Search PubMed⌕ Search

Biomedical subjects

D B Matchar

Publications and source records attributed to D B Matchar.

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

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

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

Adult↗
PubMed1997

Primary care physician-reported secondary and tertiary stroke prevention practices. A comparison between the United States and the United Kingdom.

BACKGROUND AND PURPOSE: Stroke is a major healthcare problem in both the United States (US) and the United Kingdom (UK). Little comparative data are available concerning how generalist physicians in the two countries approach the management of patients at high risk of stroke. METHODS: Contemporaneous surveys of random samples of primary care physician-reported stroke prevention practices were performed in the US and UK from 1993 to 1994. The US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke included 254 noninternist primary care physicians. The UK Survey of the Care of Patients With Stroke in General Practice obtained responses from 661 general practitioners. The two surveys used many of the same questions, allowing for direct comparisons of reported stroke prevention practices between American and British physicians. RESULTS: More than 80% of American physicians reported a variety of services (24-hour electrocardiography, echocardiography, brain CT scan, brain MR scan, carotid ultrasonography, cerebral angiography) as readily available. These same services were readily available to less than 10% of physicians in the UK (P < .001 for each comparison). Although physicians in the UK reported prescribing lower doses of aspirin for stroke prevention than physicians in the US, the proportions of physicians using aspirin were not different. In contrast, almost 70% of physicians in the US responded that they always or often anticoagulate patients with nonvalvular atrial fibrillation compared with 7% of British physicians (P < .001). Whereas 70% of American versus 14% of British physicians reported obtaining carotid ultrasound studies in patients with asymptomatic bruits (P < .001), physicians in the UK more commonly reported referring this type of patient to neurologists (46% versus 21%, P < .001). For patients with recent carotid-distribution transient ischemic attack or minor stroke, physicians in the US more commonly reported referral to neurologists (55% versus 45%, P = .022), referral to surgeons (39% versus 19%, P < .001), the performance of carotid ultrasonography (80% versus 11%, P < .001), echocardiography (45% versus 5%, P < .001), 24-hour electrocardiography (49% versus 4%, P < .001), brain CT scan (72% versus 3%, P < .001), and the prescription of anticoagulants (53% versus 4%, P < .001). CONCLUSIONS: These data show significant differences in stroke prevention practices as reported by primary care physicians practicing in the US and UK. Some of these differences may be related to the relative availability of specific services in the two countries, potentially leading to overutilization in the US and underutilization in the UK in certain circumstances.

Atrial Fibrillation↗
PubMed1997

Knowledge of risk among patients at increased risk for stroke.

BACKGROUND AND PURPOSE: Patients who recognize their increased risk for stroke are more likely to engage in (and comply with) stroke prevention practices than those who do not. We describe perceived risk of stroke among a nationally diverse sample of patients at increased risk for stroke and determine whether patients' knowledge of their stroke risk varied according to patients' demographic and clinical characteristics. METHODS: Respondents were recruited from the Academic Medical Center Consortium (n = 621, five academic medical centers, inpatients of varying age); the Cardiovascular Health Study (n = 321, population-based sample of persons aged 65+ years); and United HealthCare (n = 319, five health plans, inpatients and outpatients typically younger than 65 years). The primary outcome was awareness of being at risk for stroke. RESULTS: Only 41% of respondents were aware of their increased risk for stroke (including less than one half of patients with previous minor stroke). Approximately 74% of patients who recalled being told of their increased stroke risk by a physician acknowledged this risk in comparison with 28% of patients who did not recall being informed by a physician. Younger patients, depressed patients, those in poor current health, and those with a history of TIA were most likely to be aware of their stroke risk. CONCLUSIONS: Over one half of patients at increased risk of stroke are unaware of their risk. Healthcare providers play a crucial role in communicating information about risk, and successful communication encourages adoption of stroke prevention practices. Educational messages should be targeted toward patients least likely to be aware of their risk.

Adult↗
PubMed1997

Inaccuracy of the International Classification of Diseases (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease.

In administrative databases the International Classification of Diseases, Version 9, Clinical Modification (ICD-9-CM) is often used to identify patients with specific diagnoses. However, certain conditions may not be accurately reflected by the ICD-9 codes. We assessed the accuracy of ICD-9 coding for cerebrovascular disease by comparing ICD-9 codes in an administrative database with clinical findings ascertained from medical record abstractions. We selected patients with ICD-9 diagnostic codes of 433 through 436 (in either the primary or secondary positions) from an administrative database of patients hospitalized in five academic medical centers in 1992. Medical records of the selected patients were reviewed by trained medical abstractors, and the patients' clinical conditions during the admission (stroke, TIA, asymptomatic) were recorded, as well as any history of cerebrovascular symptoms. Results of the medical record review were compared with the ICD-9 codes from the administrative database. More than 85% of those patients with the ICD-9 code 433 were asymptomatic for the index admission. More than one-third of these asymptomatic patients did not undergo either cerebral angiography or carotid endarterectomy. For ICD-9 code 434, 85% of patients were classified as having a stroke and for ICD-9 code 435, 77% had TIAs. For code 436, 77% of patients were classified as having strokes. Limiting the identifying ICD-9 code to the primary position increased the likelihood of agreement with the medical record review. The ICD-9 coding scheme may be inaccurate in the classification of patients with ischemic cerebrovascular disease. Its limitations must be recognized in the analyses of administrative databases selected by using ICD-9 codes 433 through 436.

Arterial Occlusive Diseases↗
PubMed1997

Influence of projected complication rates on estimated appropriate use rates for carotid endarterectomy. Appropriateness Project Investigators. Academic Medical Center Consortium.

OBJECTIVE: To examine specifically the influence of estimated perioperative mortality and stroke rate on the assessment of appropriateness of carotid endarterectomy. DATA SOURCES/STUDY SETTING: An expert panel convened to rate the appropriateness of a variety of potential indications for carotid endarterectomy based on various rates of perioperative complications. We then applied these ratings to the charts of 1,160 randomly selected patients who had carotid endarterectomy in one of the 12 participating academic medical centers. STUDY DESIGN: An expert panel evaluated indications for carotid endarterectomy using the modified Delphi approach. Charts of patients who received surgery were abstracted, and clinical indications for the procedure as well as perioperative complications were recorded. To examine the impact of surgical risk assessment on the rates of appropriateness, three different definitions of risk strata for combined perioperative death or stroke were used: Definition A, low risk < 3 percent; Definition B, low risk < 5 percent; and Definition C, low risk < 7 percent. PRINCIPAL FINDINGS: Overall hospital-specific mortality ranged from 0 percent to 4.0 percent and major complications, defined as death, stroke, intracranial hemorrhage, or myocardial infarction, varied from 2.0 percent to 11.1 percent. Most patients (72 percent) had surgery for transient ischemic attack or stroke; 24 percent of patients were asymptomatic. Most patients (82 percent) had surgery on the side of a high-grade stenosis (70-99 percent). When the thresholds for operative risk were placed at the values defined by the expert panel (Definition A), only 33.5 percent of 1,160 procedures were classified as "appropriate." When the definition of low risk was shifted upward, the proportion of cases categorized as appropriate increased to 58 percent and 81.5 percent for Definitions B and C, respectively. CONCLUSIONS: Despite the high proportion of procedures performed for symptomatic patients with a high degree of ipsilateral extracranial carotid artery stenosis and generally low rates of surgical complications at the participating institutions, the overall rate of "appropriateness" using a perioperative complication rate of < 3 percent was low. However, the rate of "appropriateness" was extremely sensitive to judgments about a single clinical feature, surgical risk. These data show that before applying such "appropriateness" ratings, it is crucial to perform sensitivity analyses in order to assess the stability of the results. Results that are robust to moderate in variation in surgical risk provide a much sounder basis for policy making than those that are not.

Academic Medical Centers↗
PubMed1996

Stroke prevention: the emerging strategies.

Warfarin prophylaxis in patients with nonvalvular atrial fibrillation may be one of the most valuable public-health interventions. Barriers to its optimal utilization include wariness about bleeding complications and concern about age-related sensitivity to the drug. The risks, however, may be minimized by creation of anticoagulation clinics to ensure optimal dosing and follow-up.

Anticoagulants↗
PubMed1996

What role do neurologists play in determining the costs and outcomes of stroke patients?

BACKGROUND AND PURPOSE: Despite growing concern over the large numbers of specialists in the United States, little information is available on how stroke treatment varies by the specialty of the attending physician. This study compares the costs and outcomes of acute stroke patients by physician specialty, especially between neurologists and other specialists. METHODS: We selected a random sample of Medicare patients aged 65 years and older admitted with cerebral infarction between January 1 and September 30, 1991, identified from the principal diagnosis on Medicare Provider Analysis and Review records. All Medicare claims for these patients were extracted from the date of admission through 90 days. The attending physician was identified as that physician billing for routine hospital visits during the first 7 days of the stay. RESULTS: Neurologists treating stroke patients were significantly more expensive than other physicians but obtained better outcomes. Ninety-day mortality rates for patients treated by neurologists were significantly lower than those for other specialists. These cost and outcome differences persisted even after adjustment for patient age, comorbidity, hospital teaching status, and other characteristics. Compared with other attending physicians, neurologists were significantly more likely to order diagnostic cerebrovascular tests (especially brain MRI scans), more likely to prescribe warfarin, and more likely to discharge patients to inpatient rehabilitation facilities. CONCLUSIONS: Systematic triaging to neurologists based on clinical characteristics unmeasured by administrative data might explain these observed differences between neurologists and other physicians. Alternatively, these specialists may have been better able to identify the mechanism of stroke, information that then affected the course of treatment. Given current pressures to substitute generalists for specialists, however, more research is needed on these stroke treatment differences.

Cerebrovascular Disorders↗
PubMed1996

US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke. Carotid endarterectomy.

BACKGROUND AND PURPOSE: Data from several randomized clinical trials concerning the efficacy of carotid endarterectomy (CE) in patients with symptomatic and asymptomatic stenoses of the extracranial carotid artery are now available. Yet, there are few data concerning the patterns of use of CE by physicians for their patients at risk for stroke. These data are critical for the rational allocation of resources and targeting of educational efforts. METHODS: Between August 1993 and February 1994, we surveyed the stroke prevention practices of a stratified random sample of 2000 US physicians. The survey queried the perceived availability and use of diagnostic studies and surgery for specific types of patients who might be considered candidates for CE. RESULTS: Of eligible physicians, 67% (n = 1006) completed the survey. Seventy percent reported that they always or often obtain carotid ultrasonography for evaluation of patients with asymptomatic bruits; 89% do so in patients with recent transient ischemic attack or minor stroke (P < .001). For asymptomatic patients, 13% always or often obtain a cerebral angiogram if carotid ultrasonography indicates 50% to 70% stenosis versus 33% if carotid ultrasonography indicates > 70% stenosis (P < .001). For asymptomatic patients with > 70% stenosis, a cerebral angiogram was reported as seldom or never used by 42% of physicians who viewed the test as readily available versus 67% if cerebral angiography was perceived as not readily available (P = .005). Multinomial multiple logistic regression analysis showed that symptom status, the degree of stenosis, perceived availability of CE, and physician specialty independently contributed to the explained variance in the reported use of CE (P < .001). The odds of performing CE were approximately four times greater in patients recent symptoms compared with asymptomatic patients (P < .001) and four times greater in patients with > 70% stenosis compared with patients with 50% to 70% stenosis (P < .001). Physicians who perceived CE as not being readily available were one third as likely to report using the procedure compared with physicians who reported having ready access (P = .004). CE was reported as being always or often used by more than 80% of neurologists and surgeons but by only about half of internists and noninternist primary care physicians for patients with newly symptomatic high-grade stenosis (P < .001). Almost one in four noninternist primary care physicians responded that they would seldom or never use CE for these patients. CONCLUSIONS: These data show that (1) symptom status and degree of carotid artery stenosis strongly influence the reported frequency with which CE is used by practicing physicians; (2) the perceived availability of cerebral angiography and CE significantly affects their reported frequency of use; and (3) physician specialty significantly influences the reported frequency of use of CE.

Brain Ischemia↗
PubMed1996

US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke. Medical therapy in patients with carotid artery stenosis.

BACKGROUND AND PURPOSE: Aspirin or other platelet antiaggregants and anticoagulants are commonly used in many types of patients at elevated stroke risk. However, relatively little is known concerning how practicing physicians use these medications in their patients with extracranial carotid artery stenosis. The identification of variations in practice may help to both direct specific educational efforts and guide further research. METHODS: Between August 1993 and February 1994, we surveyed the stroke prevention practices of a stratified random sample of 2000 US physicians. The survey included clinical scenarios that probed the use of aspirin or other platelet antiaggregants and anticoagulants in symptomatic and asymptomatic patients with carotid artery stenoses of 50% to 70% or more than 70%, with and without known surgical contraindications. RESULTS: Sixty-seven percent of those eligible completed the survey (n = 1006). More than 85% of physicians responded that they always or often prescribe aspirin or other platelet antiaggregants regardless of degree of carotid artery stenosis, symptom status, or presence of surgical contraindications. However, the reported frequency of use of these medications varied independently according to physician specialty (P = .044). In contrast, in addition to physician specialty, the reported frequency of anticoagulant use varied independently with degree of carotid artery stenosis, symptom status, and presence of surgical contraindications (P < .0001 for each variable). Fifteen percent of physicians responded that they always or often use anticoagulants for asymptomatic patients with 50% to 70% carotid artery stenosis versus 43% who reported doing so for symptomatic patients with a similar degree of stenosis (P < .001); 28% often or always prescribe anticoagulants for asymptomatic patients with more than 70% carotid artery stenosis versus 49% who do so if symptoms are present (P < .001). The odds of noninternist primary care physicians responding that they always or often use anticoagulants were more than five times higher (odds ratio, 5.32; 95% confidence interval [CI], 3.79 to 7.45) than surgical specialists. Compared with surgical specialists, the odds ratios for the use of anticoagulants were 3.65 for internists (95% CI, 2.63 to 5.06) and 1.88 (95% CI, 1.40 to 2.53) for neurologists. CONCLUSIONS: These data show the following: (1) Aspirin or other platelet antiaggregants are used by most physicians regardless of degree of carotid artery stenosis, symptom status, or presence of surgical contraindications; (2) anticoagulants are prescribed selectively, with each of these variables influencing their use; and (3) the use of both classes of agents varies with physician specialty training.

Anticoagulants↗
PubMed1996

Clinical and radiographic findings that lead to intervention in diabetic patients with foot ulcers. A nationwide survey of primary care physicians.

OBJECTIVE: To determine which elements of clinical history, physical examination, and diagnostic tests are important to primary care physicians in their management of foot ulcers in diabetic patients. RESEARCH DESIGN AND METHODS: We conducted a national mail survey of 600 primary care physicians to determine which patient characteristics and diagnostic test results were important in their decisions to seek radiographic studies, surgical referrals, and hospitalization for diabetic patients with foot ulcers. RESULTS: The case characteristics most likely to influence physicians to order advanced diagnostic or therapeutic interventions are the presence of osteomyelitis on plain radiographs, the failure of the ulcer to improve with conservative therapy, and the presence of visible bone, crepitus, or necrosis within the ulcer (P < 0.001). Information from the initial clinical history was less likely to influence physicians to order advanced diagnostic or therapeutic interventions (P < 0.001) than was information from the physical examination. CONCLUSIONS: We conclude that 1) the patient's history is relatively unimportant to primary care physicians in their management of diabetic foot ulcers; 2) the failure of conservative management is a major reason that primary care physicians order surgical referral, hospitalization, or radiographic testing for diabetic patients with foot ulcers; and 3) primary care physicians rely heavily on plain X ray of the foot, a test with poor sensitivity and specificity, in deciding whether to order further interventions for their diabetic patients with foot ulcers.

Data Collection↗
PubMed1996

Using physician claims to identify postoperative complications of carotid endarterectomy.

OBJECTIVE: This study develops a methodology for identifying complications following carotid endarterectomy, using physician claims data. DATA SOURCES/STUDY SETTING: We selected a random 20 percent sample of Medicare patients undergoing carotid endarterectomy in 1991 (n = 8,345) and extracted all of their claims. STUDY DESIGN: Project neurologists identified the following services as indicative of complications following carotid endarterectomy if they were provided within 30 days of surgery: head CT, head MRI, and surgical exploration of the neck for hemorrhage, thrombosis, or infection. DATA COLLECTION/EXTRACTION METHODS: Total costs were calculated from all claims associated with the hospitalization and the 30-day postoperative period. Outcomes included mortality (obtained from Medicare eligibility files), length of stay, discharge to an institution, and readmission to an acute care hospital (the latter obtained from claims data). PRINCIPAL FINDINGS: Surgical complications were identified in one out of every ten endarterectomy patients (10.3 percent). Patients with complications were significantly more likely to die within 30 days of surgery (8.9 percent, compared with 1.1 percent of those not experiencing complications). They also were significantly more likely to be discharged to an institutional setting (24.9 percent versus 2.9 percent), and more likely to be readmitted to acute care hospitals (26.8 percent versus 8.2 percent). Patients with postoperative complications also were significantly more expensive: $22,187 versus $10,892. CONCLUSION: Our findings suggest that physician claims could be used by PROs or similar entities as a screening tool to identify potential problem hospitals or problem surgeons. First, however, the methodology would need to be clinically validated.

Aged↗
PubMed1995

Health values of the seriously ill. SUPPORT investigators.

OBJECTIVE: To assess 1) the health values and health ratings of seriously ill hospitalized patients, their surrogate decision makers, and their physicians; 2) the determinants of health values; and 3) whether health values change over time. DESIGN: Prospective, longitudinal, multicenter study. SETTING: 5 academic medical centers. PARTICIPANTS: 1438 seriously ill patients with at least one of nine diseases who had a projected overall 6-month mortality rate of 50%; their surrogates; and their physicians. MEASUREMENTS: Time-tradeoff utilities (reflecting preferences for a shorter but healthy life) and health ratings. RESULTS: At study day 3, patients had a mean time-tradeoff utility of 0.73 +/- 0.32 (median [25th, 75th percentile], 0.92 [0.63, 1.0]), indicating that they equated living 1 year in their current state of health with living 8.8 months in excellent health. However, scores varied widely; 34.8% of patients were unwilling to exchange any time in their current state of health for a shorter life in excellent health (utility, 1.0), and 9.0% were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility, 0.04). Health rating scores averaged 57.8 +/- 24.0 (median [25th percentile, 75th percentile], 60 [50, 75]) on a scale of 0 (death) to 100 (perfect health). The patients' mean time-tradeoff score exceeded that of their paired surrogates (n = 1041) by 0.08 (P < 0.0001). Time-tradeoff scores were related to psychosocial well-being; health ratings; desire for resuscitation and extension of life rather than relief of pain and discomfort; degree of willingness to live with constant pain; and perceived prognosis for survival and independent functioning. Scores of surviving patients increased by an average of 0.06 after 2 months (P < 0.0001) and 0.08 after 6 months (P < 0.0001). CONCLUSIONS: Health values of seriously ill patients vary widely, are higher than patients' surrogates believe, are related to few other preference and health status measures, and increase over time.

Aged↗
PubMed1995

Noninvasive carotid artery testing. A meta-analytic review.

PURPOSE: To compare the operating characteristics of six noninvasive tests for carotid artery stenosis. DATA SOURCES: A structured search was done using MEDLINE, reference lists from selected articles, and bibliographies from neurology textbooks that focused on the diagnosis of carotid artery stenosis in humans. The search yielded 568 articles. STUDY SELECTION: Articles were selected if the noninvasive test results they presented used carotid angiography as the reference standard for comparison, if carotid artery occlusion was considered as a separate category, and if contingency tables could be constructed. DATA EXTRACTION: At least two physicians reviewed all selected articles. Items abstracted included patient demographics, study design, sites of patient enrollment, whether the interpretation of test outcomes was blinded, and specific results. Sensitivity, specificity, receiver operating characteristic (ROC) curves, and summary measures of effectiveness for each test were calculated. RESULTS: Carotid duplex ultrasonography, carotid Doppler ultrasonography, and magnetic resonance angiography have sensitivities between 0.82 and 0.86, specificities at 0.98, and test-effectiveness measures at or exceeding 3.0 when predicting 100% occlusion. For carotid stenosis of 70% or more, these three tests and supraorbital Doppler ultrasonography all have sensitivities of 0.83 to 0.86, specificities of 0.89 to 0.94, test-effectiveness measures approaching 3.0, and composite ROC areas of 0.91 to 0.92. Limiting analysis to studies that enrolled consecutive patients and those in which interpretation of the noninvasive tests was independent of the angiograms did not substantially change our results. CONCLUSIONS: Carotid duplex ultrasonography, carotid Doppler ultrasonography, and magnetic resonance angiography are all similarly successful at predicting 100% carotid artery occlusion and 70% stenosis. Other factors, such as cost, availability, and local experience may influence the decision to use these tests to screen for carotid artery atherosclerosis that may respond to surgery.

Carotid Stenosis↗
PubMed1995

Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly.

BACKGROUND: Our goal was to determine whether patient age affects a physician's reported likelihood of using anticoagulant therapy or the intensity of anticoagulant therapy for patients with nonvalvular atrial fibrillation. METHODS: We surveyed a nationwide sample of 1189 randomly selected office-based practitioners in three strata: primary care (geriatrics, internal medicine, family practice, and general practice), cardiology, and neurology. A vignette-based questionnaire was used to measure attitudes and beliefs regarding anticoagulation risks and effectiveness, barriers to anticoagulation in clinical practice, and likelihood of using anticoagulation and target intensity of anticoagulation at three patient ages (55, 65, and 75 years) for four clinical scenarios (chronic non-valvular atrial fibrillation with mild left atrial enlargement, intermittent or paroxysmal atrial fibrillation, recent-onset atrial fibrillation, and atrial fibrillation with recent [3 months] embolic stroke). RESULTS: The overall response rate was 38%. The mean likelihoods of using anticoagulation for the three ages were unequal (P < .0001) for each scenario. Most physicians were "very" or "somewhat" likely to use anticoagulant therapy for a 65-year-old with left atrial enlargement (71%), intermittent or paryoxysmal atrial fibrillation (68%), recent-onset atrial fibrillation (86%), or embolic stroke (96%). Fewer physicians were likely to use anticoagulant therapy for a 75-year-old with left atrial enlargement (63%), intermittent or paroxysmal atrial fibrillation (56%), recent-onset atrial fibrillation (80%), or embolic stroke (93%). Among physicians equally likely to use anticoagulation for 65- and 75-year-old patients, intensity of anticoagulant therapy (target international normalized ratio or prothrombin time ratio) was lower (P < .04) for the 75-year-old. CONCLUSION: Anticoagulant therapy may be less often and less intensively used for elderly patients with nonvalvular atrial fibrillation.

Aged↗
PubMed1995

Accuracy and reliability of apical S3 gallop detection.

This study assessed physician performance in detecting the apical S3 gallop using a cardiology patient simulator. Six physicians (two cardiology fellows, two medicine residents, and two attending physicians) performed two sets of 24 cardiac examinations that included the presence or absence of an apical S3 gallop. All the examiners were able to significantly alter the prior odds of an apical S3 gallop's being present, but the cardiology fellows had higher sensitivities. Sensitivity was lower for detecting soft S3 gallops, and specificity was lower when a diastolic murmur was also present. Physician performance in detecting apical S3 gallops is variable, but can be excellent.

Heart Murmurs↗
PubMed1995

US national survey of physician practices for the secondary and tertiary prevention of ischemic stroke. Design, service availability, and common practices.

BACKGROUND AND PURPOSE: Stroke is largely a preventable disease. However, there are little data available concerning the use of stroke prevention diagnostic and treatment modalities by practicing physicians. These data are critical for the rational allocation of resources and targeting of educational efforts. The purposes of this national survey were to gather information about physicians' stroke prevention practice patterns and their attitudes and beliefs regarding secondary and tertiary stroke prevention strategies. METHODS: We conducted a national survey of stroke prevention practices among a stratified random sample of 2000 physicians drawn from the American Medical Association's Physician Masterfile. The survey focused on the availability of services and the use of diagnostic and preventive strategies for patients at elevated risk of stroke. RESULTS: Sixty-seven percent (n = 1006) of eligible physicians completed the survey. Diagnostic studies considered readily available by at least 90% of physicians included carotid ultrasonography, transthoracic echocardiography, Holter monitoring, and brain CT and MRI scans. MR angiography was perceived as being readily available by 68% and transesophageal echocardiography by 74% of respondents. Twelve percent of physicians reported cerebral arteriography and 10% reported carotid endarterectomy as not being readily available. Multiple logistic regression analyses showed that the availability of services varied with physician specialty (noninternist primary care, internal medicine, neurology, surgery), practice setting (nonmetropolitan versus small metropolitan or large metropolitan areas), and for carotid endarterectomy, region of the country (South, Central, Northeast, and West). The odds of carotid endarterectomy being reported as readily available were approximately 2.5 to 3.5 times greater for physicians practicing in the central, northeastern, and western regions compared with those practicing in the South, independent of practice setting and specialty. With regard to stroke prevention practices, 61% of physicians reported prescribing 325 mg of aspirin for stroke prevention, while 33% recommend less than 325 mg and 4% use doses of 650 mg or more. Seventy-one percent of physicians using warfarin reported monitoring anticoagulation with international normalized ratios, and 78% reported monitoring anticoagulated patients at least once a month. Fewer than 20% of physicians reported knowing the perioperative carotid endarterectomy complication rates at the hospital where they perform the operation themselves or refer patients to have the procedure done. CONCLUSIONS: Although all routine and most specialized services for secondary and tertiary stroke prevention are readily available to most physicians, variation in availability exists. The use of international normalized ratios for monitoring warfarin therapy has not yet become universal. Physician knowledge of carotid endarterectomy complication rates is generally lacking. Depending on their causes, these problems may be addressed through targeted physician education efforts and systematic changes in the way in which services are provided.

Aspirin↗