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Biomedical subjects

D Blumenthal

Publications and source records attributed to D Blumenthal.

At least 55 records · Page 3Linked to original sources
PubMed1998

The declining impact of race and insurance status on hormone replacement therapy.

OBJECTIVE: Socioeconomic barriers may limit the adoption of hormone replacement therapy, but little is known about recent trends in their influence. We evaluated trends in the impact of race and insurance status on national rates of hormone replacement therapy. DESIGN: We analyzed 32,608 physician office visits by nonpregnant women 40 years of age and older available from the 1989 through 1996 National Ambulatory Medical Care Surveys. The proportion of visits with new or continuing use of noncontraceptive estrogens reported was the main outcome measured. Multiple logistic regression was used to evaluate the independent effects of year, race, and expected payment source on hormone replacement therapy. RESULTS: Overall, the report of hormone replacement therapy increased from 5.7% of visits in 1989-1990 to 10.9% in 1995-1996. In 1989-1990, hormone replacement therapy was less likely in nonwhite women (3.6% vs. 6.3% for whites) and in women with Medicaid coverage (1.3% vs. 8.4% for privately insured women). These differences diminished over time, particularly for women without menopausal symptoms. In 1989-1990, the adjusted odds ratio of hormone replacement in women without menopausal symptoms was 0.31 (95% confidence interval 0.2-0.5) in nonwhites compared with whites, but increased to 0.57 (0.4-0.8) by 1995-1996. In 1989-1990, the adjusted odds ratio for hormone replacement among women with Medicaid was 0.31 (0.09-1.0) compared with those with private insurance. This ratio increased to 0.86 (0.5-1.4) by 1995-1996. CONCLUSIONS: Racial and payment source influences on hormone replacement therapy appeared to have lessened over time. Despite these changes substantial socioeconomic differences in treatment patterns remain to be addressed.

Estrogen Replacement Therapy↗
PubMed1997

Is gatekeeping better than traditional care? A survey of physicians' attitudes.

CONTEXT: Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven. OBJECTIVE: To assess physicians' attitudes about the effects of gatekeeping compared with traditional care on administrative work, quality of patient care, appropriateness of resource use, and cost. DESIGN: Cross-sectional survey of primary care physicians SETTING: Outpatient facilities in metropolitan Boston, Mass. PARTICIPANTS: All physicians who served as both primary care gatekeepers and traditional Blue Cross/Blue Shield providers for the employees of Massachusetts General Hospital, Boston. Of the 330 physicians surveyed, 202 (61%) responded. OUTCOMES MEASURES: Physician ratings of the effects of gatekeeping on 21 aspects of care, including administrative work, physician-patient interactions, decision making, appropriateness of resource use, cost, and quality of care. RESULTS: Physicians reported that gatekeeping (compared with traditional care) had a positive effect on control of costs, frequency, and appropriateness of preventive services and knowledge of a patient's overall care (P<.001). They also felt that gatekeeping increased paperwork and telephone calls and negatively affected the overall quality of care, access to specialists, ability to order expensive tests and procedures, freedom in clinical decisions, time spent with patients, physician-patient relationships, and appropriate use of hospitalizations and laboratory tests (P<.001). Overall, 32% of physicians rated gatekeeping as better than traditional care, 40% the same, 21% gatekeeping as worse, and 7% were of mixed opinion. Positive ratings of gatekeeping were associated with fewer years in clinical practice, generalist training, and experience with gatekeeping and health maintenance organization plans. CONCLUSIONS: Physicians identified both positive and negative effects of gate-keeping. Overall, 72% of physicians thought gatekeeping was better than or comparable to traditional care arrangements.

Attitude of Health Personnel↗
PubMed1997

National patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure.

BACKGROUND: While the use of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure (CHF) is supported by the results of clinical trials and expert guidelines, national physician practices are unknown. METHODS: We analyzed 1529 physician office visits by patients with CHF available from the 1989 through 1994 National Ambulatory Medical Care Surveys. We examined changes over time in the use of ACE inhibitors and use of other medications for CHF. Potential clinical and nonclinical predictors of use of ACE inhibitors were evaluated using multiple logistic regression. RESULTS: The prevalence of CHF increased from 0.9% of all office visits in 1989 to 1.1% in 1994. Use of ACE inhibitors increased from 24% in visits by patients with CHF in 1989 to 31% in 1994 (P = .02). From 1989 through 1994, use of ACE inhibitors was more likely in visits to cardiologists (46% vs 22% for all other physicians), in the Midwest (31% vs 24% in all other regions), in whites (27% vs 21% in nonwhites), in privately insured patients (31% vs 24% in all others), and in men (29% vs 23% in women). Multiple logistic regression analysis showed independent effects of specialty, region, and sex. Other medications commonly used for patients with CHF included diuretics (62% of visits for 1989-1994), digoxin (38%), and calcium channel antagonists (15%). Use of diuretics showed no significant trend between 1989 and 1994, whereas use of digoxin decreased significantly. CONCLUSION: The low rates of use of ACE inhibitors in patients with CHF and the wide variations in their use suggest a need to move beyond clinical trials and focus attention on modifying physician practices.

Aged↗
PubMed1997

Relationship between market competition and the activities and attitudes of medical school faculty.

CONTEXT: Growth in health care market competition and the concomitant increasing dependence of academic health centers on clinical revenues may require medical school faculty to increase patient care activity, perhaps at the expense of research and teaching. However, the relationship between health care market competitiveness and the activities and attitudes of medical school faculty has not been established. OBJECTIVE: To examine the relationship between market competitiveness and the activities and attitudes of medical school faculty members. DESIGN: Mailed survey of 3394 life-science faculty in the 50 universities that received the most funding from the National Institutes of Health in 1993. SETTING: Medical schools in research-intensive universities. PARTICIPANTS: A total of 2167 faculty responded to the survey (response rate, 64%). We analyzed the responses of 1671 medical school research faculty located in markets of differing health care competitiveness, ranging from least competitive (stage 1) to most competitive (stage 4) markets. MAIN OUTCOME MEASURES: The number of publications in refereed journals in the last 3 years, the average number of hours per week of teaching contact, whether faculty in clinical departments had patient care responsibilities, and measures of departmental community, cooperation, and conflict. RESULTS: Clinical researchers in stage 1 and 2 markets published more scientific articles than those in stage 3 markets (14.5 vs 12.6, P=.04) or in stage 4 markets (14.5 vs 12.0, P=.03). Among 96 young faculty (professional age-<10 years) in clinical departments, 11 (44%) of those in stage 1 and 2 markets had patient care duties compared with 32 (56.1%) of young faculty members in stage 3 markets (P=.04) and 12 (85.7%) of those in stage 4 markets (P=.01). The percentage of senior faculty in clinical departments (n=691) with patient care responsibilities did not differ significantly by market stage. Compared with faculty in less competitive markets, faculty in stage 4 markets perceived lower levels of departmental cooperation and higher levels of conflict. CONCLUSIONS: Increased competitiveness of health care markets seems to hinder the capacity of academic health centers to conduct clinical research and to foster the careers of young clinical faculty.

Academic Medical Centers↗
PubMed1997

Withholding research results in academic life science. Evidence from a national survey of faculty.

OBJECTIVES: To identify the prevalence and determinants of data-withholding behaviors among academic life scientists. DESIGN: Mailed survey of 3394 life science faculty in the 50 universities that received the most funding from the National Institutes of Health in 1993. PARTICIPANTS: A total of 2167 faculty responded to the survey, a 64% response rate. OUTCOME MEASURES: Whether respondents delayed publication of their research results for more than 6 months and whether respondents refused to share research results with other university scientists in the last 3 years. RESULTS: A total of 410 respondents (19.8%) reported that publication of their research results had been delayed by more than 6 months at least once in the last 3 years to allow for patent application, to protect their scientific lead, to slow the dissemination of undesired results, to allow time to negotiate a patent, or to resolve disputes over the ownership of intellectual property. Also, 181 respondents (8.9%) reported refusing to share research results with other university scientists in the last 3 years. In multivariate analysis, participation in an academic-industry research relationship and engagement in the commercialization of university research were significantly associated with delays in publication. Odds ratios (ORs) and 95% confidence intervals (CIs) were 1.34 (1.07-1.59) and 3.15 (2.88-3.41), respectively. Variables associated with refusing to share results were conducting research similar to the Human Genome Project (OR, 2.09; 95% CI, 1.75-2.42), publication rate (OR, 1.02; 95% CI, 1.01-1.03), and engagement in commercialization of research (OR, 2.45; 95% CI, 2.08-2.82). CONCLUSIONS: Withholding of research results is not a widespread phenomenon among life-science researchers. However, withholding is more common among the most productive and entrepreneurial faculty. These results also suggest that data withholding has affected a significant number of life-science faculty and further study on data-withholding practices is suggested.

Biological Science Disciplines↗
PubMed1997

Low rates of hormone replacement in visits to United States primary care physicians.

Our objective was to determine national rates and predictors of hormone replacement therapy. We analyzed a nationally representative sample of 6341 office visits by women aged > or = 40 years to primary care physicians in the 1993 and 1994 National Ambulatory Medical Care Surveys. Independent predictors of estrogen use were determined by logistic regression. Time trends from 1989 through 1994 also were evaluated. Hormone replacement therapy was documented in 4.7% of visits in 1989 to 1990 and 8.0% in 1993 to 1994. In 1993 to 1994 women with menopausal symptoms were six times more likely to have hormone replacement reported. In the absence of symptoms, obstetrician-gynecologists were nearly four times as likely to report hormone replacement therapy. Age 50 to 59 years, white race, osteoporosis, hyperlipidemia, and residence in the West and in nonmetropolitan areas also independently-predicted hormone replacement. Low rates of estrogen therapy by non-obstetrician-gynecologists and substantial practice variations suggest missed opportunities for hormone replacement therapy.

Adult↗
PubMed1997

Variations in cholesterol management practices of U.S. physicians.

OBJECTIVES: This study sought to evaluate national cholesterol management practices of U.S. physicians. BACKGROUND: Past studies show that nonclinical factors affect physician practices. We tested the hypothesis that physician and patient characteristics influence cholesterol management. METHODS: We used a stratified, random sample of 2,332 office-based physicians providing 56,215 visits to adults in the 1991-1992 National Ambulatory Medical Care Surveys. We investigated physicians' reporting of cholesterol-related screening, counseling or medications during office visits and used multiple logistic regression to assess independent predictors. RESULTS: An estimated 1.12 billion adult office visits occurred in 1991 and 1992 (95% confidence interval 1.06 to 1.18 billion). For the 1.03 billion visits by patients without reported hyperlipidemia, cholesterol screening (2.8% of visits) and counseling (1.2%) were not frequent. The likelihood of screening increased with older age, cardiovascular disease risk factors, white race and private insurance. We estimate that only 1 in 12 adults received cholesterol screening annually. In the 85 million visits by patients with hyperlipidemia, cholesterol testing was reported in 22.9%, cholesterol counseling in 34.4% and lipid-lowering medications in 23.1%. Testing was more likely in diabetic and nonobese patients. Counseling was more likely with younger age, cardiovascular disease and private insurance. Medications use was associated with cardiovascular disease, Northeast region of the United States, nonobese patients and visits to internists. Physician practices did not differ by patient gender. CONCLUSIONS: Although clinical conditions strongly influence cholesterol management, the appropriateness of variations noted by payment source, geographic region and physician specialty deserve further evaluation. These variations and the low estimated volume of services suggest that physicians have not fully adopted recommended cholesterol management practices.

Adult↗
PubMed1997

Academic-industry research relationships in genetics: a field apart.

Academic-industry research relationships (AIRRS) have become widely accepted and increasingly common in the life sciences. Using nationwide surveys from the United States, we found significant differences between the AIRRs of genetics firms and faculty and those of other firms and faculty. Significantly more genetics than non-genetics firms funded AIRRs, and genetics firms' AIRRs were larger and longer. Genetics faculty with AIRRs were significantly more likely than non-genetics faculty to report that patents, licenses, new companies and trade secrets had resulted from their university research; and that they had refused to share research results of biomaterials with colleagues.

Academies and Institutes↗
PubMed1996

Four sibs with arterial tortuosity: description and review of the literature.

We described four offspring of a consanguineous couple with arterial tortuosity "syndrome" (ATS). The affected children had extensive arterial involvement although the clinical presentations were quite variable. Clinical manifestations included cutis laxa or soft/thin skin, joint laxity or contractures, and arachnodactyly. Aortic tortuosity and pulmonary artery aneurysms with or without peripheral stenoses were demonstrated in all four sibs. All three males had inguinal hernias. Inconsistent facial anomalies were downslanting palpebral tissues, beaked nose, micrognathia, and high-arched palate. Results of collagen type I and type III biosynthesis studies were normal on skin fibroblasts. Histologic findings on autopsy of one affected child showed arterial changes with disruption of elastic fibers of the media and fragmentation of the internal elastic membrane as well as mucosal and transmural necrosis of the stomach, small bowel, colon, and extensive necrosis of the liver. Coronary artery involvement was also seen in this child as well as biventricular hypertrophy. We conclude that ATS is an autosomal recessive connective tissue condition associated with diffuse arterial changes and involvement of the skin, joints, and other organs.

Angiography↗
PubMed1996

Participation of life-science faculty in research relationships with industry.

BACKGROUND: Recent research on academic-industrial research relationships in the life sciences has examined their frequency, benefits, risks, and evolution from the standpoint of industrial sponsors of research. We collected information on the extent and effects of academic-industrial research relationships from the standpoint of faculty members who participate in them. METHODS: We used a mailed questionnaire to collect data between October 1994 and April 1995 from 2052 faculty members (of 3169 eligible respondents; response rate, 65 percent) in the life sciences at the 50 U.S. universities receiving the most research funding from the National Institutes of Health. RESULTS: Twenty-eight percent of the respondents received research support from industry. Faculty members receiving industrial funds had more peer-reviewed articles published in the previous three years, participated in more administrative activities in their institutions or disciplines, and were more commercially active than faculty members without such funding. However, faculty members receiving more than two thirds of their research support from industry were less academically productive than those receiving a lower level of industrial support, and their articles were less influential than those by researchers with no industrial support. Faculty members with industrial support were significantly more likely than those without industrial support to report that trade secrets had resulted from their work (14.5 percent vs. 4.7 percent, P<0.001) and that they had taken commercial considerations into account when choosing research topics (35 percent vs. 14 percent, P<0.001). CONCLUSIONS: Faculty members with industrial research support are at least as productive academically as those without such support and are more productive commercially. However, faculty members who have research relationships with industry are more likely to restrict their communication with colleagues, and high levels of industrial support may be associated with less academic activity without evidence of proportional increases in commercial productivity.

Biology↗
PubMed1996

TennCare and academic medical centers: the lessons from Tennessee.

OBJECTIVE: To ascertain the potential impact of public-sector-driven health system reform (Medicaid and Medicare programs) on academic medical centers (AMCs). DESIGN: A qualitative, case-study investigation of how 2 of Tennessee's 4 AMCs were affected by the TennCare program, which enrolled all of the state's Medicaid recipients and a sizable portion of its uninsured in managed care organizations (MCOs) in January 1994. METHODS: We reviewed pertinent documents related to the AMCs, response to TennCare; interviewed AMC executives and staff, state officials, and representatives of MCOs serving TennCare beneficiaries; and conducted site visits at both AMCs. MAIN OUTCOME MEASURES: Changes in clinical revenues, clinical volume, patient selection, support for the AMCs, teaching and research missions, and the AMCs' response to these changes. RESULTS: Both AMCs studied experienced large revenue shortfalls, the closure of some specialty services, adverse patient selection, and loss of the patient volume needed to do clinical research, and had to reduce the number of training program positions. Longer-term consequences of TennCare for AMCs may include the integration of community-based services into academic missions, the acceleration of clinical diversification, and the attainment of experience in managed care, anticipating the evolution of the private-sector market. CONCLUSIONS: The consequences of public-sector health system reform for AMCs are similar to, and equally as challenging as, the effects of private-sector changes in health care delivery. Important differences include the rapidity with which public-sector reforms can transform the AMC market, the vulnerability of special payments to AMCs, such as graduate medical education funding, and the accountability of managers of public-sector initiatives to the political process. It remains to be seen whether public-sector reforms will afford some competitive advantage to AMCs over the long term.

Academic Medical Centers↗