Search PubMed⌕ Search

Biomedical subjects

C L Bennett

Publications and source records attributed to C L Bennett.

At least 109 records · Page 6Linked to original sources
PubMed1997

The learning curve for laparoscopic colorectal surgery. Preliminary results from a prospective analysis of 1194 laparoscopic-assisted colectomies.

BACKGROUND: Laparoscopic-assisted colectomy is an emerging technology for patients with cancer, polyps, inflammation, and other types of pathologic conditions. While previous studies have shown better outcomes for laparoscopic cholecystectomies when surgeons perform more procedures, there is no information on the relationship between surgeon volume and outcomes for laparoscopic-assisted colectomy. OBJECTIVE: To evaluate whether better clinical outcomes are found for surgeons who perform higher numbers of laparoscopic-assisted colectomies and whether such a relationship, if it exists, applies to both intraoperative and postoperative outcomes. DESIGN: Analysis of a data set of 1194 patients, operated on by 114 surgeons, from a prospective registry sponsored by the American Society of Colon and Rectal Surgeons, from May 1991 to October 1994. MAIN OUTCOME MEASURES: Completion rate, intraoperative and postoperative complications, and length of hospital stay. RESULTS: In 75% of cases, surgery was completed laparoscopically, with no difference between high-volume surgeons (> or = 40 cases) and low-volume surgeons. Length of stay (average, 6 days) did not vary according to surgeon volume. Postoperative complications occurred in 15% of cases, with a significantly lower rate for high-volume surgeons (10% vs 19%; P < .001). Intraoperative complications occurred in 5% of cases, with a nonsignificant trend toward a lower rate for high-volume surgeons (3.7% vs 6.3%). A multivariate regression analysis, adjusting for type of disease (cancer vs inflammation vs polyps) and for level of difficulty of the procedure (high vs low) showed that for high-volume surgeons there is a lower probability of both intraoperative complications (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-0.97; P = .04) and postoperative complications (adjusted odds ratio, 0.48; 95% confidence interval, 0.34-0.68; P < .001). CONCLUSIONS: There is a learning curve for laparoscopic-assisted colectomy with respect to intraoperative and postoperative outcomes. As with other laparoscopic procedures, surgeons who perform higher volumes of laparoscopic-assisted colectomy have lower rates of intraoperative and postoperative complications.

Colectomy↗
PubMed1997

Treatment considerations for persons with metastatic prostate cancer: survival versus out-of-pocket costs.

OBJECTIVES: Treatment decisions for metastatic prostate cancer require the consideration of factors such as survival, quality of life, costs of care, and toxicities. In this study, we queried physicians who had extensive experience with prostate cancer about features of metastatic prostate cancer, patients' quality of life, and factors influencing their decision to prescribe flutamide. METHODS: Data were gathered through physician surveys and focus group discussions. Demographic information on the physicians and their patients was collected. Physicians made assessments of five health states related to metastatic prostate cancer, based on the time trade-off technique, and on the desirability of flutamide, based on average expected improvement in survival free of progressive disease, side effects, and drug cost. RESULTS: Physicians were internally consistent in their judgments of the factors most important to quality of life for individuals with metastatic prostate cancer. Physicians considered bone pain and weight loss/anorexia the most important factors. Physicians who cared for a higher proportion of older persons or Medicare recipients rated each scenario as less undesirable than did physicians with a lower proportion of these patients. Out-of-pocket cost was the major factor predicting whether a physician would prescribe flutamide. Physicians working for health maintenance organizations were more likely to prescribe flutamide but were more sensitive to out-of-pocket costs than were other physicians. CONCLUSIONS: Physicians-varied in their perceptions of quality of life for persons with metastatic prostate cancer and in their willingness to prescribe flutamide. These perceptions and prescribing preferences are strongly influenced by factors other than health status or specific health benefits. In deciding to prescribe flutamide, concerns over out-of-pocket expenditures loom large for most clinicians. It would be important to know the degree to which these concerns are shared by patients and whether prescribing preferences differ for Medicare managed-care patients who have pharmaceutical benefits.

Adult↗
PubMed1997

Approaches to prostate cancer by managed care organizations.

OBJECTIVES: Managed care organizations (MCOs) are developing population-based approaches to illnesses with large numbers of patients, wide variations in care and outcomes, and high costs. This is the first survey that evaluates current prostate cancer approaches by MCOs. METHODS: Case studies and a survey of corporate medical directors at large MCOs were conducted. RESULTS: Two approaches, broadly based on disease management strategies for men with prostate cancer, have been implemented in managed care settings on the West Coast. While both have provided comprehensive approaches to the disease, assessment of improvement in outcomes will require longer follow-up. A survey of corporate medical directors of MCOs indicates that population-based disease approaches nationwide for malignant prostate disease lag behind more well-developed efforts for nonmalignant illnesses such as diabetes and asthma. CONCLUSIONS: Prostate cancer may be a feasible area for development and evaluation of population-based approaches. MCOs have the potential to improve clinical care and outcomes for large numbers of men with prostate cancer. While limitations exist related to specific managed care considerations of data needs and lack of medical and surgical consensus on disease management, programs based on shared decision making have the potential to improve patient care and outcomes.

Health Care Surveys↗
PubMed1997

Comparison of perspectives on prostate cancer: analyses of survey data.

OBJECTIVES: Prostate cancer will account for 334,500 new cases and 41,800 deaths among men in the United States in 1997. Patients and physicians are faced with many concerns related to benefits and side effects of alternative treatments, educational needs, emotional support, and costs of care. Support groups for prostate cancer patients have been established to help satisfy needs in these areas. Therefore, we addressed three issues among patients who belong to a prostate cancer support group as well as among a second group of urologists who treat prostate cancer: (1) goals for prostate cancer treatment, (2) information that is given and recalled about the disease and therapy, and (3) extent to which educational and emotional needs are being met. METHODS: Random telephone surveys were made of 1000 men with prostate cancer who belong to the prostate cancer support group US TOO, the largest prostate cancer support group in the United States, and 200 urologists who provide care to men with prostate cancer. The surveys were conducted by the Louis Harris & Associates survey research firm. RESULTS: About four fifths of patients and urologists prefer aggressive therapy for prostate cancer. Patient goals with therapy included preservation of quality of life (45%), extension of life (29%), and delaying disease progression (13%), whereas physicians overwhelmingly focused on treatment efficacy (86%), with side effects (43%) and costs (29%) being secondary considerations. Urologists and patients differed markedly in the description of the patient-physician discussion. Whereas almost 100% of physicians stated that they always discussed important considerations such as options for no therapy, life expectancy with and without therapy, patient preferences, costs, and changes in sexual function, only about one fifth of patients recalled similar discussions. Patients and physicians both believed that physicians were an excellent source of educational support, but often did not report provision of emotional support. Although support groups were viewed as good providers of educational and emotional support by 85% to 90% of patients, physicians appeared to underestimate the benefit of support groups in these areas. CONCLUSIONS: Patients who belong to US TOO have many emotional and educational needs that are not currently being fulfilled by physicians. Although the goals of therapy are viewed similarly by patients and physicians, much of the important cancer- and treatment-related information that physicians report they have provided is not recalled by patients. Policy makers would be wise to devise systematic strategies such as shared decision-making tools and better linkages to support groups to ensure that patients' needs are being met.

Aged↗
PubMed1997

The white gene of the tephritid fruit fly Bactrocera tryoni is characterized by a long untranslated 5' leader and a 12kb first intron.

A 300 bp fragment from exon 6 of the white gene of Bactrocera tryoni was used to screen a B. tryoni genomic library. One positive (approximately 14 kb) insert contained exons 2-6 of white by nucleotide and amino acid sequence similarity to the white genes of D. melanogaster (O'Hare et al., 1984; Pepling & Mount, 1990). Lucilia cuprina (Garcia et al., 1996). Ceratitis capitata (Zwiebel et al., 1995) and Anopheles gambiae (Besansky et al., 1995). A white 5' cDNA fragment containing exons 1, 2 and part of exon 3 was amplified, cloned and sequenced. An inverse PCR fragment of genomic DNA was generated, containing the exon 1 coding region plus approximately 2.1 kb of upstream sequence, encompassing the putative promoter of the gene. Exon 1 was found to be 728 bp long, encoding the first twenty-five amino acids. The full length of intron 1 was shown to be 12 kb (amplified using long PCR protocols), up to 3 times the length of the longest white intron 1 isolated to date.

ATP-Binding Cassette Transporters↗
PubMed1997

Gender differences in early suspicion of tuberculosis in hospitalized, high-risk patients during 4 epidemic years, 1987 to 1990.

OBJECTIVES: To assess the degree to which, from 1987 to 1990, physicians suspected tuberculosis (TB) in the first 2 hospital days in human immunodeficiency virus (HIV)-infected patients with pulmonary disease. DESIGN: Retrospective cohort study. SETTING: 96 hospitals in five US cities. PATIENTS: 2,174 adult patients with acquired immunodeficiency syndrome discharged with a diagnosis of Pneumocystis carinii pneumonia from 1987 to 1990. The diagnosis generally was not known on admission. RESULTS: Physicians suspected TB in the first 2 hospital days in 66% of these patients in 1987, a rate that increased steadily to 74% in 1990. However, the extent to which physicians considered TB among female patients decreased from 76% to 71% over the 4 years. Controlling for confounding variables by multiple logistic regression, the odds that TB would be suspected early increased 1.8-fold among men (odds ratio [OR], 1.8; 95% confidence interval [CI95], 1.4-2.4), but not in women (OR, 0.6; CI95, 0.2-1.9). Among the five cities, the odds of early suspicion of TB increased most in New York City (OR, 3.9; CI95, 2.0-7.9). CONCLUSIONS: Physicians considered TB in a timely manner in an increasing majority of male, but not female, high-risk patients during the first years of TB resurgence in the United States. Physicians must be aware of the changing epidemiology of HIV and TB, as well as their practice patterns, to prevent nosocomial transmission of this disease.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Variations in medical care for HIV-related Pneumocystis carinii pneumonia: a comparison of process and outcome at two hospitals.

BACKGROUND: Institutional variation in the quality of medical care may be evaluated by examining process measures, such as use of diagnostic procedures or treatment modalities, or outcome measures, such as mortality. We undertook this study to examine variations in both process and outcome of care for patients with HIV-related Pneumocystis carinii pneumonia (PCP) at two geographically diverse, HIV-experienced, public municipal hospitals. DESIGN: Retrospective review of hospitalized patients diagnosed as having PCP cared for at two municipal hospitals from 1988 to 1990. At hospital A, charts of all patients diagnosed as having PCP were abstracted (n=209); at hospital B, a random sample of 15% were abstracted (=136). RESULTS: Among all hospitalized patients diagnosed as having PCP, the frequency of making a definitive diagnosis of PCP (as opposed to treating empirically) differed markedly at the two hospitals (85% in hospital A vs 26% in hospital B; p<0.001), as did the use of intensive care (18% vs 3%; p<0.001) and "do-not-resuscitate" orders (39% vs 14%; p<0.001), although the timing of starting anti-Pneumocystis medications (89% vs 88% within the first 2 hospital days) and the use of corticosteroids (21% vs 23%) were similar. Despite differences in the process of care, survival rates were similar at the two institutions (75% vs 76%; p=0.8) and remained similar when logistic regression was used to control for demographic variables and severity of illness (odds ratio for survival, hospital B vs A, 1.2 [95% confidence interval, 0.7, 2.0]). The 95% confidence intervals (0.7, 2.0), however, were consistent with a considerable (and clinically significant) disparity in survival (from 30% lower to a twofold higher odds of survival). Sample size calculations showed that a sample of 10 cases in each hospital would be required to detect the observed difference in definitive diagnosis rates (85% vs 26%), but 722 cases in each hospital would be required to detect a relevant difference in mortality. CONCLUSIONS: The process of care for hospitalized patients with PCP in these two institutions differed considerably, but the survival rates were not significantly different, even after adjusting for confounding factors. While sample sizes available at the individual institutions were sufficient for evaluation of the process of care, they did not provide the power necessary to evaluate outcomes. Comparisons of outcomes such as mortality between individual hospitals may not have the statistical power to exclude important differences.

AIDS-Related Opportunistic Infections↗
PubMed1997

Economic analyses of phase III cooperative cancer group clinical trials: are they feasible?

Both economic and clinical evaluations of new pharmaceutical agents are important to physicians who practice in the current health care environment. While cooperative cancer groups carry out large-scale phase III clinical evaluations of these agents, few cooperative group studies incorporate economic analyses because of concerns over overburdening of data management, investigators, and statistical center personnel. In this study, we describe the results and operational considerations of one of the first completed economic analyses of a phase III cooperative group trial of the Eastern Cooperative Oncology Group (ECOG). We developed an economic model estimating economic benefits of yeast-derived granulocyte-macrophage colony-stimulating factor (GM-CSF) as adjunct therapy for adult patients (56-70 years) with acute myelogenous leukemia. Clinical data were based on prospectively collected information from a recently reported double-blind phase III multi-institutional study carried out by ECOG. Retrospective economic data were obtained from financial information systems at our hospital, one of the study sites. The cost-minimization analyses were based on the perspective of a third-party payer. Indirect costs related to loss of earnings by patients and caregivers as well as quality-of-life adjustments were not incorporated into the model. Clinical trial results indicated that patients treated with GM-CSF had shorter times to recovery of absolute neutrophil count of 500 cells/mm3 and 1000 cells/mm3 and fewer serious infections than patients who received placebo following induction chemotherapy, while no significant differences were noted in red blood cell and platelet transfusion dependency, toxicities, and duration of hospitalization. The economic model estimated that the group treated with GM-CSF was estimated to have lower costs of care, associated with lower frequencies of serious infections and lower overall infection-related costs. Sensitivity analyses indicated that these results held true over a wide range of estimates of costs and infection rates. Prospective economic analyses of phase III cooperative cancer group clinical trials have not been completed to date. Strategies that are not likely to overburden data managers and statistical center personnel are possible to devise. However, these studies require careful planning and coordination between clinical trialists, economists, and health services researchers.

Adult↗
PubMed1997

Economic analyses in clinical trials for cooperative groups: operational considerations.

Clinical trials have served as valuable tools for evaluating new therapeutic strategies in the treatment of cancer. Traditionally, new pharmaceuticals and procedures have been appraised on the basis of effectiveness, efficacy, and safety. Recently, economic concerns have become increasingly important when considering treatment strategies for cancer patients. The national emphasis on assessing the costs of health care has focused primarily on the cost-effectiveness of resource allocation. Policy makers are exhibiting greater interest in economic data to supplement clinical data of new procedures and pharmaceutical agents before the approval and widespread application of such methodologies. Clinical trials have increasingly become viewed as a proper setting for such economic analyses. In this paper, we review operational details for carrying out economic analyses of clinical trials being conducted in the cancer cooperative group setting.

Clinical Trials as Topic↗
PubMed1997

Itraconazole plasma and tissue concentrations in the spiny lizard (Sceloporus sp.) following once-daily dosing.

Mycotic infections in reptiles present as primary diseases and as secondary problems in healing wounds and immunocompromised animals. A triazole antimycotic drug, itraconazole is orally active and well distributed and is effective against many common fungal pathogens in humans. To assess plasma and tissues concentrations after oral dosing in reptiles, a 23.5-mg/kg (mean) itraconazole dose was administered orally with a standard food bolus once daily for 3 days to 10 groups of three or four spiny lizards (Sceloporus sp.). On days 0, 1, 2, 3, 4, 6, 9, 12, and 18, group samples of blood, liver, and muscle were collected. Microbiologic assay of itraconazole concentrations was performed on these pooled samples. Values from an elimination graph of the concentrations of area under the curve (377.21 micrograms.hr/ml) and terminal elimination half-life (48.3 hr) were obtained for itraconazole in spiny lizard plasma. Peak itraconazole concentration of 2.48 micrograms/ml was obtained in two half-lives and would be expected to achieve steady state at approximately 3.1 micrograms/ml plasma concentration in 10 days. Peak liver concentration of 4.27 micrograms/ml was attained in 89.95 hr. Muscle concentration did not exceed 0.63 micrograms/ml and declined by 97.3 hr. With this dosing regimen, itraconazole plasma and liver concentrations would persist within reported minimum inhibitory concentrations for many fungal pathogens for 6 days beyond the peak concentration.

Administration, Oral↗
PubMed1997

A comparison of perspectives on prostate cancer: analysis of utility assessments of patients and physicians.

BACKGROUND: Quality-of-life considerations are important in metastatic prostate cancer. In this study, we interviewed physicians and patients about their assessments and expectations on quality of life as metastatic prostate cancer progresses. METHODS: Physicians and patients made utility assessments of three hypothetical health states for metastatic disease using the time trade-off technique. Scores were bounded on a scale from 0.0 (death) to 1.0 (perfect health). RESULTS: Patients rated each of the health states as less desirable than the physicians. CONCLUSIONS: Physicians and patients differ in their perspectives on expected quality of life with metastatic prostate cancer. Our results emphasize the need to assess patients' utilities directly.

Decision Making↗
PubMed1997

Variations in the use of prostate cancer staging tests: results from one NCCN Institution.

Medical care for prostate cancer accounts for as much as $26 billion in medical expenditures. There is debate about whether urologists who treat a large number of cases of prostate cancer use medical resources more efficiently than do urologists who treat fewer patients. This study focuses on one aspect of this debate by addressing the following issue: Are men with prostate cancer more likely to undergo noninvasive staging tests when they are treated by urologists who have higher caseloads than urologists with lower caseloads? Our study identified variations in patterns of ordering staging tests for prostate cancer. The finding supports the use of guidelines. Adherence to the guidelines is likely to be associated with more efficient use of medical resources by physicians with lower caseloads of prostate cancer.

Data Interpretation, Statistical↗
PubMed1996

Geographic variation in the management and outcome of patients with AIDS-related Pneumocystis carinii pneumonia.

Pneumocystis carinii pneumonia (PCP) is one of the most common reasons for the hospitalization of AIDS patients; however, geographic differences in PCP management have not been evaluated previously. Therefore, we abstracted data on socioeconomic characteristics, prior HIV care, severity of illness, timeliness and intensity of in-hospital care, duration of hospitalization, and survival from 1547 randomly selected medical records of patients hospitalized with AIDS-related PCP between 1987 and 1990 at 82 hospitals in Chicago, Los Angeles, Miami, New York City, and Raleigh-Durham, North Carolina. Multivariate regression models were used to assess factors associated with longer hospital stays and increased inpatient mortality. Our results showed that in-hospital mortality ranged from 15% to 27%, bronchoscopy rates from 53% to 70%, and mean length of stay from 14 days to 23 days. Geographic variations in mortality were accounted for by differences in severity of illness at admission, insurance status, and in-hospital patient management. However, significant regional variations in hospital length of stay persisted, even after adjusting for patient demographics, severity of illness, and use of diagnostic and therapeutic care resources.

AIDS-Related Opportunistic Infections↗
PubMed1996

U.S. hospital care for HIV-infected persons and the role of public, private, and Veterans Administration hospitals.

Hospitals are a major provider of medical care for human immunodeficiency virus (HIV)-infected persons. Although utilization and patterns of care profiles in public and private hospitals have been evaluated for acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), one of the most costly and common severe complications of AIDS, information from Veterans Administration (VA) hospitals has not been reported previously. This article reports on inpatient care for PCP patients by obtaining data from VA, private, and public hospitals. Cost and resource utilization data were obtained from reviews of medical records, claims, and provider bills from 26 non-VA hospitals and 18 VA hospitals in 10 cities in the United States. Data on severity of illness, patterns of care, and outcomes for PCP were obtained from medical record reviews from 2,174 PCP cases treated in 82 non-VA and 14 VA hospitals in five U.S. cities. Estimates were made of the average costs and the rates of use of diagnostic tests, anti-PCP medications, and intensive care units for samples of public hospital, private hospital, and VA patients with PCP. With mean charges for a single PCP episode of $14,500 to $16,060, PCP remains one of thea most costly complications of AIDS. Although the severity of PCP illness at admission was greatest at public hospitals, the intensity of care was lowest: for frequency of cytologic diagnosis (48% at public, 62% at VA, and 66% at private hospitals), bronchoscopy (45% at public, 60% at VA, and 66% at private hospitals), and intensive care unit use (11% at public, 22% at VA, and 19% at private hospitals). In-hospital mortality rates for PCP also differed in the three types of hospitals (20% at public, 24% at VA, and 18% at private hospitals). Patterns of PCP care differ among VA, public, and private hospitals. Future studies on the HIV epidemic should include data collected from uniform data sources from VA hospitals, in addition to public and private hospitals, to provide insight on the processes of care and outcomes for HIV-infected persons.

AIDS-Related Opportunistic Infections↗
PubMed1996

Predictors of resource utilization for hospitalized patients with Pneumocystis carinii pneumonia (PCP): a summary of effects from the multi-city study of quality of PCP care.

To determine whether patient and hospital characteristics were significantly associated with variations in Pneumocystis carinii (PCP) care and outcomes, we analyzed the use of diagnostic tests, intensive care units (ICUs), anti-PCP medications for persons hospitalized with human immunodeficiency virus (HIV)-related PCP, and hospital discharge status. We conducted retrospective chart reviews of a cohort of 2,174 patients with PCP hospitalized in 1987-1990. Outcomes included process of care for PCP and in-hospital mortality rates. Persons with PCP who were more severely ill at admission were more likely to have early medical care, to receive care in an intensive care unit, and to die in hospital. After we adjusted for differences in this severity of illness, we noted that Medicaid patients, injection drug users (IDUs), and patients treated at VA or county hospitals were significantly less likely than others to have diagnostic bronchoscopies and that persons covered by Medicaid, with a previous diagnosis of acquired immunodeficiency syndrome (AIDS), who did not receive prior zidovudine (AZT) or who received care in a VA hospital had the highest chances of in-hospital death. Insurance and risk group characteristics, severity of illness, and hospital characteristics appear to be the most important determinants of the intensity and timing of medical care and outcomes among patients hospitalized with PCP.

AIDS-Related Opportunistic Infections↗
PubMed1996

Cost-effective models for flutamide for prostate carcinoma patients: are they helpful to policy makers?

BACKGROUND: More than 50,000 male patients received hormonal therapy for metastatic prostate carcinoma in 1995. Nonsteroidal antiandrogens, such as flutamide, when used in conjunction with castration, are effective in prolonging the time to progression of disease and survival. Only one-third of newly diagnosed patients with metastatic prostate carcinoma receive flutamide. Physicians may be reluctant to prescribe flutamide because of quality of life, toxicity, and cost considerations. METHODS: Physician focus groups evaluated quality of life factors for metastatic prostate cancer. RESULTS: Using quality of life estimates with the National Cancer Institute's (NCI) 0036 clinical trial results, our revised model of flutamide use predicted that, for minimal disease, survival increased by 4.33 quality adjusted months (QAMs) at an incremental cost of $25,000 per quality adjusted life year (QALY) saved and for severe disease, survival increased by 4.11 QAM at a cost of $18,000 per QALY saved. However, if quality of life estimates are used in conjunction with the Prostate Cancer Trialists' Collaborative Group (PCTCG) meta-analysis estimates, survival increased by 2.1 QAM at an incremental cost of $41,000 per QALY saved for persons with severe disease and increased by 2.6 QAM at an incremental cost of $53,700 per QALY saved for persons with minimal disease. CONCLUSIONS: Using NCI 0036 trial data, flutamide has an incremental cost-effectiveness more favorable than most therapies, while estimates based on the PCTCG found a less favorable outcome for the drug. Concerns about out-of-pocket expenditures and efficacy limit flutamide utilization; quality of life considerations are less cogent.

Androgen Antagonists↗