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Biomedical subjects

D A Asch

Publications and source records attributed to D A Asch.

At least 55 records · Page 3Linked to original sources
PubMed1997

Response rates to mail surveys published in medical journals.

OBJECTIVE: The purpose of this study was to characterize response rates for mail surveys published in medical journals; to determine how the response rate among subjects who are typical targets of mail surveys varies; and to evaluate the contribution of several techniques used by investigators to enhance response rates. METHODS: One hundred seventy-eight manuscripts published in 1991, representing 321 distinct mail surveys, were abstracted to determine response rates and survey techniques. In a follow-up mail survey, 113 authors of these manuscripts provided supplementary information. RESULTS: The mean response rate among mail surveys published in medical journals is approximately 60%. However, response rates vary according to subject studied and techniques used. Published surveys of physicians have a mean response rate of only 54%, and those of non-physicians have a mean response rate of 68%. In addition, multivariable models suggest that written reminders provided with a copy of the instrument and telephone reminders are each associated with response rates about 13% higher than surveys that do not use these techniques. Other techniques, such as anonymity and financial incentives, are not associated with higher response rates. CONCLUSIONS: Although several mail survey techniques are associated with higher response rates, response rates to published mail surveys tend to be moderate. However, a survey's response rate is at best an indirect indication of the extent of non-respondent bias. Investigators, journal editors, and readers should devote more attention to assessments of bias, and less to specific response rate thresholds.

Allied Health Personnel↗
PubMed1997

A new instrument for residency program evaluation.

The purpose of the study was to develop a comprehensive program evaluation instrument. Following pilot work with residents, a 69-item instrument consisting of statements with 5-point strongly agree to strongly disagree response options was distributed to 107 residents; 104 responded. Psychometric analyses revealed no ceiling or floor effects; 9 items were deleted. There were three subscales: workload (19 items; alpha = .76); educational environment (29 items; alpha = .72) and lifestyle issues (12 items; alpha = .62). Mean item scores were significantly higher for educational environment (3.53; SD 0.28) than for workload (2.78; SD 0.39) and lifestyle (2.96; SD 0.42). Items with the lowest scores reflected issues that were largely fixable. The 60-item instrument appears to be psychometrically sound, comprehensive, and exportable.

Adult↗
PubMed1997

Euthanasia among US critical care nurses. Practices, attitudes, and social and professional correlates.

OBJECTIVES: The authors sought to identify associations between critical care nurses' self-reported participation in euthanasia, their social and professional characteristics, and their attitudes toward end-of-life care. METHODS: Data were collected through an anonymous mail survey of 1,560 US critical care nurses, of whom 1,139 (73%) responded. Nurses were asked to report whether they had received requests to engage in euthanasia and whether they had engaged in euthanasia. In addition, nurses were asked to respond to items assessing their attitudes toward end-of-life care. RESULTS: Of 852 nurses who identified themselves as practicing exclusively in adult intensive care units, 164 (19%) reported that they had engaged in euthanasia, 650 (76%) reported that they had not engaged in euthanasia, and 38 (4%) could not be classified. Only 30% of respondents believed that euthanasia is unethical. Logistic regression indicated that older nurses, more religious nurses, nurses practicing in cardiac care units, and nurses with less favorable attitudes toward euthanasia were significantly less likely to report having engaged in euthanasia, although the effects of age and religious beliefs appear to have been mediated by attitudes. CONCLUSIONS: These results help explain why some US critical care nurses engaged in euthanasia despite legal and professional prohibitions against it. Because critical care nurses may have a special understanding of the needs of critically ill patients, these results may indicate that current guidelines for end-of-life care are inadequate.

Adult↗
PubMed1997

Are supplementary services provided during methadone maintenance really cost-effective?

OBJECTIVE: Previous research has suggested that support services supplementing methadone maintenance programs vary in their cost-effectiveness. This study examined the cost-effectiveness of varying levels of supplementary support services to determine whether the relative cost-effectiveness of alternative levels of support is sustained over time. METHOD: A group of 100 methadone-maintained opiate users were randomly assigned to three treatment groups receiving different levels of support services during a 24-week clinical trial. One group received methadone treatment with a minimum of counseling, the second received methadone plus more intensive counseling, and the third received methadone plus enhanced counseling, medical, and psychosocial services. The results at the end of the trial period have been published elsewhere. This article reports the results of an analysis at a 6-month follow-up. RESULTS: The follow-up analysis reaffirmed the preliminary findings that the methadone plus counseling level provided the most cost-effective implementation of the treatment program. At 12 months, the annual cost per abstinent client was $16,485, $9,804, and $11,818 for the low, intermediate, and high levels of support, respectively. Abstinence rates were highest, but modestly so, for the group receiving the high-intensity, high-cost methadone with enhanced services intervention. CONCLUSIONS: This study suggests that large amounts of support to methadone-maintained clients are not cost-effective, but it also demonstrates that moderate amounts of support are better than minimal amounts. As funding for these programs is reduced, these findings suggest a floor below which supplementary support should not fall.

Adult↗
PubMed1997

Costs, true costs, and whose costs in economic analyses in medicine?

Cost-effectiveness analyses of clinical practices are becoming more common in the development of health policy. However, such analyses can be based on misconceptions and flawed assumptions, leading to flawed policies. We argue that such is the case with the recent recommendations for routine measurement of umbilical cord gases at delivery, a policy based on the assumption that this clinical strategy will pay for itself by reduced malpractice awards. As we demonstrate, this argument reflects the physician's perspective, not that of society or of patients. It also ignores the fact that malpractice awards are largely transfer payments, not cost of healthcare.

Blood Gas Analysis↗
PubMed1997

How preliminary data affect people's stated willingness to enter a hypothetical randomized controlled trial.

PURPOSE: To explore how preliminary trial data affect the general public's stated willingness to enter a randomized clinical trial. METHODS: We asked 165 prospective jurors to imagine that their physicians wanted them to enroll in a clinical trial. We then presented them with scenarios portraying preliminary trial results--for example, 9 out of 10 patients get better with drug A and 5 out of 10 get better with drug B--and asked after each scenario, whether they would choose to be part of the trial. We designed the scenarios to test how stated willingness to enter the trial would be influenced by: 1) the difference in effectiveness of the 2 treatments based on the patients enrolled thus far; and 2) by the chance that the difference in effectiveness was random (i.e., the P value). The subjects' willingness to enter the trial at various decision points was analyzed using logistic regression. RESULTS: Fewer subjects were willing to enter the trial as preliminary data indicated either an increasing difference in the effectiveness of the two treatments or an increasing statistical significance of that difference. For example 75% of subjects were willing to enter the research trial before any preliminary data were presented, but this number fell to 49% when subjects were presented with preliminary data showing that 9 out of 10 patients improved with one treatment and 5 out of 10 with the other. Multivariable logistic regression revealed that higher P values (odds ratio = 4.29; P < 0.001; 95% CI: 2.22-8.28) and smaller differences in effectiveness (odds ratio = 0.02; P < 0.001; 95% CI: 0.00-0.07) implicit in preliminary data presented to subjects made subjects less likely to agree to enter clinical trials. After adjustment for other relevant variables, male gender was associated with increased willingness to enter the trial. CONCLUSION: A subjects' willingness to enter the hypothetical trial was influenced by preliminary data. Fewer subjects were willing to enter the trial as the differences in benefit between 2 treatment groups increased. However, the majority of subjects were willing to enter the hypothetical trial even when preliminary evidence strongly favored one treatment over another. Given the importance of informed consent in entering patients in clinical trials, these results should be confirmed in actual trial settings.

Adult↗
PubMed1996

The role of critical care nurses in euthanasia and assisted suicide.

BACKGROUND: Euthanasia and assisted suicide has received considerable attention recently in medical literature, public discussion, and proposed state legislation. Almost all the discussion in this area has focused on the role of physicians. However, nurses--especially critical care nurses--may be in a special position to understand the wishes of patients and to act on this understanding. METHODS: I mailed a survey to 1600 critical care nurses in the United States, asking them to describe anonymously any requests from patients, family members or others acting for patients (surrogates), or physicians to perform euthanasia or assisted suicide, as well as their own practices. RESULTS: Of the 1139 nurses who responded (71 percent), 852 said they practices exclusively in intensive care units for adults in the United States. Of these 852 nurses, 141 (17 percent) reported that they had received requests from patients or family members to perform euthanasia or assist in suicide; 129 (16 percent of those for whom data were available) reported that they had engaged in euthanasia; and an additional 36 (4 percent) reported that they had hastened a patient's death by only pretending to provide life-sustaining treatment ordered by a physician. Some nurses reported engaging in these practices without the request for advance knowledge of physicians or others. The method of euthanasia most commonly described was the administration of a high dose of an opiate to a terminally ill patient. CONCLUSIONS: As public debate continues about euthanasia and assisted suicide, some critical care nurses in the United States are engaging in the practice.

Adult↗
PubMed1996

Cost-effectiveness analysis in a setting of budget constraints--is it equitable?

BACKGROUND: One of the promises of cost-effective analysis is that it can demonstrate how to maximize health benefits attainable within a specific limited budget. Many people argue, however, that when there are budget limitations, the use of cost-effectiveness analysis leads to health care policies that are inequitable. METHODS: We asked prospective jurors, medical ethicists, and experts in medical decision making to choose between two screening tests for a population at low risk for colon cancer. One test was more cost effective than the other but because of budget constraints was too expensive to be given to everyone in the population. With the use of the more effective test for only half the population, 1100 lives could be saved at the same cost as that of saving 1000 lives with the use of the less effective test for the entire population. RESULTS: Fifty-six percent of the prospective jurors, 53 percent of the medical ethicists, and 41 percent of the experts in medical decision making recommended offering the less effective screening test to everyone, even though 100 more lives would have been saved by offering the more expensive test to only a portion of the population. Most of the study participants justified this recommendation on the basis of equity. A smaller number stated either that it was not politically feasible to offer a test to only half the population or that the additional benefit of the more expensive test (100 more lives saved) was too small to justify offering it to only a portion of the public. CONCLUSIONS: People place greater importance on equity than is reflected by cost-effectiveness analysis. Even many experts in medical decision making -- those often responsible for conducting cost-effectiveness analyses -- expressed discomfort with some of its implications. Basing health care priorities on cost effectiveness may not be possible without incorporating explicit considerations of equity into cost-effectiveness analyses or the process used to develop health care policies on the basis of such analyses.

Colonic Neoplasms↗
PubMed1996

Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions.

OBJECTIVES: To describe a new quality assessment method used to classify the preventability of hospitalization in terms of patient, clinician, or system factors. DESIGN: The instrument was developed in two phases. Phase 1 was a prospective comparison of admitting residents' and their attending physicians' classifications of the perceived preventability of consecutive admissions to one Veterans Affairs Medical Center (VAMC) excluding admissions to the intensive care unit (ICU). In phase 2, a panel of 10 physicians rated 811 abstracted records of readmissions from nine VAMCs. SETTING: Nine VAMCs across the United States with varying degrees of university hospital affiliation. PATIENTS: Phase 1, 156 patients admitted to the general medicine service at the Durham VAMC. Phase 2, 514 patients accounting for 811 readmissions within 6 months of a general medicine service discharge at nine VAMCs. MEASUREMENTS AND MAIN RESULTS: Physicians used a checklist to record the reason for hospitalization, the preventability of the hospitalization, and, if preventable, a reason defining preventability, which was classified in terms of system, clinician, and patient factors. In phase 2, two physician panelists assessed preventability for each chart. When two panelists disagreed on the preventability of hospitalization, a third panelist, blind to the original assessments, rated the chart. In phase 1, residents and attending physicians rated 33% and 34% of admissions as preventable (kappa = 0.41), respectively. In phase 2, 277 (34%) of 811 readmissions were deemed preventable. Intraobserver accuracy for the assessment of preventability was 96% (kappa = 0.89). interobserver accuracy was 73% (kappa = 0.43). Hospital system factors accounted for 37% of preventable readmissions, clinician factors for 38%, and patient factors for 21%. The nine hospitals differed markedly in their profile of reasons for preventable readmissions (p = .005). CONCLUSIONS: Using a new method of determining the preventability of hospitalizations, we identified several factors that might avert hospitalizations. Focusing efforts to identify preventable hospitalizations may yield better methods for managing patients' total health care needs; however, the content of those efforts will vary by institution.

Adult↗
PubMed1996

Cognitive processes and the decisions of some parents to forego pertussis vaccination for their children.

Public health analyses suggest that, in spite of the possibility that pertussis vaccine may cause rare cases of neurological injury, catastrophic risks to individual children are lower if they are vaccinated. A number of parents, however, choose not to vaccinate their children. The purpose of this study was to investigate the decision processes of some parents who choose to vaccinate and some parents who choose not to do so. Surveys were mailed to 500 randomly selected subscribers of Mothering magazine. Two hundred and ninety-four completed questionnaires were returned (59%). In addition to well-recognized factors in vaccination decisions, perceived dangers of the vaccine, and of the disease and susceptibility to the disease, several cognitive processes not previously considered in vaccination decision studies were found to be important predictors in this population of parents: perceived ability to control children's susceptibility to the disease and the outcome of the disease; ambiguity or doubts about the reliability of vaccine information; a preference for errors of omission over errors of commission; and recognition that if many other children are vaccinated, the risk to unvaccinated children may be lowered. Although perhaps most cases of undervaccination for pertussis reflect more general problems of health care access, some parents choose to forego vaccination for their children for other reasons. Traditional risk-benefit arguments alone will be unlikely to persuade these parents to reassess their decisions. Efforts to increase childhood vaccination must incorporate an understanding of the cognitive processes that help drive these decisions.

Adult↗
PubMed1996

Why do physicians prefer to withdraw some forms of life support over others? Intrinsic attributes of life-sustaining treatments are associated with physicians' preferences.

Some physicians caring for critically ill patients have preferences for withdrawing some forms of life support over others, even after the decision to withdraw life support has already been made. Past research has attempted to explain these preferences by variations in clinical circumstances. The authors wondered whether differences in the forms of life support themselves might be important, and whether these differences would reveal implicit goals that physicians attempt to achieve. Four hundred fifty-six university-affiliated internists were surveyed and their rank-ordered preferences for withdrawing eight different forms of life support were assessed. The authors then sought to explain these preferences on the basis of intrinsic characteristics of the eight forms of life support determined by an expert panel of critical care physicians. In general, the physicians studied prefer to withdraw forms of life support that are scarce, expensive, invasive, artificial, unnatural, emotionally taxing, high technology, and rapidly fatal when withdrawn. They prefer not to withdraw forms of therapy that require continuous rather than intermittent administration, and forms of therapy that cause pain when withdrawn. Even when a decision has been made to withdraw life-sustaining treatment from a patient, many physicians have preferences for the manner in which this is accomplished. These preferences may reflect perceived intrinsic characteristics of different forms of life support that are consistent across physicians.

Adult↗
PubMed1996

Individual choice in spending accounts. Can we rely on employees to choose well?

Flexible spending accounts (FSA) represent a current health care financing tool that may become an important component of incremental health care reform. Because FSAs require employees to make financial contributions based on anticipated health care needs, contribution decisions are likely to be subject to many of the errors made in other insurance decisions. The authors analyzed the benefits selections, benefits forms completion, and FSA contribution levels of approximately 9,500 employees of the University of Pennsylvania from 1987 to 1992. Default and repeat choice trends characterize the completion of benefits forms and the reselection of health insurance options by employees. Despite the economic benefits of contributing to an FSA, only 14% of employees contributed in any one year and 73% never made a contribution. Multivariate models of these contributions fail to demonstrate the importance of what ought to be relevant influences in contribution decisions (for example, age, income, family status, or underlying health insurance). Whereas most FSA decisions are characterized by default contributions of $0, employees who contribute in one year are most likely to contribute exactly the same amount the next year, even when other circumstances change. The pervasiveness of these patterns raises concerns that health care reform plans that rely on financial incentives at the consumer level--for example, proposed medical saving accounts--will be inefficient.

Choice Behavior↗
PubMed1996

Genetic screening for reproductive planning: methodological and conceptual issues in policy analysis.

OBJECTIVES: This paper explores several critical assumptions and methodological issues arising in cost-effectiveness analyses of genetic screening strategies in the reproductive setting. METHODS: Seven issues that arose in the development of a decision analysis of alternative strategies for cystic fibrosis carrier screening are discussed. Each of these issues required a choice in technique. RESULTS: The presentations of these analyses frequently mask underlying assumptions and methodological choices. Often there is no best choice. In the case of genetic screening in the reproductive setting, these underlying issues often touch on deeply felt human values. CONCLUSIONS: Space limitations for published papers often preclude explaining such choices in detail; yet these decisions determine the way the results should be interpreted. Those who develop these analyses need to make sure that the implications of important assumptions are understood by the clinicians who will use them. At the same time, clinicians need to enhance their understanding of what these models truly mean and how they address underlying clinical, ethical, and economic issues.

Cystic Fibrosis↗
PubMed1996

The role of employee flexible spending accounts in health care financing.

Employee flexible spending accounts for health care represent one component of the current health care financing system that merits serious reform. These accounts create a system of undesirable incentives, force employees and employers to take complicated gambles, reduce tax revenues, and fail to meet their purported policy objectives. This paper describes shortcomings in these accounts from both a theoretical and an empirical perspective. Some proposed alternatives; including medical spending accounts and zero balance accounts, resolve many of these concerns but not all of them.

Accounting↗
PubMed1996

Use of a coded postcard to maintain anonymity in a highly sensitive mail survey: cost, response rates, and bias.

In a survey about euthanasia, 1,600 critical care nurses were randomly assigned to receive either three complete, anonymous mailings of the questionnaire or, with each mailing, a coded postcard to be returned separately from the questionnaire to reduce subsequent mailings to previous responders. The response rate in these two groups was 76.5% [95% confidence interval (CI) = 73.6-79.4%] and 69% (95% CI = 65.7-72.4%), respectively. The two strategies yielded similar responses, and costs were much lower for the postcard group. Using coded postcards to be returned separately from completed instruments appears to lower the response rate to anonymous mail surveys, but it also lowers cost and may not introduce additional bias.

Bias↗