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Biomedical subjects

C M Callahan

Publications and source records attributed to C M Callahan.

At least 55 records · Page 3Linked to original sources
PubMed1995

Health services use and mortality among older primary care patients with alcoholism.

OBJECTIVE: To describe the prevalence of alcoholism in an older primary care population and to compare rates of health services use and mortality among those with and those without evidence of alcoholism. DESIGN: Baseline screening for alcoholism using the CAGE questionnaire and longitudinal assessment of health services use and mortality using an electronic medical record system. SETTING: An academic primary care group practice at an urban ambulatory care clinic. PATIENTS: A total of 3954 patients aged 60 and older who completed the CAGE alcoholism screening questionnaire during routine office visits. MAIN OUTCOME MEASURES: Comorbidity, preventive health services use, hospital episodes and length of stay, emergency room visits, ambulatory care visits, total outpatient charges, and mortality. RESULTS: The prevalence of current evidence of alcoholism, as defined by a CAGE score > or = 2 and alcohol use in the previous 12 months, was 10.6%. Patients with evidence of alcoholism were younger (66.2 vs 68.3 years), had fewer years of education (8.4 vs 9.1), were more likely to be male (65.8 vs 27.2%), black (71.2 vs 62.6%), smokers (40.4 vs 26.3%), and malnourished (32.5 vs 26.3%). Patients with alcoholism were more likely to have a diagnosis of obstructive lung disease (22.9 vs 18.3%), injuries (14.2 vs 8.3%), and gout (6.7 vs 2.9%) and less likely to have a diagnosis of hypertension (56.9 vs 61.8%), arthritis (23.3 vs 29.3%), and diabetes (15.9 vs 23.3%). Among those with evidence of alcoholism, 41.6% had a diagnosis of alcoholism in their outpatient medical record. Rates of completion of preventive health services did not differ between the two groups, and there was no difference in the number of ambulatory care visits, emergency room visits, or total outpatient charges. Patients with evidence of alcoholism were more likely to be hospitalized (21.5 vs 16.9%) and more likely to die within 2 years (10.6% vs 6.3%). CONCLUSIONS: One of 10 older patients in this primary care practice had current evidence of alcoholism, fewer than half of whom had documentation of alcohol abuse in their medical records. These patients were more likely to be hospitalized and more likely to die but did not consume a greater amount of outpatient resources. Further research is needed to determine if interventions to reduce alcohol use would also reduce excess hospitalizations and mortality among these older patients.

Age Distribution↗
PubMed1994

Patient outcomes following tricompartmental total knee replacement. A meta-analysis.

OBJECTIVE: To provide estimates of patient outcomes following tricompartmental knee replacement and to examine variation in outcomes due to patient and prosthesis characteristics. DATA SOURCES: English-language articles identified through a computerized literature search and bibliography review. STUDY SELECTION: Studies were included if they enrolled 10 or more patients at the time of initial knee replacement and measured patient outcomes using a global knee-rating scale. DATA EXTRACTION: Each study was subjected to a blinded qualitative assessment and unblinded abstraction of patient characteristics, surgical techniques, and outcomes. DATA SYNTHESIS: A total of 130 studies reporting patient outcomes on 154 cohorts satisfied inclusion criteria. The total number of enrolled patients was 9879 with a mean enrollment of 64.1 patients. The mean follow-up was 4.1 years. The mean patient age was 65.0 years, 71.7% of patients were women, 62.6% had osteoarthritis, and 26.6% underwent bilateral knee replacement. Global rating scale scores improved by 100% for the typical enrolled patient, and 89.3% of patients reported good or excellent outcomes. Anatomic classification of the prosthesis, percentage of enrolled patients with osteoarthritis, publication year, and number of enrolled patients explained 27% of the variation in reported mean postoperative global rating scale scores. The weighted mean complication rate was 18.1%, and the mean mortality rate per year of follow-up was 1.5%. The overall rate of revision during 4.1 years was 3.8%. CONCLUSIONS: Tricompartmental knee replacement was a safe and effective procedure for the patients reported in these studies. The knee pathology and the type of prosthesis were significant predictors of outcomes. Limitations in the reporting style of these articles severely constrain the ability to explore variation in outcomes due to study, patient, or prosthesis characteristics and restrict their generalizability.

Aged↗
PubMed1994

How residents spend their time in clinic and the effects of clerical support.

The authors conducted a time study of residents in clinic to determine the effects of providing clerical assistance. The residents recorded their activities at 5-minute intervals at baseline and six months after hiring three clerical assistants. Before and after introduction of the clerical assistants, approximately 40% of the time was devoted to direct interaction with patients. Statistically significant improvements were observed in the availability of medical records (89% vs 100%) and the time spent looking up test results (5% vs 3% of the clinic time). The residents felt the clerical assistants greatly improved their clinic experience and the quality of patient care.

Allied Health Personnel↗
PubMed1994

Anticoagulation therapy and primary care internal medicine: a nurse practitioner model for combined clinical science.

The anticoagulation clinics at the University of Virginia Health Sciences Center and the University of California at Davis Medical Center are nurse-practitioner-operated, are affiliated with the general medicine clinic, and rely on portable prothrombin time (PT) monitors that use whole blood and provide timely as well as accurate results reported in PT seconds or as the international normalized ratio (INR). On-site PT/INR testing at these clinics simplifies anticoagulation, mandates direct patient contact, and facilitates primary as well as comprehensive care for patients requiring multispecialty services in large tertiary care centers. Encounters are relatively brief, averaging 19 minutes; 72% of the encounter time involves anticoagulation care and 28% involves primary care. Anticoagulation results using portable PT/INR monitors are safe and accurate based on comparisons with results from clinics relying on standard instruments.

Academic Medical Centers↗
PubMed1994

A computerized intervention to improve timing of outpatient follow-up: a multicenter randomized trial in patients treated with warfarin. National Consortium of Anticoagulation Clinics.

OBJECTIVE: To evaluate a computerized scheduling model that employs nonlinear optimization to recommend optimal follow-up intervals for patients taking warfarin. DESIGN: Randomized trial. SETTING: 5 anticoagulation clinics. PATIENTS/PARTICIPANTS: 620 patients expected to receive warfarin for > or = 6 weeks. INTERVENTIONS: Computer-generated recommendations for scheduling the next visit were presented to or withheld from practitioners. MEASUREMENTS AND MAIN RESULTS: The main outcome measures were the follow-up interval scheduled by the provider, the interval at which the patient actually returned to clinic, and the quality of anticoagulation control (computed as the absolute difference between the measured and target prothrombin times [PTRs] or international normalized ratios [INRs]). Follow-up intervals scheduled for the patients whose practitioners received computer-generated recommendations were significantly longer than those for control patients (mean, 4.4 vs 3.5 weeks, p < 0.001), despite the fact that the practitioners modified the suggested return interval by > 1 week on 40% of the visits. The interval at which the intervention group actually returned to clinic was also longer (mean, 4.4 vs 4.1 weeks, p < 0.05), even though the control patients tended to return at longer intervals than were scheduled by their practitioners. Control of anticoagulation was nearly the same among experimental and control patients. Life-threatening complications occurred in the care of three experimental patients and one control patient, while other serious complications occurred in the care of 16 experimental patients and 17 control patients. CONCLUSIONS: Recommendations based on nonlinear optimization prompted clinicians to schedule less frequent follow-up for patients taking warfarin, with no deterioration in anticoagulation control. This approach to scheduling can potentially reduce utilization while maintaining quality of care for patients who require long-term monitoring.

Appointments and Schedules↗
PubMed1994

Global rating systems used in assessing knee arthroplasty outcomes.

Global, aggregated knee rating systems are commonly used to assess patient outcomes following knee arthroplasty. In this study, the authors performed a systematic literature search and found that 17% of the English-language studies addressing primary knee arthroplasty reported on patient outcomes following the procedure using a standardized global rating system. The authors describe, in detail, the rating systems' development and format. This study found 34 different rating systems represented in the literature from 1972 to 1992. Great variability was found in the rating systems' design and utilization. Additionally, these condition-specific, physician-based rating systems did not have documented studies demonstrating their reliability or validity. Future research will need to address the issues of selecting and aggregating outcome measures and of deriving any necessary weighting schemes. The ability of researchers to compare patient outcomes across studies will be enhanced when there is consistency in reported outcome measures.

Humans↗
PubMed1994

Depression in late life: the use of clinical characteristics to focus screening efforts.

BACKGROUND: The objective of the study was to identify clinical characteristics associated with depressive symptoms in late life so that screening could focus on elderly patients most likely to benefit from further evaluation. METHODS: We used cross-sectional screening for significant symptoms of depression using the Center for Epidemiologic Studies Depression scale and identification of patients' clinical characteristics from patient interviews and a computerized medical record. The setting was an academic primary care group practice at an urban ambulatory care center. Participants were 1,633 consecutively consenting patients aged 60 and older who visited the center between January and August 1991. Mean age was 70 years; 72% were women, 32% were White, 47% had less than 8 years of education, and 7% had no health insurance. RESULTS: There were 251 (15%) patients with significant symptoms of depression. Antidepressants were prescribed to 1 in 7 patients with such symptoms, with amitriptyline being the most commonly prescribed. Bivariate analyses indicated that patients with significant symptoms of depression were more likely to be White, female, without health insurance, and were more likely to have probable alcoholism, mild cognitive loss, and to receive narcotics, histamine H2 antagonists, and/or benzodiazepines. Depressive symptoms were not significantly correlated with age, education, income, or chronic medical conditions. CONCLUSIONS: Significant symptoms of depression were common and correlated with several readily available clinical variables. However, these variables lack sufficient discriminatory power to allow for the selective screening of elderly patients most likely to suffer from symptoms of depression. Thus, formal screening for depression among all elderly patients in primary care may be necessary to improve the recognition of this morbid illness.

Adrenergic beta-Antagonists↗
PubMed1994

Hospital resource consumption among older adults: a prospective analysis of episodes, length of stay, and charges over a seven-year period.

After linking their administrative records and interview data, the consumption of Medicare-reimbursed hospital resources during 1984 through 1990 by the 7,527 LSOA respondents was prospectively assessed using a two-part design. First, logistic regression was used to model whether a hospital episode occurred. Second, among those having had hospital episodes, OLS regression was used to model the number of episodes, as well as the natural logarithms of the total length of stay and the total charges. The risk of hospitalization was mostly associated with being male, prior hospital and physician utilization, and lower body limitations. Among those hospitalized: (a) greater numbers of episodes were mostly associated with prior hospital and physician utilization, and poorer perceived health; (b) longer lengths of stay were mostly associated with prior hospital and physician utilization, and poorer perceived health; and, (c) higher charges were mostly associated with population density, poorer perceived health, and prior physician and hospital utilization. Decedents consistently consumed substantially more hospital resources than survivors.

Activities of Daily Living↗
PubMed1994

The effect of gender and race on the measurement properties of the CES-D in older adults.

Having observed a three-fold difference in the prevalence of significant symptoms of depression among four race-gender groups of elderly adults attending an urban primary care practice, we investigated the extent to which these differences might be explained by variability in the measurement properties of the Centers for Epidemiologic Studies depression scale (CES-D). Although the internal consistency of the CES-D was acceptable for all groups, 5% of our patients were excluded for inability to complete the minimum required number of CES-D items, and nearly 40% of patients required response imputation for the allowable one to four items that they could not answer. Imputation was most frequently required for items tapping positive affect. Principal components factor analysis was performed separately for respondents answering all items and for respondents with imputed values. In both analyses we found important race-gender differences in factor structure. Moreover, the factor structure for those with imputed values was markedly different from that of respondents answering all items, including a dissolution of the positive affect dimension. Neither the race-gender differences in factor structure nor the differences among those with and without imputed data were resolved by eliminating respondents with poor education, cognitive impairment, or alcoholism, or by varying the assumptions for data imputation. However, the disparities in factor structure were essentially resolved by eliminating five CES-D items, suggesting the need to modify the CES-D in populations like ours. Although eliminating these five items results in a more pure factor structure, it does not resolve the differences in prevalence of depressive symptoms. These differences may, however, be partially due to differential response tendencies among the race-gender groups.

Black or African American↗
PubMed1994

Longitudinal study of depression and health services use among elderly primary care patients.

OBJECTIVE: To describe the prevalence and 9-month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use. DESIGN: Prospective study of depressive symptoms as measured by the Center for Epidemiologic Studies Depression (CES-D) scale and identification of patients' outpatient health services use through an electronic medical record system. SETTING: An academic primary care group practice at an urban ambulatory care clinic. PATIENTS/PARTICIPANTS: 1711 patients aged 60 and older who completed the CES-D at baseline and 9 months later; 935 of these patients also completed the CES-D at 6 months. MEASUREMENT AND MAIN RESULTS: The prevalence of significant symptoms of depression (CES-D > or = 16) was 17.1% at baseline and 18.8% at 9 months; 26.8% of patients exceeded the threshold on the CES-D either at baseline or 9 months, and the 9-month incidence was 11.7%. Among the patients re-interviewed at both 6 and 9 months, the 6-month incidence was 12%, and the incidence between the 6- and 9-month assessments was 10%. Of the 292 patients with depression at baseline, 140 (47.6%) remained depressed at the 9-month follow-up. Baseline and 6-month CES-D score, in addition to perceived health at 6 months, explained 45% of the variance in the 9-month CES-D score. Patients above the threshold on the CES-D at any time were more likely to rate their health as fair or poor (69.8% vs 43.7%) and more likely to have an emergency room visit (40.4% vs 29.4%). These patients also had 38% more outpatient visits (7.7 vs 5.6) and 61% higher total outpatient charges ($1209 vs $751) than patients who never exceeded the CES-D threshold over the 9-month window (all P values < 0.01). CONCLUSIONS: Depressive symptoms were frequent and often persistent in this patient population. We identified patterns of oscillating severity of symptoms within individuals but relatively stable incidence and prevalence rates over a 9-month period. Patients who exceeded the threshold on the CES-D at any time during the study had significantly greater health services use and poorer perceived health.

Aged↗
PubMed1994

Improving treatment of late life depression in primary care: a randomized clinical trial.

OBJECTIVE: Facilitate primary care physicians' compliance with recommended standards of care for late life depression by reducing barriers to recognition and treatment. DESIGN: Randomized controlled clinical trial of physician-targeted interventions. SETTING: Academic primary care group practice caring for an urban, medically indigent patient population. PATIENTS/PARTICIPANTS: Patients aged 60 and older who exceeded the threshold on the Centers for Epidemiologic Studies Depression Scale (CES-D) and the Hamilton Depression Rating Scale (HAM-D) and their primary care physicians. INTERVENTION: Physicians of intervention patients were provided with patient-specific treatment recommendations during 3 special visits scheduled specifically to address the patient's symptoms of depression. In general, physicians were encouraged to establish a diagnosis of depression and educate their patient about the diagnosis, discontinue medications that can cause or exacerbate depressive symptoms, initiate antidepressants when appropriate, and consider referral to psychiatry. Guidelines for prescribing antidepressants were provided. Control physicians received no intervention, and control patients received usual care. MAIN OUTCOME MEASURES: Frequency of recording a depression diagnosis, stopping medications associated with depression, initiating antidepressant medication, and psychiatry referral; mean changes in HAM-D and Sickness Impact Profile (SIP) scores. RESULTS: One hundred three physicians and 175 patients were involved in the clinical trial. Physicians of intervention patients were more likely to diagnose depression and prescribe antidepressants (P < 0.01). There were no differences between the groups in the frequency of stopping medications associated with depression or referrals to psychiatry. Medications with the strongest cause and effect relationship to depression were infrequently used in this cohort of patients. Although both groups showed improvement in HAM-D and SIP scores, we were unable to demonstrate significant differences in HAM-D or SIP scores between the 2 groups. CONCLUSIONS: Intensive screening and feedback of patient-specific treatment recommendations increased the recognition and treatment of late life depression by primary care physicians. However, we were unable to demonstrate significant improvement in depression or disability severity among intervention patients despite the informational support provided to their physicians. Efforts to improve the functional status of these patients may require more integrated interventions and more aggressive attempts to target psychosocial stressors traditionally outside the purview of primary care.

Aged↗
PubMed1993

Youth in detention and handguns.

The objective of this work was to describe the frequency and correlates of handgun ownership and firearm injury experiences among youth in a detention facility. A convenience sample of 89 males detained in the King County Youth Services Center, a short-term holding facility, voluntarily completed an anonymous survey. Results showed that 59% of the youth reported owning a handgun. Firearm experiences included carrying a gun to school (46%); firing at another person (68% of handgun owners); firearm injury to self (27%); death of a close friend or family member to firearm homicide or suicide (35%). Personal safety far exceeded recreational use of guns as motivation for self-arming (52% versus 4%). Handgun ownership was more common among youth who reported problem behaviors. Adjusting for age and controlling for covariation of the problem behaviors, gang membership [odds ratio (OR) 6.7; 95% confidence interval (CI) 1.7-26.1], committing assault and battery (OR 7.7; 95% CI 2.2-26.8) and selling drugs (OR 3.6; 95% CI 0.99-13.4) were associated with handgun ownership. Our conclusion was that firearm experiences for youth in detention pose health risks equal to or far exceeding other high-risk behaviors in this population.

Adolescent↗
PubMed1993

Changes in functional status and the risks of subsequent nursing home placement and death.

This research examined the effects of changes in functional status on the risks for subsequent nursing home placement and death. Using data on the 3,646 baseline self-respondents to the Longitudinal Study on Aging who were successfully reinterviewed at the first follow-up (1986) and who were not in a nursing home at that time, a two-stage analysis was conducted. First, the risks for nursing home placement and death between the 1986 and 1988 follow-ups were modeled based on a static set of baseline (1984) indicators. Measures of the change in functional health status between baseline and first follow-up were then introduced to determine whether such change had significant net effects and enhanced model fit. Substantial improvement in model fit was obtained for both outcomes. The risk of nursing home placement was associated with deterioration in advanced (i.e., cognitive) ADLs and lower body function. Deterioration in basic ADLs and lower body function was associated with the risk of dying.

Activities of Daily Living↗