Search PubMed⌕ Search

Biomedical subjects

D A Redelmeier

Publications and source records attributed to D A Redelmeier.

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

Charges for medical care at different hospitals.

BACKGROUND: The United States has a high proportion of people without health insurance (15%) and a low proportion of people without employment (5%), resulting in millions who lack insurance but have some ability to pay. We tested whether hospitals charge similar prices for well-specified elective services to individuals paying out-of-pocket for medical care. METHODS: We surveyed the 2 largest general hospitals from every large city (population >500 000) in the United States and Canada. At each hospital we evaluated 5 diagnostic, 7 therapeutic, and 3 nonclinical services to determine the total charge to patients who pay directly. RESULTS: Overall, 66 hospitals were included (average, 758 beds; not-for-profit, 97% [n = 64]; teaching, 80% [n = 53]). The range in charges was substantial; for example, a screening mammogram was $40 at one hospital in Los Angeles, Calif, and $346 at one hospital in Quebec City. Charges for a screening mammogram were relatively stable between 1996 and 1997 (r=0.79; 95% confidence interval, 0.68-0.87) and unrelated to the hospital's location or charges for other services. The relative amount of variation in charges was similar for high-priced and low-priced services, similar for diagnostic and therapeutic services, and similar for the United States and Canada. CONCLUSIONS: Charges for the same hospital service vary substantially. Greater visibility might reduce some variation by bringing outliers into closer scrutiny. Patients seeking care and paying out-of-pocket could save financially by comparison shopping.

Canada↗
PubMed2000

Carotid endarterectomy for women and men.

Carotid endarterectomy is the standard of care for people with severe symptomatic carotid stenosis. We analyzed population administrative data and clinical trial data to determine whether sex differences exist in the use and outcomes of this surgical procedure. We studied patients in Ontario who underwent carotid endarterectomy between 1982 and 1994 (n = 12,949) and patients with severe carotid stenosis who were enrolled in two randomized trials of endarterectomy (n = 1646). We compared the proportion of men and women who underwent carotid endarterectomy in each group, over time, and after adjustment for demographic factors. Men were twice as likely as women to receive carotid endarterectomy in the administrative analysis (65% versus 35%, p < 0.001) and in the clinical trial analysis (70% versus 30%, p < 0.001). The relatively lower use in women was consistent in every age group and in every year studied. Men in the administrative database were somewhat less likely than women to die or be institutionalized after surgery (5% versus 6%, p = 0.007). Men in the clinical trial database were also less likely than women to experience perioperative stroke or death, although the results were not statistically significant (6% versus 7%, p = 0.32). Patients who were assigned to surgical therapy, compared with those assigned to medical therapy, had a significant decrease in the risk of adverse events at 1 year, and the net benefit appeared similar in women and men. Carotid endarterectomy is performed relatively infrequently on women despite their similar lifetime burden of disease and similar short-term perioperative risks compared with men.

Age Distribution↗
PubMed2000

Effects of trauma cases on the care of patients who have chest pain in an emergency department.

BACKGROUND: Trauma victims sometimes take priority over other patients because their injuries require immediate treatment. We examined whether such demands might compromise the care of patients with acute chest pain in an emergency department. METHODS: Case patients were patients with chest pain who arrived immediately after a major trauma victim. Control patients were patients with chest pain who arrived on a preceding day when no trauma patient was in the emergency department. RESULTS: Case and control patients were similar in mean age (60 vs. 60 years, p = not significant), percentage male (47 vs. 53%, p = not significant) and percentage ultimately diagnosed as cardiac (29 vs. 33%, p = not significant). Case patients spent an average of 81 minutes longer in the emergency department (297 vs. 216 minutes, p = 0.009). Similar delays were observed in the subgroup of patients ultimately diagnosed as cardiac (309 vs. 217 minutes, p = 0.029). Case patients had generally worse scores on the American College of Emergency Physicians Quality Assurance Index (75.6 vs. 84.4, p = 0.027), particularly those ultimately diagnosed as cardiac (60.3 vs. 85.1, p = 0.002). The common failures were failure to administer aspirin, undertreatment of ongoing pain, and failure to provide instructions regarding treatment and need to return. CONCLUSION: Trauma victims can decrease the timeliness and quality of care for other patients who have potentially life-threatening conditions in an emergency department.

Canada↗
PubMed2000

Continuous electrocardiographic monitoring and cardiac arrest outcomes in 8,932 telemetry ward patients.

OBJECTIVE: To estimate the benefit of routine electrocardiographic (ECG) telemetry monitoring on in-hospital cardiac arrest survival. METHODS: In a tertiary care hospital, all telemetry ward admissions and cardiac arrests occurring over a five-year period were reviewed. Ward location and survival to discharge were determined for all patients outside of critical care areas. RESULTS: During the study period, 8,932 patients were admitted to the telemetry ward, and 20 suffered cardiac arrest (0.2%; 95% CI = 0.1 to 0.3). Telemetry monitors signaled the onset of cardiac arrest in only 56% (95% CI = 30 to 80) of monitored arrests. Three patients survived to discharge, and in two of these three patients the arrest onset was signaled by the monitor. This yields a monitor-signaled survival rate among telemetry ward patients of 0.02% (95% CI = 0 to 0.05). All survivors suffered significant arrhythmias prior to their cardiac arrests. CONCLUSIONS: Cardiac arrest is an uncommon event among telemetry ward patients, and monitor-signaled survivors are extremely rare. Routine telemetry offers little cardiac arrest survival benefit to most monitored patients, and a more selective policy for telemetry use might safely avoid ECG monitoring for many patients.

Aged↗
PubMed2000

Diffuse pulmonary arteriovenous malformations: characteristics and prognosis.

OBJECTIVE: To study the clinical characteristics and prognosis of patients with diffuse pulmonary arteriovenous malformations (AVMs). DESIGN: Retrospective chart review of all patients (n = 16) with diffuse pulmonary AVMs seen at Yale New Haven Hospital, Johns Hopkins Hospital, and St. Michael's Hospital. Up-to-date follow-up information was obtained in all living patients. RESULTS: All patients were severely hypoxic. Neurologic complications (stroke or brain abscess) had occurred in 70% of patients by the time of diagnosis. During the follow-up period (mean, 6 years), three patients died and two others developed new neurologic complications. One of the deaths occurred perioperatively during lung transplantation. All patients underwent transcatheter embolotherapy of any large pulmonary AVMs. A selected group underwent pulmonary flow redistribution, a novel technique. Oxygenation did not improve significantly with embolotherapy of the larger AVMs, but there was a small significant improvement in those patients who underwent pulmonary flow redistribution. The majority (85%) of the living patients are currently working or studying full-time. CONCLUSIONS: Patients with diffuse pulmonary AVMs are at increased risk of neurologic complications. Transcatheter embolotherapy does not significantly improve the profound hypoxia, but it may reduce the risk of neurologic complications. Antibiotic prophylaxis is recommended for bacteremic procedures to prevent brain abscess. These patients can live for many years and lead productive lives. We do not recommend lung transplantation because survival with disease is difficult to predict and we have observed a perioperative transplant death.

Adolescent↗
PubMed2000

Comparison of molecular and conventional strategies for followup of superficial bladder cancer using decision analysis.

PURPOSE: Patients with superficial bladder cancer require long-term surveillance for recurrence. We compared the cost of cystoscopy and cytology (standard care) to that of urinary markers (modified care) for patients with a history of superficial bladder cancer. MATERIALS AND METHODS: We constructed a decision analysis model that compared the 2 strategies for a hypothetical followup interval of 3 years. Probabilities required for the decision tree were based on a cohort of 361 patients diagnosed with superficial bladder cancer from 1987 to 1997. Sensitivity analyses were used to determine whether test sensitivity and specificity would affect cost thresholds. Costs for each strategy were then applied to actual practice patterns. RESULTS: The cost of modified care ranged from $158 to $228 for each followup visit when using a urinary marker with a sensitivity and specificity of 95% and 77%, respectively. The cost of standard care was $240 for each followup visit. Based on sensitivity analyses the probability of disease recurrence and urinary marker accuracy were important determinants of expected costs. Mean number of followup assessments for patients followed more than 3 years was 4.3, 2.2 and 1.5 for years 1, 2 and 3, respectively. Cumulative costs of modified care were lower than those of standard care. CONCLUSIONS: Urinary marker testing for followup of patients with superficial bladder cancer is less expensive than the standard method of cystoscopy and urinary cytology based on our model. Future studies will be required to consider other factors that could affect the cost advantage of urinary markers, including indirect costs, the psychosocial impact of testing and different surveillance frequencies.

Decision Support Techniques↗
PubMed1999

Economic methods for measuring the quality of life associated with HIV infection.

BACKGROUND: Quality of life is measured as utilities for cost-effectiveness analyses. OBJECTIVE: To test the adequacy of three common utility elicitation methods for individuals with Human Immunodeficiency Virus (HIV) disease. MEASUREMENTS: HIV-positive participants (n = 75) rated three standardized health states (symptomatic HIV infection, minor AIDS defining illness, and major AIDS defining illness) with two utility elicitation methods (Standard Gamble [SG], and Time Trade-off [TTO]) and one value method (Visual Analog [VA]). Participants also rated their own health with one utility method (Health Utilities Index [HUI]) and one conventional quality of life method (Medical Outcomes Study--HIV Health Survey [MOS-HIV]). RESULTS: For all states, SG and TTO scores ranged from near 0.00 (equivalent to death) to 1.00 (best possible quality of life). Mean scores for symptomatic HIV were similar with the SG (0.80) and TTO (0.81) but higher than with the VA (0.70). Similar results were observed for minor AIDS defining illnesses (0.65, 0.65, 0.46 respectively) and major AIDS defining illnesses (0.42, 0.44, 0.25 respectively). Discrepant SG and TTO scores were observed in many individuals and were not explained by demographic characteristics. As expected, HUI scores of an individual's own health were related to the disease state. Four of ten MOS-HIV subscales (overall health, physical functioning, role functioning, and pain) were also related to disease state. HUI scores were correlated with the MOS-HIV score for overall health and for all MOS-HIV subscales except health transition. CONCLUSIONS: Mean utility scores for HIV-related health states elicited by the Standard Gamble and Time Trade-off were similar but a large degree of individual variation persists. Economic methods provide imprecise estimates of the quality of life associated with HIV infection.

Adult↗
PubMed1999

Adhesive tape and intravascular-catheter-associated infections.

Adhesive tape is placed in close contact with intravascular catheters for extended periods and could theoretically contribute to local infections. We found that 74% of specimens of tape collected in one hospital were colonized by pathogenic bacteria. However, only 5% of specimens had significant growth from an inner layer obtained by discarding the outside layer from each roll. We suggest that adhesive tape is a potential source of pathogenic bacteria and that discarding the outer layer from a partially used roll might be a simple method for reducing the risk of infection to patients.

Bacteria↗
PubMed1999

Electromotive drug administration of lidocaine as an alternative anesthesia for transurethral surgery.

PURPOSE: A multicenter study was undertaken to evaluate the safety, efficacy and cost of electromotive drug administration of intravesical lidocaine to produce bladder local anesthesia as an alternative to traditional methods of spinal or general anesthesia. MATERIALS AND METHODS: A total of 94 patients were enrolled in the study who had either a history of bladder tumor that required cold cup bladder biopsy with fulguration for possible recurrence as a comparison trial, a bladder tumor treated with transurethral resection/fulguration or benign prostatic hyperplasia/carcinoma treated with transurethral resection. Pain scores using a Verbal Rating Scale were recorded for each individual biopsy, fulguration and resection event. Data for direct and indirect costs were collected using a standardized form for each patient to capture the details of the procedure, including times, drugs and disposables for each patient. RESULTS: There was a significant reduction in pain for patients who received electromotive intravesical lidocaine compared to no anesthesia for biopsy (p<0.03). Similarly, electromotive intravesical lidocaine for bladder biopsy and transurethral bladder tumor resection/fulguration was associated with higher patient satisfaction compared to previous treatments (p<0.00002). In contrast, electromotive intravesical lidocaine was insufficient for 3 of 6 transurethral prostatic resections. The cost per patient was about $146 Cdn less with electromotive intravesical lidocaine than with conventional general/spinal anesthesia. CONCLUSIONS: Electromotive intravesical lidocaine may be a safe, effective and affordable form of anesthesia for the ambulatory care of patients requiring transurethral bladder biopsy, resection or fulguration with a potential for cost savings.

Aged↗
PubMed1998

Preventing Mycobacterium avium complex in patients who are using protease inhibitors: a cost-effectiveness analysis.

BACKGROUND: Practice guidelines recommending Mycobacterium avium complex (MAC) prophylaxis for patients with HIV disease were based on clinical trials in which individuals did not receive protease inhibitors. OBJECTIVE: To estimate the cost-effectiveness of strategies for MAC prophylaxis in patients whose treatment regimen includes protease inhibitors. DESIGN: Decision analysis with Markov modelling of the natural history of advanced HIV disease. Five strategies were evaluated: no prophylaxis, azithromycin, rifabutin, clarithromycin and a combination of azithromycin plus rifabutin. MAIN OUTCOME MEASURES: Survival, quality of life, quality-adjusted survival, health care costs and marginal cost-effectiveness ratios. RESULTS: Compared with no prophylaxis, rifabutin increased life expectancy from 78 to 80 months, increased quality-adjusted life expectancy from 50 to 52 quality-adjusted months and increased health care costs from $233000 to $239800. Ignoring time discounting and quality of life, the cost-effectiveness of rifabutin relative to no prophylaxis was $44300 per life year. Adjusting for time discounting and quality of life, the cost-effectiveness of rifabutin relative to no prophylaxis was $41500 per quality-adjusted life year (QALY). In comparison with rifabutin, azithromycin was associated with increased survival, increased costs and an incremental cost-effectiveness ratio of $54300 per QALY. In sensitivity analyses, prophylaxis remained economically attractive unless the lifetime chance of being diagnosed with MAC was less than 20%, the rate of CD4 count decline was less than 10 x 10(6) cells/l per year, or the CD4 count was greater than 50 x 10(6) cells/l. CONCLUSION: MAC prophylaxis increases quality-adjusted survival at a reasonable cost, even in patients using protease inhibitors. When not contraindicated, starting azithromycin or rifabutin when the patient's CD4 count is between 50 and 75 x 10(6) cells/l is the most cost-effective strategy. The main determinants of cost-effectiveness are CD4 count, viral load, place of residence and patient preference.

AIDS-Related Opportunistic Infections↗
PubMed1998

The treatment of unrelated disorders in patients with chronic medical diseases.

BACKGROUND: Patients can have several illnesses concurrently, yet some of these diseases may be neglected if one problem consumes attention. We conducted a population-based analysis in Ontario, Canada - where universal health insurance is provided - to determine whether unrelated disorders are less likely to be treated in patients with chronic diseases. METHODS: We studied the 1,344,145 residents of Ontario in 1995 who were 65 or older and eligible to receive prescription medications free of charge as part of the Ontario Drug Benefit program. Patients with diabetes mellitus were identified by prescriptions for insulin, pulmonary emphysema by prescriptions for ipratropium bromide, and psychotic syndromes by prescriptions for haloperidol. For each chronic disease, we selected an unrelated treatment: estrogen-replacement therapy for patients with diabetes mellitus, lipid-lowering medications for those with pulmonary emphysema, and medical treatment of arthritis for those with psychotic syndromes. RESULTS: The 30,669 patients with diabetes mellitus were less likely to receive estrogen-replacement therapy than the other subjects in the study (2.4 percent vs. 5.9 percent, P<0.001). The disease was associated with a 60 percent reduction in the odds of estrogen treatment (odds ratio, 0.40; 95 percent confidence interval, 0.37 to 0.43). Findings were similar for the 56,779 patients with pulmonary emphysema, who were less likely to receive lipid-lowering medications (odds ratio, 0.69; 95 percent confidence interval, 0.67 to 0.72; P<0.001), and the 17,336 patients with psychotic syndromes, who were less likely to receive medical treatments for arthritis (odds ratio, 0.59; 95 percent confidence interval, 0.57 to 0.62; P<0.001). CONCLUSIONS: In patients 65 or older who have chronic medical diseases and who receive prescription medications free of charge, unrelated disorders are undertreated. Clinicians caring for patients with chronic diseases should remain alert to other disorders and minimize the number of missed opportunities for treating them.

Aged↗
PubMed1998

Shopping around for hospital services: a comparison of the United States and Canada.

CONTEXT: Historical comparisons indicate that US hospitals are more expensive than Canadian hospitals, but health care system reform might have changed the relative costs and timeliness of health care in the 2 countries. OBJECTIVE: To estimate the price and convenience of selected hospital services in the United States and Canada for patients in 1997 had they paid out-of-pocket. DESIGN: Cross-sectional telephone survey conducted May 1996 to April 1997. PARTICIPANTS: The 2 largest acute care general hospitals from every city in the United States and Canada with a population greater than 500000. MEASURES: Each hospital was telephoned and asked their price and waiting time for 7 services: magnetic resonance imaging of the head without gadolinium; a screening mammogram; a 12-lead electrocardiogram; a prothrombin time measurement; a session of hemodialysis; a screening colonoscopy; and a total knee replacement. Waiting times were measured in days until earliest appointment and charges were converted to American currency. RESULTS: Overall, 48 US and 18 Canadian hospitals were surveyed. Median waiting times were significantly shorter in American hospitals for 4 services, particularly a magnetic resonance imaging of the head (3 days vs 150 days; P<.001). Median charges were significantly higher in American hospitals for 6 services, particularly for a total knee replacement ($26805 vs $10651; P<.001). Individual services showed no association between shorter waiting times and higher prices within each country, with the exception of a total knee replacement in the United States. CONCLUSION: US hospitals still provide higher prices and faster care than Canadian hospitals for patients who pay out-of-pocket.

Canada↗