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Biomedical subjects

D A Revicki

Publications and source records attributed to D A Revicki.

At least 19 recordsLinked to original sources
PubMed1995

Evaluating the quality of life associated with rifabutin prophylaxis for Mycobacterium avium complex in persons with AIDS: combining Q-TWiST and multiattribute utility techniques.

Our objective was to evaluate the effect of rifabutin prophylaxis in patients with AIDS and CD4 counts of less than 200 per cubic millimetre using a combination of Q-TWiST (quality-adjusted time without symptoms and toxicity) and multiattribute health utility assessment. The design consisted of a secondary analysis of two previously reported multicentre, randomized, placebo-controlled clinical trials conducted in 78 academic, community and Department of Veterans Affairs HIV centres and private practices. 542 patients with AIDS and CD4 counts of less than 200 per cubic millimetre were assigned to rifabutin 300 mg/day and 562 were assigned to a placebo. A modified Q-TWiST approach was used for comparing treatments based on the occurrence and duration of time with and without severe symptoms and clinical endpoints. Health states were constructed to represent combinations of clinical events experienced by study patients. Five physicians assigned utilities for health states using a six-attribute health classification system. These utilities were used to adjust survival for QOL. The rifabutin and placebo groups were compared using estimated quality-of-life-adjusted days. The incidence of MAC was 9% for the rifabutin group and 18% for the placebo group (p < 0.001). Differences, although not statistically significant, were observed for rates of survival and hospitalization. The rifabutin group experienced less anaemia (p < 0.02), and fever and night sweats (p < 0.02) than the placebo group. Average Q-TWiST days were 325 for the rifabutin group and 309 for the placebo group (p < 0.05). Q-TWiST days were significantly lower for patients with MAC bacteraemia (p < 0.04) and hospitalizations (p < (0.003). Rifabutin prophylaxis resulted in fewer MAC infections and greater quality-of-life-adjusted days of survival compared to no rifabutin. Quality-of-life-adjusted survival, based on a combination of the Q-TWiST and multiattribute health utility index, is a feasible approach for evaluating the outcomes of medical treatment. Future studies should, however, use patient-assigned utility weights to compute Q-TWiST scores, since physician generated utilities may differ significantly from those of patients.

AIDS-Related Opportunistic Infections↗
PubMed1995

Health-related quality of life associated with recombinant human erythropoietin therapy for predialysis chronic renal disease patients.

The investigators evaluated the impact of recombinant human erythropoietin (r-HuEPO) therapy on health-related quality of life (HRQL) in predialysis chronic renal disease patients with anemia. Eighty-three patients were entered into a randomized, parallel-group, open-label clinical trial with follow-up evaluations over 48 weeks. Forty-three patients were assigned to r-HuEPO treatment, and 40 patients were assigned to an untreated control group. Hematocrit levels were measured at baseline and monthly. HRQL was assessed at baseline and at weeks 16, 32, and 48. The HRQL assessment included measures of physical function, energy, role function, health distress, cognitive function, social function, home management, sexual dysfunction, depression, and life satisfaction. Significant improvements in hematocrit levels were observed in the r-HuEPO-treated group (P < 0.0001), and no changes were seen in the untreated group. Correction of anemia (hematocrit > or = 36) occurred in 79% of r-HuEPO-treated patients and 0% of control patients. Significant improvements in assessments of energy (P < 0.05), physical function (P < 0.05), home management (P < 0.05), social activity (P < 0.05), and cognitive function (P < 0.05) were found for the r-HuEPO-treated group. No changes were observed in the control group, except for a decrease in physical function (P < 0.05). Between-group differences favoring the r-HuEPO-treated group were found for energy (P < 0.05) and physical functioning (P < 0.05). In patients receiving r-HuEPO, significant improvements were seen in hemotocrit levels, and these increases resulted in improvements in HRQL.

Adolescent↗
PubMed1995

The use of decision analysis in the pharmacoeconomic evaluation of an antidepressant: a cost-effectiveness study of nefazodone.

A decision model can be a useful tool for evaluating the cost-effectiveness of a drug during research and development, before the drug is marketed. Decision analysis provides a structured process for comparing the costs and consequences of a new drug with those of standard drug therapy. This article introduces the use of a decision model and discusses the advantages and disadvantages of such a model. A cost-utility study of nefazodone, a new antidepressant, illustrates the application and interpretation of decision models. Decision analyses using data from clinical trials are a great potential source of information on the economic impact of new drugs. However, the development and use of such models require tolerance of uncertainty, the ability to represent complex relationships accurately, awareness of all factors that might influence the results, and a willingness to validate the model to the extent that validation is possible. The disadvantage of clinical decision models is that the findings are only as reliable as the information on which the model is based. Nevertheless, sensitivity analyses can be used to vary any information in question and assess the impact of that variation on the findings of the analyses. The advantage of clinical decision models is that they encourage the consideration and explicit representation of all pertinent inputs and outcomes. They clearly differentiate knowledge supported by data from assumptions, and compel assessment of the effect of those assumptions on the findings. The cost-effectiveness of nefazodone relative to standard treatment for major depression was evaluated using a decision model that simulated the lifetime direct medical costs and health outcomes associated with nefazodone and two comparators, imipramine and fluoxetine. The model included the possible clinical management pathways and the use of medical resources in treating major depression from early adulthood until death. Sensitivity analyses were performed to determine the impact of variation in model parameters on the results of the model. Using the base case assumptions of the model, which included parity of pricing with fluoxetine, nefazodone was found to be a cost-effective treatment for major depression.

Antidepressive Agents↗
PubMed1995

Abdominal pain in an HMO.

BACKGROUND: Previous surveys have found that 14%-25% of the population report abdominal pain. Only one study examined the age-gender specific prevalence of abdominal pain in the population, and no study has examined the self-reported causes of abdominal pain. METHODS: To describe the epidemiology of abdominal pain in a large health maintenance organization population, 6,199 randomly selected members were contacted and interviewed by telephone about the occurrence of abdominal pain and related health care in the past year. RESULTS: Of those interviewed, 27% reported abdominal pain in the past year, while 38% of those individuals saw a physician for their pain. Women were more likely than men to have had pain and to have seen a physician for their pain. Fewer older individuals reported abdominal pain, but when pain occurred, they sought medical care more often than younger individuals. CONCLUSIONS: Women and younger individuals report abdominal pain more frequently. Women and older individuals are more likely to seek care for their pain.

Abdominal Pain↗
PubMed1995

Quality of care in cataract surgery cases experiencing post-operative complications with co-managed care.

BACKGROUND: The quality of co-managed services and the ability of community optometrists to diagnose complications following cataract surgery were investigated in a previous study of 2,458 cases. Questions were raised about the quality of co-managed care in 50 of the cases; this study evaluates the care received by these patients. METHODS: Medical records for 44 cases (6 cases could not located) were reviewed to determine whether community optometrists diagnosed post-surgical complications and whether cases were effectively managed. All reviews were performed by two optometrists and an ophthalmologist. Six cases were excluded because of no complication or attribution to underlying disease. RESULTS: In 34 of the 38 remaining cases (89.5%), co-management was successful in diagnosing complications and in managing the patient to maximize vision function. 99.8% (2,454 of 2,458) of co-managed cases contained evidence that the optometrists provided high quality post-operative care and were able to diagnose complications. Using physician evaluations as the standard, the sensitivity of detection of complications by optometrists was 95.9% and the specificity was 99.5%. CONCLUSIONS: Co-managing optometrists provide quality care and can diagnose post-operative complications.

Aged↗
PubMed1995

Methods of pharmacoeconomic evaluation of new medical treatments in psychiatry.

There is concern in developed countries about the increasing cost of health care. Developers of new psychopharmacologic agents are asked to demonstrate cost-effectiveness as well as safety and efficacy before widespread use is encouraged. Pharmacoeconomic studies are designed to evaluate the health outcomes and cost-effectiveness of new medical treatments relative to existing treatments. Retrospective and prospective research designs have been used in pharmacoeconomic studies. New approaches such as medical effectiveness studies and modeling studies based on clinical decision analysis are increasingly used to evaluate cost-effectiveness. This article introduces important concepts of pharmacoeconomic evaluation and discusses the methods and their strengths and weaknesses. Safety and efficacy studies and pharmacoeconomic studies provide useful and complementary evidence on how a new treatment affects clinical, health-related quality-of-life, and economic outcomes.

Drug Evaluation↗
PubMed1995

Change in clinical status, health status, and health utility outcomes in HIV-infected patients.

Psychometric health status scales and health utility scales were compared to measure the impact of changes in clinical status in patients infected with the human immunodeficiency virus (HIV). The data used included the first two waves of a longitudinal study of 160 HIV-infected patients, a population that was 34% women and 65% African American. The Medical Outcome Study-HIV Health Survey (MOS-HIV); sleep, cognitive function, and depression scales; the Sickness Impact Profile Home Management Scale; and questions on HIV-related clinical symptoms were administered. Standard gamble utilities and categorical rating scale preferences were assessed for current health state. The MOS-HIV scale scores of asymptomatic patients were significantly higher than those of symptomatic patients and patients with acquired immune deficiency syndrome. No differences were observed for utilities. Increases in clinical symptoms over 4 months were associated with changes in health perception, pain, physical role function, social function, mental health, depression, energy, cognitive function, and categorical rating scale preferences. The MOS-HIV and other health status measures discriminated between HIV disease stages and were associated with clinical status. Standard gamble utilities did not discriminate among the three groups and were not correlated with clinical status.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Responsiveness and calibration of the General Well-Being Adjustment Scale in patients with hypertension.

We examined the discriminant ability and responsiveness of the General Well-Being Adjustment Scale in patients enrolled in a randomized clinical trial of antihypertensive therapy. We also tried to translate the effects of physical symptoms on general well-being. This secondary analysis used demographic, clinical, physical symptom, and general well-being data for 545 white, male hypertensive patients. General well-being was measured by the General Well-Being Adjustment Scale (GWB) collected on 2 occasions over 8 weeks of treatment. Patients with any one of 14 physical symptoms or problems, compared to those without symptoms, had lower GWB scores (p < 0.003 to p < 0.0001). Decreases of 2.83-8.76 points in GWB scores were observed in patients developing physical symptoms over the 8 week study period (p < 0.05 to p < 0.0001). These effects were demonstrated in patients developing cold sensitivity, sexual problems, chest pain, shortness of breath, loss of taste, nausea, hot or cold spells, numbness and tingling, dry mouth, blurred vision, and dizziness. We conclude that the GWB is responsive to clinically meaningful changes in symptoms and may provide a more complete evaluation of the effects of medical treatment. The GWB is a valid and responsive measure of health status outcomes in the evaluation of antihypertensive treatment.

Adult↗
PubMed1994

Work-related stress and depression among practicing emergency physicians: an international study.

STUDY OBJECTIVE: To compare the levels of work-related stress and depression reported by practicing emergency physicians in three survey sites and to determine the effects of gender and marital status on the stress and depression experienced by these physicians. DESIGN: Cross-sectional mail surveys. SETTING AND PARTICIPANTS: Seven hundred sixty-four practicing emergency physicians from the United States, 91 fellows in full-time practice from Australasia, and 154 consultants and 47 senior registrars from the United Kingdom. INTERVENTION: Administration of questionnaires requesting demographic information and including an inventory to assess work-related stress and a scale to measure depressive symptomatology. MEASUREMENTS AND MAIN RESULTS: A 3 x 2 x 2 multivariate analysis of variance performed to compare scores on the stress inventory and depression scale simultaneously by survey site, gender, and marital status revealed significant differences in stress and depression by survey site and marital status. Univariate analyses of variance revealed significant differences in both stress and depression among the three survey sites and in depression by marital status. Adjusted means indicated that physicians from the United Kingdom reported higher levels of stress and depression than physicians from the United States and Australasia. Physicians from the United States and Australasia did not differ with respect to stress or depression. Physicians who were not married reported higher levels of depression than married physicians. No large mean differences, actual or adjusted, were found for any of the grouping factors. CONCLUSION: Statistical differences among practicing emergency physicians from the United States, Australasia, and the United Kingdom were observed, but the actual levels of work-related stress and depression were similar and did not appear severe. Marriage was associated with lower levels of depressive symptomatology.

Analysis of Variance↗
PubMed1994

Recombinant human erythropoietin and health-related quality of life of AIDS patients with anemia.

To evaluate the effect of recombinant human erythropoietin on anemia and health-related quality of life in patients with acquired immunodeficiency syndrome (AIDS), we initiated an observational study with an open-label multicenter treatment protocol that involved multiple academic and community physicians in the United States. Our subjects comprised 251 anemic (i.e., hematocrit < 30%) patients with a clinical diagnosis of AIDS using 1987 CDC criteria, age > or = 12 years, and serum erythropoietin level < or = 500 IU/L. The initial dosage of recombinant human erythropoietin was 4,000 units subcutaneously for 6 days each week. Based on the patient's response to therapy, the dosage was increased sequentially to 8,000 units subcutaneously for 6 days per week. Our measurements included changes in mean hematocrit and health-related quality of life. The interview included measures of energy/fatigue; physical, social, role and cognitive function; depression; health perceptions; and life satisfaction. Adverse experiences were also documented to assess safety. Changes in mean hematocrit level from a baseline of 27.9% to 33.6% at week 12 (p < .0001) and 34.5% at week 24 (p < .0001) were observed in patients treated with recombinant human erythropoietin. Adverse experiences, not clearly associated with AIDS, were reported by 10% of patients. Increases in energy (p < .05) were observed after 12 and 24 weeks of drug therapy, and increases in health perceptions were seen after 24 weeks (p < .05). No statistically significant increases or decreases were observed on measures of physical functioning, cognitive functioning, depression, social functioning, or home management activities over the 24-week follow-up. Anemia correctors (defined as hematocrit > or = 38%) showed greater improvement in energy, health perceptions, home management, and role function than noncorrectors. Study dropouts and those who died had significantly worse scores for health-related quality of life at baseline compared to study completers. Thus, the AIDS patients with anemia and serum erythropoietin levels < or = 500 IU/L treated with recombinant human erythropoietin showed increased mean hematocrit and improved health perceptions and energy levels. The drug therapy was associated with increased feelings of energy, but it was not associated with other changes in health status and well-being in the AIDS patients completing the study. These observations need to be confirmed in randomized clinical trials.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Methods for assessing relative importance in preference based outcome measures.

This paper reviews issues relevant to preference assessment for utility based measures of health-related quality of life. Cost/utility studies require a common measurement of health outcome, such as the quality adjusted life year (QALY). A key element in the QALY methodology is the measure of preference that estimates subjective health quality. Economists and psychologists differ on their preferred approach to preference measurement. Economists rely on utility assessment methods that formally consider economic trades. These methods include the standard gamble, time-trade off and person trade-off. However, some evidence suggests that many of the assumptions that underlie economic measurements of choice are open to challenge because human information processors do poorly at integrating complex probability information when making decisions that involve risk. Further, economic analysis assumes that choices accurately correspond to the way rational humans use information. Psychology experiments suggest that methods commonly used for economic analysis do not represent the underlying true preference continuum and some evidence supports the use of simple rating scales. More recent research by economists attempts integrated cognitive models, while contemporary research by psychologists considers economic models of choice. The review also suggests that difference in preference between different social groups tends to be small.

Choice Behavior↗
PubMed1993

Relationship between psychometric and utility-based approaches to the measurement of health-related quality of life.

This paper summarizes selected evidence pertaining to the relationship between psychometric health status measures and utility/preference measures of health outcome. Few studies contain measures of both health status and utility/preference. The evidence to date suggests that various health status measures are at best only moderately correlated with standard gamble (SG) and time trade-off (TTO) utilities. Results from regression analysis, predicting SG or TTO utilities from combinations of health status scales, typically have an R2 of 0.18 to 0.43. Preferences determined by rating scale methods are more strongly related to health status scores, but correlations are variable ranging from 0.17 to 0.46 and only about 27% to 34% of variance can be explained in regression models. The Quality of Well-Being Scale and other multi-attribute preference measures have low to moderate correlations with health status measures (r = 0.03 to 0.71). Health utility/preference measures and psychometric health status scores are only moderately correlated. Health utility and psychometric health status scales may measure different attributes of health. Although both approaches are useful for evaluating medical outcomes, they are not interchangeable indicators of health-related quality of life.

Choice Behavior↗
PubMed1993

Patient outcomes with co-managed post-operative care after cataract surgery.

This study examined the practice of co-managed post-operative care and the visual acuity outcomes and complications associated with co-managed services. Data on service utilization and medical outcomes were collected for 2822 cataract surgery procedures performed in 5 ambulatory eye centers between January and July 1988. Average age of patients was 72.8 (SD = 10.4) and 63% were female. Eighty-seven percent of eyes were co-managed. Average number of post-operative visits within 90 days was 4.7 and 6.2 for co-managed cases with and without complications, respectively. Successful visual acuity outcomes (< 20/40) were experienced by 86% of all co-managed patients. There was evidence that patients with pre-existing ocular conditions (e.g. glaucoma, macular degeneration) and serious post-surgical complications were not referred for co-management. For co-managed patients without pre-existing medical or ocular conditions, 92% had successful vision outcomes, while 77-90% with these conditions had successful outcomes. Ninety-three percent of co-managed cases had no post-operative complications, and the rate of specific types of complications ranged from 0.04 to 2.0%. Using physician evaluations as the standard, sensitivity of optometrist detection of complications was 59% and specificity was 99.6%. Optometrists located in separate offices demonstrated 95.8% accuracy in assessing patients for post-operative complications.

Aged↗
PubMed1993

Organizational characteristics, perceived work stress, and depression in emergency medicine residents.

A structural equation analysis of data collected from 484 members of the Emergency Medicine Residents Association was used to test a model in which peer support and work-group cohesiveness predicted role ambiguity. Role ambiguity was then specified as a predictor of work-related stress. Stress was hypothesized to affect depression and work satisfaction. The analysis confirmed the direct relationship between stress and depression and indicated that support from peers and the work group reduces stress. This impact is influenced by the amount of role ambiguity perceived by residents. Peer support, role ambiguity, and stress explain 52% of the variance in depression reported by residents. Residents are more satisfied with their work when their peers are supportive and when levels of occupational stress and role ambiguity are not high. The model accounted for 47% of the variance in reported work satisfaction. The results suggest that role ambiguity leads to perceptions of stress. This perceived stress, in the absence of strong support groups, results in increased depressive symptomatology and decreased work satisfaction.

Adult↗
PubMed1993

Issues in the measurement of health status in asthma research.

Asthma is a chronic condition of increasing prevalence and high cost to patients, their families, and society. Research into the causes and consequences of asthma has increased during the last few years, but the use of health status measures to help characterize patient outcomes is infrequent. Those studies that have included health status measures have focused on different dimensions of health status, making comparisons across studies difficult. The purpose of this article is to provide information about the selection of health status measures in studies of persons with asthma and to review applications of and make recommendations for health status assessment in asthma research. These recommendations include: use of both generic and specific instruments where appropriate, the development of new asthma-specific measures and rigorous testing of the several new measures that have been reported recently, and the development and inclusion of utility measures in studies of asthma.

Adult↗
PubMed1993

Correlates of work-related stress among consultants and senior registrars in accident and emergency medicine.

A mail survey was conducted of consultants and senior registrars practising accident and emergency (A&E) medicine in the United Kingdom. The 201 respondents (72%) comprised 154 consultants (70.6%) and 47 senior registrars (77%), who provided demographic information and completed inventories measuring stress, depression, task and role clarity, work group functioning and overall satisfaction with work. The respondents did not report particularly high levels of stress or depression and generally evaluated aspects of their work environments favourably. Higher levels of stress were reported by consultants and respondents from district general hospitals. Levels of stress were similar to those reported by other groups of health care providers. Respondents generally considered tasks and roles to be clearly defined, work groups to be supportive, efficient units and work satisfying. There was no statistically significant correlation on the affective scales for the number of patient attendances, on call commitment or staffing numbers. Senior staff with more than 10 years experience in the specialty reported more satisfaction with work and work group functioning, and perceived their tasks and roles to be significantly clearer. Consultants over 45 evaluated their work groups favourably and were more likely to view them as cohesive, smoothly functioning units than senior registrars. The results probably reflect the ad hoc coping strategies adopted by a group of doctors, who have already demonstrated appropriate personality characteristics by completing a long training programme, with no realistic alternative late career opportunities. To prevent mid or late career attrition, however, A&E doctors should receive formal training in stress recognition and avoidance. Accessible counselling without stigma should be easily available. Senior A&E doctors have a role in detecting and managing stress amongst other staff in the department.

Adaptation, Psychological↗
PubMed1993

Predictors of work satisfaction among SHOs during accident and emergency medicine training.

The purpose of this study was to assess the ability of work-related stress, and other work environment characteristics that might affect stress, to predict work satisfaction among senior house officers (SHOs) during accident and emergency (A&E) training. Questionnaires were returned by 365 SHOs, who indicated their year in training, the number of hours worked per week, the type of training hospital, the number of new A&E attendances per year, the ratios of patients and consultants to SHOs at their training hospitals and their likelihood of specializing in A&E. They also completed inventories measuring work-related stress, task and role clarity, work group functioning and work satisfaction. Scores on the satisfaction scale served as the dependent variable in a multiple regression equation. Using an alpha level of 0.05, a significant relationship was detected between satisfaction and the 10 independent variables (P = 0.0001). Direct relationships between task and role clarity (P = 0.0001) and work group functioning (P = 0.0002) were significant, as were inverse relationships between stress (P = 0.0001) and the number of new attendances (P = 0.0321). Management practices, such as orientation sessions, that define tasks and roles, enhance work group cohesiveness and mitigate against stress, should result in increased satisfaction among SHOs.

Accidents↗