSIONS: Inappropriate use of UGE is high in Switzerland. However, to better reflect primary care decision making, overuse should be related not only to patients referred for a medical test, but also to the number of patients who complain of the symptoms that would be investigated by the procedure.

Adolescent↗
PubMed1997

Appropriateness of upper gastrointestinal endoscopy: comparison of American and Swiss criteria.

OBJECTIVE: Examine the reproducibility of the RAND method for developing criteria for the appropriateness of medical procedures. DESIGN: Comparison of two sets of explicit criteria for appropriateness of upper gastrointestinal (UGI) endoscopy, developed by separate expert panels from two countries. SETTING: United States, Switzerland. STUDY PARTICIPANTS: National experts from different medical specialties involved in the referral or application of UGI endoscopy. INTERVENTIONS: Each panel was presented with about 500 clinical scenarios (indications) that were rated on a nine-point scale as to the appropriateness of performing UGI endoscopy for a patient with that clinical presentation. MAIN OUTCOME MEASURES: (1) distribution of appropriateness ratings and intrapanel agreement categories between the two panels, (2) between-panel agreement of assigning appropriateness for comparable indications and, (3) percentage of indications with major between-panel differences. RESULTS: Ratings for 2/3 of indications could be compared. The Swiss panel showed higher intrapanel agreement (54.6% versus 46.2%, P = 0.002). Seventy-eight per cent of comparable indications were assigned to identical categories of appropriateness by both panels (kappa = 0.76, P < 0.001). For 93% of the 376 comparable indications, there were no major interpanel differences. CONCLUSION: Separate expert panels in different countries, using a standardized methodology, produce criteria for appropriateness of medical procedures that are similar. Given the resources being invested throughout the world in developing criteria and guidelines, international collaboration in seeking optimal use of limited health care resources should be intensified.

Endoscopy, Gastrointestinal↗
PubMed1996

[Importance of the clinical profile in the postmenopausal osteoporosis screening by densitometry].

In order to test the impact of a given risk profile on the incidence of osteoporosis which could justify BMD measurement, and that of a low risk profile which could render it unnecessary, BMD was measured in 217 women under 72 in whom menopause had occurred at least 6 years previously and who corresponded to one of the two following profiles: high risk (A, n = 102) = BMI < 27 kg/m2, with no estrogen replacement treatment, and with at least one of the following risk factors: BMI < 20, early menopause, positive family history, no dairy products associated with tobacco consumption (> 10 cigarettes/day for > 20 years and/or alcohol consumption of > 0.5 l wine/day during > 10 years, corticotherapy of > 6 months, rickets, anorexia nervosa. Low risk (B, n = 115) = absence of characteristics of group A, BMI > 27 kg/m2 with (B+, n = 24) or without estrogen therapy (B-, n = 91). BMD was measured by DXA in 4 centers using Lunar or Hologic equipment. Results were expressed in % of the mean of the respective young adult control groups. As expected, BMD was significantly different in these two subgroups of the population. Osteoporosis was diagnosed (BMD < 75% = < -2.5 SD, according to WHO) in 72% of group A, and in 17% (B+) and 19% (B-) respectively of group B. There was no difference between the various risk factors in group A concerning their impact on BMD, but concerning incidence, low BMI and early menopause were the most frequent. The high risk profile of group A seems to justify densitometry, since it leads to the diagnosis of osteoporosis in over 70%. However, the protective profile of group B does not exclude osteoporosis (risk still 20%); only in severe obesity (BMI > 33) does it drop to 1%.

Absorptiometry, Photon↗
PubMed1996

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy unit.

BACKGROUND AND STUDY AIMS: This prospective study tested the appropriateness of referrals for upper gastrointestinal endoscopy in an open-access endoscopy unit, using the criteria of the American Society for Gastrointestinal Endoscopy. It also examined whether there was any relationship between appropriateness of use and the presence of significant lesions detected by endoscopy. METHODS: Four hundred fifty consecutive upper gastrointestinal endoscopies were studied prospectively. The referral indication was recorded by the endoscopist before the procedure was performed, and was compared with the current criteria of the American Society for Gastrointestinal Endoscopy and with endoscopic findings. RESULTS: The appropriateness of referral was assessed in 442 consecutive endoscopies. Of these, 252 (57%) were judged to be appropriate. In 168 (88%) of the 190 endoscopies rated as inappropriate, the reason was that the patient had not undergone empirical anti-ulcer therapy before endoscopy. The probability of finding a significant lesion did not differ between the endoscopies judged to be appropriate (50%) and those judged to be inappropriate (46%) CONCLUSIONS: Upper gastrointestinal endoscopy was frequently used for inappropriate indications. The main reason for inappropriate use was insufficient treatment, or no treatment, of dyspeptic symptoms prior to endoscopy. In this study, the criteria for appropriateness did not predict the probability of finding a significant endoscopic lesion.

Adult↗
PubMed1996

Quality assurance in Swiss University Hospitals: a survey among clinical department heads.

OBJECTIVE: To obtain information to help design and implement quality improvement programmes. DESIGN: Questionnaire survey. SETTING: Swiss University Hospitals. STUDY PARTICIPANTS: Clinical Department heads. MAIN OUTCOME MEASURES: Attitudes towards quality assurance and percentage of departments with procedures for measurement and improvement of structure, process and outcome of medical care. RESULTS: Among 138 departments responding, 69 indicated a designated person or group in charge of quality and 57 were involved in collaborative quality improvement programmes. Mortality data at the level of the department was unavailable to 33% of respondents, and data on adverse treatment effects to 67% of them. Most respondents (69%) favoured the use of outcome indicators for quality control; only 13% favoured indicators pertaining to process or structure of care. Among indicators of outcome, patient satisfaction was the preferred indicator (25% of respondents), followed by morbidity (16%) and mortality (12%) data. CONCLUSION: Although the quality of medical care in Switzerland enjoys an excellent reputation, this study highlights important gaps in the information system and the processes necessary to evaluate quality.

Adult↗
PubMed1996

Quality of work incapacity assessment in the Swiss disability insurance system.

Quality of medical assessment of work incapacity has been poorly investigated, despite the enormous costs engendered by transient incapacity of work and permanent disability. This study examined some indices of quality from a stratified, random sample (n = 120) of assessments performed by expert assessors of the Swiss disability insurance. The distribution of work incapacity (WI) percentages over a 100% scale showed a clustering around key values significantly associated with financial disability benefits. The precision of WI, expressed as the level of quantitative exactness, was found to be high in 74% (95% CI: 66-82%) of current WI assessments, and in 62% (95% CI: 53-71%) of maximal WI assessments. Disagreement was observed in 17% of cases when comparing two ways of expressing WI by the same physician (95% CI: 10-23%). This exploratory study is limited by the general lack of objective criteria and standards. Further theoretical and empirical developments are needed to determine standardized criteria and clear guidelines for medical assessments of WI, as well as for evaluating their quality.

Adult↗