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Biomedical subjects

B G Vickrey

Publications and source records attributed to B G Vickrey.

At least 37 records · Page 2Linked to original sources
PubMed2000

The impact of epilepsy from the patient's perspective I. Descriptions and subjective perceptions.

This study surveyed the perceptions about and subjective experience of 1023 people with epilepsy in two community-based samples: one from a national postal survey; the other callers to the Epilepsy Foundation. Response to a mail survey was 49%. In comparison with US Census Bureau norms, respondents had received less education, were less likely to be employed or married, and came from lower income households. Complex partial seizures were the most prevalent seizure type, but a convulsion had occurred in 61%. Fifty percent of respondents reported incomplete control of their seizure disorder, although 25% of these had a seizure in the prior year. Thirteen percent had a longest inter-seizure interval of a year or greater, 37% of 3 months, 22% of 1 month, 10% of 1 week and 4% of 1 day. Respondents listed uncertainty and fear of having a seizure as the worst thing about having epilepsy. Lifestyle, school, driving, and employment limits were also listed as major problems. When asked to rank a list of potential problems, cognitive impairment was ranked highest. These data indicate that ongoing medical and psychosocial problems continue for those with epilepsy in the view of those questioned and their families, even in a sample where the majority report good control of their epilepsy.

Adolescent↗
PubMed2000

The impact of epilepsy from the patient's perspective II: views about therapy and health care.

A national survey of 1023 people with epilepsy in the US assessed their attitudes about their therapies. Subjects were drawn from responders to a previous national survey of US households or from those who phoned the Epilepsy Foundation. Overall response rate was 49%. Approximately 90% of the respondents were taking medications for their epilepsy. Only 56% were on monotherapy, while 26% were taking two, 6% three, and 2% four medications. Only 68% of respondents were very satisfied with their current seizure medications. When asked to rank five areas of importance regarding their seizure medication, the rank order (highest to lowest) was seizure control, fewer side effects, convenient dosing regimens and cost. Adverse medication events were listed in descending rank order as problems with cognition, energy level, school performance, childbearing, coordination, and sexual function. Inter-individual differences in side effects of concern were listed, suggesting medication choices should be individualized according to potential side effects. Twenty percent of 920 respondents adjusted their medications on their own, by adjusting amount (62%), dosing schedule (31%), or both (3%). Eighty percent of respondents were satisfied with their medical care systems. In this group, 82% had health insurance that covered epilepsy. The large majority (94%) of respondents had seen a neurologist. Subjects expressed dissatisfaction about time limits and lack of accessible information about epilepsy. People with epilepsy are generally satisfied with efforts to treat their disorder, but adverse events are of concern. Many patients requested more information about epilepsy.

Adolescent↗
PubMed2000

Relationships between seizure severity and health-related quality of life in refractory localization-related epilepsy.

PURPOSE: To evaluate relationships between self-report measures of seizure severity and health-related quality of life (HRQOL) in people with refractory localization-related epilepsy. METHODS: A sample of 340 adults enrolled in a seven-center, prospective study of resective epilepsy surgery completed baseline questionnaires that included the Quality of Life in Epilepsy (QOLIE)-89 and a seven-item adaptation of the National Hospital Seizure Severity Scale. Associations between QOLIE-89 summary measures and both the total seizure severity scale score and individual seizure severity items were assessed, after adjustment for seizure frequency. RESULTS: The seizure severity measure had adequate scale score variability and reliability in this sample. Correlations between individual items in the scale did not exceed 0. 43. Product-moment partial correlations between the seizure severity scale and QOLIE-89 summary measures ranged from -0.17 to -0.29 (all p values <0.01). Of the seven seizure severity items, the average time before individuals perceived they were "really back to normal" after their seizures was broadly related to all domains of HRQOL (r values ranged from -0.16 to -0.30; p values <0.01). Severity of injury during seizures was the only other item having more than minimal associations with HRQOL, and it was selectively related to the physical health measure. Higher frequency of falls during seizures was modestly related to less employment. CONCLUSIONS: This seizure severity measure assesses constructs that are generally distinct from HRQOL, except for moderate and broad associations between HRQOL and patient's perceptions of the average duration of recovery time after seizures. Recovery time may potentially be a useful clinical indicator of seizure severity that reflects meaningful impairment of HRQOL in adults with frequent seizures.

Adolescent↗
PubMed2000

Development of a health-related quality of life measure for peripheral neuropathy.

STATEMENT OF PROBLEM: To develop and evaluate a self-administered health-related quality of life (HRQOL) measure for peripheral neuropathy. METHODS: A field test measure of 162 items was developed that included the RAND-36 Health Survey as a generic core and a neuropathy-targeted supplement whose content was driven by results from three focus groups with 22 adults having peripheral neuropathy. It was administered at baseline and at 3- and 6-month follow-ups to 80 adult clinical trial enrollees with diabetic neuropathy. Item reduction and placement into scales, reliability, construct validity, responsiveness, and HRQOL comparisons to a general U.S. population were conducted. RESULTS: The final 97-item instrument includes 16 multi-item scales and 6 single items. Internal consistency reliabilities ranged from 0.67 to 0.93 (median = 0.88); intraclass correlation coefficients for those reporting no change in health between baseline and 3 months ranged from 0.42 to 0.84 (median = 0.77). Factor analysis of scales revealed physical and mental health as the two underlying dimensions. Correlations between selected HRQOL scales and sociodemographic variables were modest; there were more noteworthy associations between HRQOL scales and employment, disability days, and neurologic symptom ratings. Associations of HRQOL with neurologic examination (strength and reflexes) and with electrophysiologic findings were nonsignificant (all p > 0.10). Responsiveness of a physical health summary score relative to a criterion of change in subject's ratings of neuropathy symptom severity yielded a moderate effect size (= 0.60) and a Guyatt statistic exceeding 1.0. CONCLUSIONS: Results provide preliminary support for the measure's reliability and validity among adults with diabetic peripheral neuropathy. HRQOL was more strongly associated with symptom ratings than with examination and electrophysiologic test results.

Adult↗
PubMed1999

General neurologist and subspecialist care for multiple sclerosis: patients' perceptions.

OBJECTIVE: To compare general neurologists and MS specialists on patients' clinical characteristics and MS care as perceived by patients with MS. METHODS: We sampled all adult patients with MS having physician visits over a 2-year period from a Midwestern managed-care organization and from the fee-for-service portion of 23 randomly selected California neurologists' practices. In mid-1996, 694 subjects were mailed questionnaires; 532 (77%) responded. Sociodemographic/clinical characteristics, recent utilization of services/treatments, unmet needs, symptom care, and research participation were measured. Of 502 subjects (94%) who indicated their usual physician providing MS care was a neurologist, 217 (43%) reported having a general neurologist and 285 (57%) reported having an MS specialist. Comparisons between these two groups were adjusted for comorbidity and disease severity. RESULTS: General neurologist and MS specialist patient groups did not differ on any sociodemographic or clinical characteristic except age (p<0.05). Although health care utilization generally was similar, higher proportions of the MS specialist group were aware of or had discussed interferon beta-1b (IFNbeta-1b) with their physician (p<0.05) and were currently taking it (p<0.05); a smaller proportion of the MS specialist group reported stopping it because of side effects (p<0.01). Overall, levels of unmet need and care for recent symptoms were similar, but the MS specialist group reported more confidence in their physician/carefulness in listening (p<0.05). Twice as many MS specialist subjects had participated in nondrug research (p<0.05); drug study participation was similar. CONCLUSIONS: Patients' perceptions of their care were similar in most ways for those who designated their main MS provider as a general neurologist compared to an MS specialist; however, care differed in potentially important areas. Prospective, longitudinal studies are needed to measure and relate neurologists' training, experience, knowledge, and MS patient volume with both process and outcome measures of quality of MS care.

Adult↗
PubMed1999

Improving adherence to dementia guidelines through education and opinion leaders. A randomized, controlled trial.

BACKGROUND: Educational methods that encourage physicians to adopt practice guidelines are needed. OBJECTIVE: To evaluate an educational strategy to increase neurologists' adherence to specialty society-endorsed practice recommendations. DESIGN: Randomized, controlled trial. SETTING: Six urban regions in New York State. PARTICIPANTS: 417 neurologists. INTERVENTION: The educational strategy promoted six recommendations for evaluation and management of dementia. It included a mailed American Academy of Neurology continuing medical education course, practice-based tools, an interactive evidence-based American Academy of Neurology-sponsored seminar led by local opinion leaders, and follow-up mailings. MEASUREMENTS: Neurologists' adherence to guidelines was measured by using detailed clinical scenarios mailed to a baseline group 3 months before the intervention and to intervention and control groups 6 months after the intervention. In one region, patients' medical records were reviewed to determine concordance between neurologists' scenario responses and their actual care. RESULTS: Compared with neurologists in the baseline and control groups, neurologists in the intervention group were more adherent to three of the six recommendations: neuroimaging for patients with dementia only when certain criteria are present (odds ratio, 4.1 [95% CI, 1.9 to 8.9]), referral of all patients with dementia and their families to the Alzheimer's Association (odds ratio, 2.8 [CI, 1.7 to 4.8]), and encouragement of all patients and their families to enroll in the Alzheimer's Association Safe Return Program (odds ratio, 10.8 [CI, 3.5 to 33.2]). For the other three recommendations, adherence did not differ between the intervention and the nonintervention groups. Agreement between scenario responses and actual care ranged from 27% to 99% for the six recommendations and was 95% or more for three of the recommendations. CONCLUSION: A multifaceted educational program can improve physician adoption of practice guidelines.

Dementia↗
PubMed1999

End-of-life care: a survey of US neurologists' attitudes, behavior, and knowledge.

OBJECTIVE: The American Academy of Neurology (AAN) surveyed the attitudes, behavior, and knowledge of its members regarding care at the end of life. Three groups of AAN members were surveyed: neuro-oncologists, ALS specialists, and a representative sample of US neurologists. METHODS: The survey presented two clinical scenarios involving end-of-life care. Neurologists were asked a series of questions to assess their knowledge of existing medical, ethical, and legal guidelines; their willingness to participate in physician-assisted suicide (PAS) or carry out voluntary euthanasia (VE); and their general attitudes regarding end-of-life care. RESULTS: Neurologists support a patient's right to refuse life-sustaining treatment, but many believe that they are killing their patients in supporting such refusals. Thirty-seven percent think it is illegal to administer analgesics in doses that risk respiratory depression to the point of death. Forty percent believe they should obtain legal counsel when considering stopping life-sustaining treatment. One half believe that PAS should be made explicitly legal by statute for terminally ill patients. Under current law, 13% would participate in PAS and 4% would carry out VE; if those procedures were legalized, 44% would participate in PAS and 28% in VE. Approximately one third believe that physicians have the same ethical duty to honor a terminally ill patient's request for PAS as they do to honor a such a patient's refusal of life-sustaining therapy. CONCLUSIONS: There is a gap between established medical, legal, and ethical guidelines for the care of dying patients and the beliefs and practices of many neurologists, suggesting a need for graduate and postgraduate education programs in the principles and practices of palliative care medicine. Many neurologists would participate in PAS and carry out VE if legalized.

Adult↗
PubMed1999

US neurologists in the 1990's: trends in practice characteristics.

BACKGROUND: The American Academy of Neurology (AAN) conducts periodic surveys of its members to profile and monitor changes in the characteristics of US neurologists and their practices. OBJECTIVE: To assess neurologists' characteristics, geographic distribution, practice arrangements, professional activities, practice volume, procedures performed, sources of revenue, involvement with managed care and capitation, and other selected topics. METHODS: The AAN Member Census survey was sent to US neurologists in the fall of 1996 (response rate = 89%), and the Practice Profile survey was sent to a random sample of 1,986 US neurologists in the summer of 1997 (response rate = 55%) who had completed a Member Census survey. The results of the Practice Profile survey were compared with those of two prior surveys conducted in 1991 to 1992 and 1993 to 1994. RESULTS: The mean age of US neurologists is 48 years, 18% are women, 93% are US citizens, and 24% are international medical graduates. The proportion of neurologists in solo practices, group practices, and medical schools/universities has not changed. The weekly hours worked has remained stable (58 hours), but the time spent in administrative activities has increased (p < 0.001). The average number of patient visits per week to neurologists appears to have increased (p < 0.001), as has the proportion of neurologists performing procedures (p < 0.05). The majority of neurologists have contracts with managed care organizations (82%), and a minority (32%) have capitated payment arrangements. Medicare continues to be the largest source of clinical revenue. Nearly 50% of all respondents have experience in developing clinical practice guidelines or critical pathways, and >20% of respondents employed physician extenders to assist in their practices. CONCLUSION: Neurologists are spending more time in administrative activities, are performing or interpreting more procedures, and are seeing more patients. Neurologists' involvement with capitation is comparable with that in a nationally representative sample of physicians, and they are exploring innovative ways, such as developing practice guidelines and using physician extenders, to improve the quality and efficiency of providing neurologic care.

Adult↗
PubMed1999

A randomized trial to implement practice recommendations: design and methods of the Dementia Care Study.

The objective of the Dementia Care Study was to design, implement, and evaluate, in a randomized controlled trial a multi-faceted, specialty-society sponsored intervention to encourage neurologists' adoption of practice recommendations. Eligible participants were 417 neurologists in six regions in New York State (NYS) who were identified through the American Academy of Neurology (AAN) Membership Database and the NYS Physician Masterfile. An Advisory Panel of experts on dementia, neurologists who were local opinion leaders, and local representatives of the Alzheimer's Association guided the development of the intervention. The intervention included six components: (1) a mailing of six practice recommendations in a course of continuing medical education (CME) sponsored by the AAN; (2) a mailing of supplementary, practice-based tools; (3) follow-up mailings reinforcing the recommendations; (4) an invitation to an AAN-sponsored seminar; (5) endorsement by opinion leaders; and (6) specialty-society sponsorship and endorsement. The primary outcome measure was neurologists' decision-making, as assessed through a mailed survey that used detailed clinical scenarios. Intervention and control neurologists received the survey six months after the intervention, and a baseline group received it three months prior to the intervention. To evaluate the concordance of responses to scenarios with actual processes of care, we reviewed medical records in one study region. Secondary outcome measures included number of patient referrals received by the local Alzheimer's Associations and by the Association's National Safe Return Program. The specialty society, the opinion leaders, the dementia experts, local advocacy groups, and the study investigators achieved a high degree of collaboration. Specialty societies can integrate within their educational programs the capability to design and evaluate the impact of novel strategies to encourage the adoption of practice recommendations that are linked to improved quality of care.

Aged↗
PubMed1999

Systematic review of risk factors for urinary tract infection in adults with spinal cord dysfunction.

Recurrent urinary tract infections (UTIs) occur frequently in persons with neurogenic bladders due to spinal cord dysfunction, resulting in increased morbidity and cost. The authors conducted a systematic review to identify risk factors for UTI using controlled clinical trials, cohort, and cross-sectional studies that assessed risk factors for UTI and included bacteriuria or UTI as an outcome. Twenty-two studies met the inclusion criteria. Quality assessment revealed important methodological deficiencies. Two studies provide evidence supporting increased bladder residual volume as a risk factor. Most of the retrieved studies investigated method of drainage with the consistent finding that persons using intermittent catheterization had fewer infections than those with indwelling catheters. There is conflicting evidence over the value of sterile or "no touch" catheter techniques compared with clean intermittent catheterization. There is insufficient evidence to assess risk due to psychosocial, behavioral, and hygiene factors; sex; level of function; and time since injury.

Adult↗
PubMed1998

Practice styles of US compared to UK neurologists.

OBJECTIVE: This study assessed variation between neurologists in the United States and United Kingdom in their diagnostic and treatment decisions for commonly encountered neurologic presentations, and identified explanatory factors for any observed variation. METHODS: All 210 consultant neurologists in the United Kingdom and a nationally representative sample of 595 US neurologists received mailed surveys containing three detailed clinical scenarios depicting patients with (1) a single unprovoked seizure occurring 3 days previously, (2) early Parkinson's disease, and (3) dementia. The main study outcome measures were self-reported decisions regarding diagnostic test ordering and treatment, which were assessed after each scenario. Neurologists' practice characteristics, certainty about the diagnosis, and attitudes toward uncertainty were also measured. Survey response rates were 92% of US and 63% of UK neurologists. RESULTS: A higher proportion of US than UK neurologists indicated they would order additional diagnostic tests for all three scenarios (all p < 0.05); 77% of UK compared with 26% of US neurologists would manage a single unprovoked seizure without antiepileptic medication (p < 0.0001), but treatment of early Parkinson's disease was not different. Nearly all US and UK neurologists would obtain a neuroimaging study in the evaluation of dementia. International differences persisted after adjustment for differences in demographic and practice characteristics and for attitudes toward test use and clinical uncertainty. CONCLUSIONS: We identified large international variation in clinical decisions across three common neurologic conditions. Cross-country collaboration should explore these differences to develop consensus on standards of care.

Attitude of Health Personnel↗
PubMed1997

Measuring quality of care in neurology.

Neurologists are being asked to incorporate methods into daily practice that measure quality of care. Standards of care are increasingly being defined using evidence-based assessments of neurological literature. To evaluate quality of care, a widely accepted and useful model considers the structure, process, and outcomes of care. Outcomes, the impact of care on patients' health, should include measures of mortality, morbidity, disability, patient functioning and well-being (health-related quality of life), and patient satisfaction with care. A variety of private organizations and government programs exist to encourage documentation and promotion of high quality of care. This explosion in quality information is not yet standardized, so that much confusion exists about appropriate data elements to be measured. The challenge is to collect, summarize, and disseminate practical data useful to neurologists and the purchasers and consumers of our services.

Evidence-Based Medicine↗
PubMed1997

Comparison of a generic to disease-targeted health-related quality-of-life measures for multiple sclerosis.

Evaluation of the relative contributions of generic and disease-targeted measures to assessing health-related quality of life (HRQOL) for chronic conditions is needed to help in selection of appropriate measures. We administered a generic HRQOL measure (the Short Form-36 [SF-36]), three disease-targeted supplemental scales to the SF-36, and two disease-targeted HRQOL instruments to 171 adults with multiple sclerosis. Most scales yielded adequate variability, internal consistency reliability, and test-retest reliability. The relationship between each measure and four primary "criterion" variables were assessed: overall symptom severity in the prior year; ambulation status; days unable to work or attend school in the prior month: and a rating of overall quality of life. Results indicate that the disease-targeted scales provided unique information not captured by the generic measure. We conclude that if a generic measure of HRQOL is desirable for a given study of multiple sclerosis, additional information will be gained by supplementing that measure with selected scales.

Absenteeism↗
PubMed1997

A randomized trial of the impact of certified mail on response rate to a physician survey, and a cost-effectiveness analysis.

This study's goals were to (a) determine whether sending a survey by certified mail results in a higher response rate from physicians compared to sending by first-class mail and (b) evaluate the cost-effectiveness of this method. The study sample was 409 physicians who were nonrespondents to two previous mailings of a medical specialty society survey. Eligible physicians were designated at random to receive a final mailing either by U.S. Postal Service certified mail including a return-receipt postcard or by first-class mail. There was a higher response rate from the certified mail group compared with the first-class mail group (41.3% versus 24.8%; relative risk = 1.66, 95% Confidence interval 1.25, 2.21). A cost-effectiveness analysis showed that the cost per respondent was higher using certified mail versus first-class mail in the third mailing ($2.77 versus $2.34). Thus, use of certified mail is effective in increasing survey response but more costly.

Cost-Benefit Analysis↗
PubMed1997

Attitudes of US neurologists concerning the ethical dimensions of managed care.

We surveyed attitudes of US neurologists about the ethical dimensions of managed care by administering a written instrument containing paradigmatic cases portraying conflicts of physicians, patients, and managed care organizations (MCOs). After each case, we assessed neurologists' attitudes by asking them their degree of agreement with a series of statements. We found that neurologists (1) generally were willing to follow clinical practice guidelines if they were created by medical societies; (2) experienced frequent conflicts of interest or conflicts of obligation in the care of their MCO patients; (3) feared legal ramifications of their clinical decisions on MCO patients; (4) were unwilling to employ deception or gaming to achieve what they perceived to be good patient care; (5) believed that their professional prerogatives and autonomy were under attack by MCOs; and (6) felt that the good of their patients should not be sacrificed for the good of society.

Attitude of Health Personnel↗
PubMed1996

Can a specialty society educate its members to think differently about clinical decisions? Results of a randomized trial.

OBJECTIVE: Measure the effect of specialty society-developed continuing medical education (CME) on clinical decision making. DESIGN: Randomized controlled trial. SETTING: National sample of neurologists. PARTICIPANTS: Of 492 neurologists randomly selected from an ongoing American Academy of Neurology CME program, 248 were randomized to receive a mailed CME course, and 244 did not receive it. INTERVENTION: A mailed educational course on movement disorders, developed by the specialty society, containing information on diseases and practice recommendations with illustrative case presentations. MEASUREMENTS AND MAIN RESULTS: We assessed adherence to 16 practice recommendations on disease detection, diagnostic test use, and treatments by mailed survey sent to all subjects 4.5 months after the intervention group received the course (73% response rate). The survey contained detailed clinical scenarios to measure self-reported clinical decision making and short open-ended questions to measure factual knowledge. More intervention participants (up to 2.6 times more) than control subjects reported clinical decision making adherent to 9 of the 16 recommendations (p < .05). For 4 of the other 7 recommendations, adherence exceeded 85% in both groups. Within the intervention group, neurologists who read the educational course were 2 to 6 times more likely to be adherent than neurologists who did not. The intervention group had better factual knowledge than control subjects in six of seven areas (p < .01). CONCLUSIONS: This educational course improved neurologists' reported decision making. Specialty society-developed CME that utilizes a similar format may enhance the effectiveness of mailed CME information to improve physicians' approach to clinical decisions.

Decision Making↗