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Biomedical subjects

D B Reuben

Publications and source records attributed to D B Reuben.

At least 91 records · Page 5Linked to original sources
PubMed1992

The use of targeting criteria in hospitalized HMO patients: results from the demonstration phase of the Hospitalized Older Persons Evaluation (HOPE) Study.

OBJECTIVE: To determine the yield of standardized targeting criteria for identifying hospitalized HMO patients who are at high risk for mortality and nursing home placement and, therefore, may be appropriate for comprehensive geriatric assessment. DESIGN: Prospective cohort study. SETTING: Four HMO (Southern California Kaiser-Permanente) hospitals. SUBJECTS: 3,697 patients 65 years of age or older admitted to any inpatient service from July 1 through September 30, 1990. MAIN OUTCOME MEASURES: Screening measures for standardized targeting criteria, administered 24-48 hours after admission. RESULTS: Overall, 35.1% of patients screened met at least one inclusionary criterion, which is considerably higher than other published reports. The most commonly met criteria were incontinence, impairment in performing activities of daily living, malnutrition, and immobility. The percentage of patients meeting at least one criterion and meeting each criterion varied considerably among hospitals. The vast majority of patients (83%) who were judged appropriate for assessment met at least three criteria. CONCLUSIONS: The yield of standardized criteria differs when applied to patients in different health care systems and to patients at different hospitals within a health care system, which may reflect differences in the populations being served and the practice styles of physicians and the delivery system. Because no single criterion identified more than approximately half of patients who were judged appropriate for assessment, it is likely that a battery of criteria will be necessary to identify these patients.

Activities of Daily Living↗
PubMed1991

Geriatrics faculty in the United States: who are they and what are they doing?

Despite increases in geriatrics training at all levels of medical education, there is a nationwide shortage of geriatrics faculty. This shortage may be due in part to demands for clinical responsibilities that preclude adequate time for teaching and research. To learn about the professional activities of geriatrics faculty, we conducted a national survey of a 50% sample of all medical schools and their affiliated residency programs that focused on physician and non-physician geriatrics faculty in internal medicine, family practice, psychiatry, neurology, and physical medicine and rehabilitation. Although we found minor differences across specialties, in general, approximately one-third of physician faculty time is spent in teaching, the majority of which is clinical teaching. Less than 15% of physician faculty time is spent in research, and fewer than 10% of physician geriatrics faculty devote over half of their time to research. The percentage of time that non-physician faculty (other than "Research Only" faculty) spend in research is only slightly higher. These findings suggest that efforts to increase geriatrics education at all levels and promote research advances will be limited unless geriatricians devote substantially more of their time to these responsibilities.

Clinical Medicine↗
PubMed1991

Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine.

Increasing attention is being paid to inappropriate medication use in nursing homes. However, criteria defining the appropriate or inappropriate use of medication in this setting are not readily available and are not uniform. We used a two-round survey, based on Delphi methods, with 13 nationally recognized experts to reach consensus on explicit criteria defining the inappropriate use of medications in a nursing home population. The criteria were designed to use pharmacy data with minimal additional clinical data so that they could be applied to chart review or computerized data sets. The 30 factors agreed on by this method identify inappropriate use of such commonly used categories of medications as sedative-hypnotics, antidepressants, antipsychotics, antihypertensives, nonsteroidal anti-inflammatory agents, oral hypoglycemics, analgesics, dementia treatments, platelet inhibitors, histamine2 blockers, antibiotics, decongestants, iron supplements, muscle relaxants, gastrointestinal antispasmodics, and antiemetics. These criteria may be useful for quality assurance review, health services research, and clinical practice guidelines. The method used to establish these criteria can be used to update and expand the guidelines in the future.

Aged↗
PubMed1990

House officer responses to impaired physicians.

Although physician impairment may have substantial personal and clinical consequences, it is commonly held that physicians fail to act in the case of impaired colleagues. To learn about initial responses when confronted with impaired house officers and attending physicians, we administered five case scenarios to all 76 internal medicine house officers at a large, urban, teaching hospital. House officer responses to an alcohol-impaired physician differed depending on whether that physician was an attending physician or a house officer. Seventy-two percent of house officers would tell the chief resident about the alcohol-impaired attending physician, whereas 96% would confront the alcohol-impaired house officer personally. The most common response to the incompetent attending physician (67%) and the incompetent house officer (49%) was to tell the chief resident; only 25% would confront an incompetent house officer. In contrast, 71% would confront a depressed house officer.

Attitude of Health Personnel↗
PubMed1990

Geriatrics in residency programs.

To determine how well geriatrics has been integrated into residency training, the authors surveyed a random 33% sample of all the 378 family practice (n = 126) and 420 internal medicine (n = 140) training programs in the United States in 1988. All the programs responded. On average, the internal medicine programs had more geriatrics faculty than did the family practice faculty, but these numbers were insufficient to meet current or future needs. Fewer than half of the residencies had geriatrics inpatient or ambulatory-care evaluation units, geriatrics consult services, geropsychiatry wards, or geriatrics clinics available as training sites. In contrast, nursing homes were available for 93% of the family practice programs and 58% of the internal medicine programs. A total of 80% of the family practice programs but only 36% of the internal medicine programs had geriatrics curricula in place. The authors conclude that integration of geriatrics content into residency training is far from universal, largely because of a shortage of faculty and clinical training sites.

Curriculum↗
PubMed1990

An objective measure of physical function of elderly outpatients. The Physical Performance Test.

Direct observation of physical function has the advantage of providing an objective, quantifiable measure of functional capabilities. We have developed the Physical Performance Test (PPT), which assesses multiple domains of physical function using observed performance of tasks that simulate activities of daily living of various degrees of difficulty. Two versions are presented: a nine-item scale that includes writing a sentence, simulated eating, turning 360 degrees, putting on and removing a jacket, lifting a book and putting it on a shelf, picking up a penny from the floor, a 50-foot walk test, and climbing stairs (scored as two items); and a seven-item scale that does not include stairs. The PPT can be completed in less than 10 minutes and requires only a few simple props. We then tested the validity of PPT using 183 subjects (mean age, 79 years) in six settings including four clinical practices (one of Parkinson's disease patients), a board-and-care home, and a senior citizens' apartment. The PPT was reliable (Cronbach's alpha = 0.87 and 0.79, interrater reliability = 0.99 and 0.93 for the nine-item and seven-item tests, respectively) and demonstrated concurrent validity with self-reported measures of physical function. Scores on the PPT for both scales were highly correlated (.50 to .80) with modified Rosow-Breslau, Instrumental and Basic Activities of Daily Living scales, and Tinetti gait score. Scores on the PPT were more moderately correlated with self-reported health status, cognitive status, and mental health (.24 to .47), and negatively with age (-.24 and -.18). Thus, the PPT also demonstrated construct validity. The PPT is a promising objective measurement of physical function, but its clinical and research value for screening, monitoring, and prediction will have to be determined.

Activities of Daily Living↗
PubMed1990

Hierarchical measures of physical function in ambulatory geriatrics.

Brief and uncomplicated methods for obtaining information on functional status would facilitate the assessment of older patients. We evaluated the potential usefulness, reliability, and validity of four hierarchical measures of physical function in 123 elderly subjects seen in four ambulatory geriatrics settings. Although the vast majority (83.2%) of subjects were fully independent on the Katz Activities of Daily Living Scale, a broader scope of functional difficulty was reported on the Spector-Katz, five-item OARS, and Rosow-Breslau scales. The three scales all had either borderline or more acceptable coefficients of scalability (0.57-0.77); the hierarchical order of items was not observed in 5.3% to 13.6% of subjects. Combining items from these established measures resulted in two new scales with acceptable scalability and construct validity; however, some errors in item order persisted. Although their ease of administration is clearly advantageous, clinicians using short hierarchical scales to assess functional status of older patients should be aware of their limitations.

Activities of Daily Living↗
PubMed1990

Candidates for the Certificate of Added Qualifications in Geriatric Medicine. Who, why, and when?

We surveyed physicians who took the examination for certification for Added Qualifications in Geriatric Medicine, physicians who only inquired about the examination, and physicians who expressed no interest in the examination to learn about practice characteristics of those who took the examination and their reasons for taking it. Based on a 72% response rate, we were able to demonstrate that those who took the examination took care of an older population of patients and disproportionately more of the oldest-old. These physicians were more likely to report the care of older people to be a professional focus and, in internal medicine, were more likely to have had formal training in geriatrics. Their reasons for taking the examination were primarily to obtain credentials but also frequently to improve their ability to care for older people. Nearly two-thirds of those who had inquired about the exam but did not take it in 1988 plan to do so at a later date.

Certification↗
PubMed1990

A hierarchical exercise scale to measure function at the Advanced Activities of Daily Living (AADL) level.

Standard functional assessment instruments often fail to capture subtle impairment in community-dwelling older persons. To create a scale to measure function at the Advanced Activities of Daily Living (AADL) level, we chose three questions to separate a community sample into four levels: frequent vigorous exercisers (8.0%), frequent long walkers (10.8%), frequent short walkers (23.7%), and nonexercisers (57.5%). These levels of exercise formed a hierarchical scale that correlated positively in a graduated manner with progressively advanced social activities of daily living, current health status, and mental health. At 1-year follow-up, 20% of persons declined in exercise level, 63% showed no change in exercise level, and 17% improved their exercise level. Changes in exercise level in both directions were associated with changes in mental health status. The Advanced Activities of Daily Living scale may be a sensitive measure of earlier functional decline, but longer follow-up will be necessary to determine its clinical usefulness.

Activities of Daily Living↗
PubMed1989

Influences on medical students' health beliefs.

Physicians' personal health beliefs may have a substantial influence on their attitudes and practice of preventive health care. To assess influences on these health beliefs and gain further insight into these beliefs, a survey containing open ended questions and the Health Locus of Control (HLC) scale was administered to an entire class of medical students at the end of their preclinical training and again after an average of 18 months of clinical training. The most frequent major influence mentioned by preclinical students was medical education/teaching (by 27 per cent) but after clinical training, patients/clinical experiences was cited more often. Although medical students' responses on the HLC were more internal than the theoretical midpoint, they were less internal than persons adhering to exercise programs. Moreover, HLC scores did not change after initial clinical training. These findings suggest that HLC may be established before the clinical years. Nevertheless, medical school has the potential for substantially influencing health beliefs.

Attitude to Health↗
PubMed1988

The aging driver. Medicine, policy, and ethics.

With the graying of America, more older persons will be driving. Physiological changes associated with normal aging and diseases that commonly affect the elderly may compromise their ability to drive safely. Although all states have regulations governing driving licensure, few offer specific guidelines regarding older persons. Accordingly, much of the responsibility for determining medical competence to drive and counseling patients in this regard is left to physicians. Normal physiologic changes may limit sensory information, particularly visual, available to the driver. In addition, chronic diseases in older persons including coronary artery disease, dementia and other neurologic disorders, diabetes mellitus, and drug use may increase the risk of crashes while driving. Once the question of competence to operate an automobile has been raised, ethical dilemmas must be addressed regarding the benefit of continued driving for the individual versus the risk to that person and society as a whole. In this article, we review the medical grounds for determining competence to drive, discuss ethical implications, and report current legal regulations for physicians and aging drivers. Future directions and possible areas for further research are outlined.

Aged↗
PubMed1988

The residency-practice training mismatch. A primary care education dilemma.

Primary care practice requires clinical skills and knowledge that differ greatly from those required for successful completion of residency training. Discrepant clinical settings and physician responsibilities have thus created a mismatch between the educational content of residency training and the content of clinical practice, which may result in suboptimal preparation of internists, family practitioners, and pediatricians for patient care. Of equal concern, the psychosocial environment of residency does not prepare physicians for their future community and personal adult roles. Barriers to correcting this worsening mismatch include the following: (1) economic pressures to use house staff to meet service needs of hospitals, (2) changes in patient demographics and the focus of hospital-based medicine that are making hospitals progressively more unsuitable as the principal training site for primary care physicians, (3) the deemphasis of practicing physicians as role models and teachers in postgraduate training, and (4) the often heated disagreement among medical educators regarding the purpose and content of residency training. Efforts to resolve this mismatch should include the following: reexamining the educational objectives of the current system of postgraduate training, better counseling of physicians in training regarding career goals, and emphasizing the primary care physician as role models and faculty.

Clinical Competence↗
PubMed1988

Clinical symptoms and length of survival in patients with terminal cancer.

Planning terminal care for patients with malignant neoplasms is difficult, in part, because accurate measures of prognosis have not been defined. Using data from the National Hospice Study, we examined the correlation of 14 easily assessable clinical symptoms with survival in patients with terminal cancer. Performance status was the most important clinical factor in estimating survival time, but five other symptoms had independent predictive value as well (shortness of breath, problems eating or anorexia, trouble swallowing, dry mouth, and weight loss). We generated four parametric accelerated time survival models to estimate survival in patients with combinations of these symptoms and validated the log-normal model on the entire data set. This model was unaffected by patient age, sex, primary tumor type, or site. Our findings illustrate the value of biologically "soft" clinical data in predicting survival in patients with terminal cancer. The prevalence of similar symptoms among patients with cancer of various primary and metastatic sites also supports the concept of a common final clinical pathway in patients with advanced malignant neoplasms.

Aged↗
PubMed1987

Community health projects as part of a core clinical clerkship: teaching research skills in a community setting.

Although medical student research has been advocated as a valuable learning experience and specific programs have been developed to offer research opportunities, only a minority of students have participated in these programs. We report a student research program that is integrated into a required six week clinical clerkship in Community Health, thus ensuring that all students participate in a research project. The program offers the additional advantage that research projects are student initiated and executed. Although the limited time frame usually results in pilot or exploratory studies, the program introduces students to all facets of a research project within a community setting and promotes independent learning. The program has been well received by students and may stimulate further research interests in some students.

Clinical Clerkship↗
PubMed1987

The care of elderly patients by elderly physicians.

To examine the content of care that elderly patients receive from physicians greater than or equal to 65 years of age, data from the 1981 National Ambulatory Medical Care Survey were analyzed. Compared to physicians aged 35 to 54 years, elderly physicians devoted a larger proportion of their practices to the care of elderly patients. In caring for these patients, elderly physicians spent more time per visit than did younger physicians and were more likely to conduct general examinations and provide counseling. In contrast, elderly physicians were less likely to perform mental status or vision examinations. Elderly physicians were also less likely to provide telephone follow-up for those patients greater than or equal to 75 years of age and more likely to discharge patients greater than or equal to 65 years of age without any specific follow-up planned. These data suggest that the content of care for elderly patients may differ substantially depending upon the physician's age.

Aged↗
PubMed1986

Dyspnea in terminally ill cancer patients.

To determine the epidemiology of dyspnea in terminal cancer patients, we examined data from the National Hospice Study, which followed up patients during their last six weeks of life. The incidence of dyspnea in these patients was 70.2 percent, with prevalence rates generally exceeding 50 percent at any of three measurements. In addition to lung or pleural involvement by the tumor, the presence of underlying lung disease or cardiac and low performance on the Karnofsky scale were significantly associated with dyspnea. Lung, colorectal, and breast carcinomas were the most common tumor sites in our dyspneic patients and accounted for almost 60 percent of cancer diagnoses in these patients. In 23.9 percent of dyspneic terminal cancer patients, neither lung or pleural involvement nor underlying lung or heart disease could be identified as risk factors.

Aged↗