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Biomedical subjects

D K Martin

Publications and source records attributed to D K Martin.

At least 19 recordsLinked to original sources
PubMed2003

Access to intensive care unit beds for neurosurgery patients: a qualitative case study.

OBJECTIVES: The purpose of this study was to describe the process used to decide which patients are admitted to the intensive care unit (ICU) at a hospital with special focus on access for neurosurgery patients, and evaluate it using "accountability for reasonableness". METHODS: Qualitative case study methodology was used. Data were collected from documents, interviews with key informants, and observations. The data were subjected to thematic analysis and evaluated using the four conditions of "accountability for reasonableness" (relevance, publicity, appeals, enforcement) to identify good practices and opportunities for improvement. RESULTS: ICU admissions were based on the referring physician's assessment of the medical need of the patient for an ICU bed. Non-medical criteria (for example, family wishes) also influenced admission decisions. Although there was an ICU bed allocation policy, patient need always superceded the bed allocation policy. ICU admission guidelines were not used. Admission decisions and reasons were disseminated to the ICU charge nurse, the bed coordinator, the ICU resident, the intensivist, and the requesting physician/surgeon by word of mouth and by written documentation in the patient's chart, but not to the patient or family. Appeals occurred informally, through negotiations between clinicians. Enforcement of relevance, publicity, and appeals was felt to be either non-existent or deficient. CONCLUSIONS: Conducting a case study of priority setting decisions for patients requiring ICU beds, with a special focus on neurosurgical patients, and applying the ethical framework "accountability for reasonableness" can help critical care units improve the fairness of their priority setting.

Decision Making↗
PubMed2001

Priority-setting decisions for new cancer drugs: a qualitative case study.

BACKGROUND: Frameworks for legitimate and fair priority setting emphasise the importance of the rationales for priority setting decisions. However, priority setting rationales, in particular for new cancer drugs, are not well described. We describe the rationales used by a committee making funding decisions for new cancer drugs. METHODS: We did a qualitative case study of a priority setting committee (Cancer Care Ontario Policy Advisory Committee for the New Drug Funding Program) by analysing documents, interviewing committee members, and observing committee meetings. FINDINGS: We identified and described decisions and rationales related to 14 drugs in eight disease conditions over 3 years. Our main findings were that: priority setting existed in relation to resource mobilisation; clinical benefit was the primary factor in decisions; in the context of an expanding budget, rationales changed; rationales could change as costs for individual treatments increased; when all options were reasonable, groups funded a range of options and let patients decide; and priority setting rationales involve clusters of factors, not simple trade-offs. INTERPRETATION: Observing priority-setting decisions and their rationales in actual practice reveals lessons not contained in theoretical accounts.

Antineoplastic Agents↗
PubMed2001

Waiting lists for radiation therapy: a case study.

BACKGROUND: Why waiting lists arise and how to address them remains unclear, and an improved understanding of these waiting list "dynamics" could lead to better management. The purpose of this study is to understand how the current shortage in radiation therapy in Ontario developed; the implications of prolonged waits; who is held accountable for managing such delays; and short, intermediate, and long-term solutions. METHODS: A case study of the radiation therapy shortage in 1998-99 at Princess Margaret Hospital, Toronto, Ontario, Canada. Relevant documents were collected; semi-structured, face-to-face interviews with ten administrators, health care workers, and patients were conducted, audio-taped and transcribed; and relevant meetings were observed. RESULTS: The radiation therapy shortage arose from a complex interplay of factors including: rising cancer incidence rates; broadening indications for radiation therapy; human resources management issues; government funding decisions; and responsiveness to previous planning recommendations. Implications of delays include poorer cancer control rates; patient suffering; and strained doctor-patient relationships. An incompatible relationship exists between moral responsibility, borne by government, and legal liability, borne by physicians. Short-term solutions include re-referral to centers with available resources; long-term solutions include training and recruiting health care workers, improving workload standards, increasing compensation, and making changes to the funding formula. CONCLUSION: Human resource planning plays a critical role in the causes and solutions of waiting lists. Waiting lists have harsh implications for patients. Accountability relationships require realignment.

Cancer Care Facilities↗
PubMed2000

Priority setting for new technologies in medicine: qualitative case study.

OBJECTIVE: To describe priority setting for new technologies in medicine. DESIGN: Qualitative study using case studies and grounded theory. SETTING: Two committees advising on priorities for new technologies in cancer and cardiac care in Ontario, Canada. PARTICIPANTS: The two committees and their 26 members. MAIN OUTCOME MEASURES: Accounts of priority setting decision making gathered by reviewing documents, interviewing members, and observing meetings. RESULTS: Six interrelated domains were identified for priority setting for new technologies in medicine: the institutions in which the decision are made, the people who make the decisions, the factors they consider, the reasons for the decisions, the process of decision making, and the appeals mechanism for challenging the decisions. CONCLUSION: These domains constitute a model of priority setting for new technologies in medicine. The next step will be to harmonise this description of how priority setting decisions are made with ethical accounts of how they should be made.

Costs and Cost Analysis↗
PubMed2000

An entrustment model of consent for surgical treatment of life-threatening illness: perspective of patients requiring esophagectomy.

OBJECTIVE: Consent to treatment has been extensively discussed and prescribed from the viewpoint of law, ethics, and policy experts; the viewpoint of patients is less well represented. The purpose of this study was to describe the process of decision making and consent to surgical treatment from the patients' perspective, in the context of life-threatening illness. METHODS: Face-to-face interviews with 36 patients who had recovered from esophagectomy for cancer at university hospitals in Toronto, Ontario, were analyzed by means of a qualitative analytic approach. RESULTS: Instead of the accepted model of informed consent and shared decision making, patients identified 6 concepts that describe their experience: (1) cultural belief in surgical cure, (2) enhancement of trust through the referral process, (3) idealization of the specialist surgeon, (4) belief in expertise rather than medical information, (5) resignation to risks of treatment, and (6) acceptance of an expert recommendation as consent to treatment. These concepts were developed into a model of entrustment that unites the narratives of all our patients. CONCLUSIONS: There is a gap between accepted legal and ethical theories concerning consent and the patients' account of their experiences with surgical treatment of esophageal cancer. Although our findings should not be used to circumvent the ethical and legal requirements of the consent process and are limited to survivors of treatment of life-threatening disease, they support a careful reassessment of informed consent that includes the perspective of patients.

Adult↗
PubMed1999

Sensitive and selective gas chromatographic methods for the quantitation of camphor, menthol and methyl salicylate from human plasma.

Analytical methods using gas chromatography-flame ionization detection (GC-FID) for the quantitation of camphor and menthol and GC-MS for the quantitation of methyl salicylate have been developed for measurement of low concentrations from human plasma. Anethole serves as the internal standard for camphor and menthol and ethyl salicylate serves as the internal standard for methyl salicylate. Plasma samples undergo multiple, sequential extractions with hexane in order to provide optimal recovery. For menthol and camphor, the extracting solvent is reduced in volume and directly injected onto a capillary column (Simplicity-WAX). Extracted methyl salicylate is derivatized with BSTFA prior to injection onto a capillary column (Simplicity-5). Between-day variation (% RSD) at 5 ng/ml varies from 6.2% for methyl salicylate to 13.5% for camphor. The limit of detection for each analyte is 1 ng/ml and the limit of quantitation is 5 ng/ml. These analytical methods have been used in a clinical study to assess exposure from dermally applied patches containing the three compounds.

Camphor↗
PubMed1999

Quality end-of-life care: patients' perspectives.

CONTEXT: Quality end-of-life care is increasingly recognized as an ethical obligation of health care providers, both clinicians and organizations. However, this concept has not been examined from the perspective of patients. OBJECTIVE: To identify and describe elements of quality end-of-life care from the patient's perspective. DESIGN: Qualitative study using in-depth, open-ended, face-to-face interviews and content analysis. SETTING: Toronto, Ontario. PARTICIPANTS: A total of 126 participants from 3 patient groups: dialysis patients (n = 48), people with human immunodeficiency virus infection (n = 40), and residents of a long-term care facility (n = 38). OUTCOME MEASURES: Participants' views on end-of-life issues. RESULTS: Participants identified 5 domains of quality end-of-life care: receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving burden, and strengthening relationships with loved ones. CONCLUSION: These domains, which characterize patients' perspectives on end-of-life care, can serve as focal points for improving the quality of end-of-life care.

Adult↗
PubMed1999

A new model of advance care planning: observations from people with HIV.

BACKGROUND: Although theoretical concepts from ethics and law have been applied, there is no conceptual model of advance care planning rooted in the perspective of individuals engaged in it. OBJECTIVE: To develop a conceptual model of advance care planning by examining the perspectives of individuals engaged in it. METHODS: In this qualitative research, we studied 140 individuals with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome who were engaged in advance care planning. Respondents' experience with and opinions about advance care planning were noted in interviews that were audiotaped, transcribed, and analyzed. RESULTS: The primary goal of advance care planning was to prepare for death, which entailed facing death, achieving a sense of control, and strengthening relationships. CONCLUSIONS: We have developed a conceptual model of advance care planning rooted in the perspectives of individuals engaged in it. The model has implications for theory, research, and practice regarding end-of-life care.

Acquired Immunodeficiency Syndrome↗
PubMed1999

The Regenstrief Medical Record System: a quarter century experience.

Entrusted with the records for more than 1.5 million patients, the Regenstrief Medical Record System (RMRS) has evolved into a fast and comprehensive data repository used extensively at three hospitals on the Indiana University Medical Center campus and more than 30 Indianapolis clinics. The RMRS routinely captures laboratory results, narrative reports, orders, medications, radiology reports, registration information, nursing assessments, vital signs, EKGs and other clinical data. In this paper, we describe the RMRS data model, file structures and architecture, as well as recent necessary changes to these as we coordinate a collaborative effort among all major Indianapolis hospital systems, improving patient care by capturing city-wide laboratory and encounter data. We believe that our success represents persistent efforts to build interfaces directly to multiple independent instruments and other data collection systems, using medical standards such as HL7, LOINC, and DICOM. Inpatient and outpatient order entry systems, instruments for visit notes and on-line questionnaires that replace hardcopy forms, and intelligent use of coded data entry supplement the RMRS. Physicians happily enter orders, problems, allergies, visit notes, and discharge summaries into our locally developed Gopher order entry system, as we provide them with convenient output forms, choice lists, defaults, templates, reminders, drug interaction information, charge information, and on-line articles and textbooks. To prepare for the future, we have begun wrapping our system in Web browser technology, testing voice dictation and understanding, and employing wireless technology.

Computer Terminals↗
PubMed1998

Racial disparity in cardiac decision making: results from patient focus groups.

BACKGROUND: While numerous studies suggest that African Americans receive fewer invasive cardiac procedures than whites, the basis for these treatment differences is not understood. METHODS: We conducted focus group sessions with patients who had received treatment in the hospital or the emergency department within the preceding 3 months for ischemic heart disease at 2 urban, university-affiliated hospitals. RESULTS: Discussions with patients identified the following factors that influenced their decision making: clarity, simplicity, and consistency of treatment recommendations; advice from friends and family about whether to accept recommendations; availability to speak with others who accepted similar recommendations; and having honest and caring physicians. African American patients identified the following additional factors that influenced their decision making: perceptions of health care discrimination; perceptions of undesirable physician behavior; faith in God to control one's destiny; and patient-physician camaraderie. CONCLUSIONS: Participants identified common issues influencing health care decision making, regardless of race. However, additional factors were expressed only by African American participants. These factors conveyed racial differences in perceptions of the health care system that may, in part, contribute to differences in health care decision making and treatment.

Black or African American↗
PubMed1998

Reconceptualizing advance care planning from the patient's perspective.

BACKGROUND: Traditional academic assumptions about advance care planning (ACP) include the following: (1) the purpose of ACP is preparing for incapacity; (2) ACP is based on the ethical principle of autonomy and the exercise of control; (3) the focus of ACP is completing written advance directive forms; and (4) ACP occurs within the context of the physician-patient relationship. These assumptions about ACP have never been empirically validated. OBJECTIVE: To examine the traditional academic assumptions by exploring ACP from the perspective of patients actively participating in the planning process. METHODS: Forty-eight patients (30 men and 18 women with a mean age of 48.3 years) who were undergoing hemodialysis were interviewed 6 months after receiving an advance directive form. Their experience of ACP was noted in interviews that were audiotaped, transcribed, and analyzed. RESULTS: The participants said that their purpose in ACP was to prepare for death and dying, and their underlying goals included the exercise of control and an attempt to relieve burdens placed on loved ones. Advance care planning was viewed as a social process, and completing a written advance directive form was often regarded as unnecessary. Participants often involved close loved ones, but physicians infrequently. CONCLUSIONS: The traditional academic assumptions are not fully supported from the perspective of patients involved in ACP. The patients we interviewed stated that (1) the purpose of ACP is not only preparing for incapacity but also preparing for death; (2) ACP is not based solely on autonomy and the exercise of control, but also on personal relationships and relieving burdens placed on others; (3) the focus of ACP is not only on completing written advance directive forms but also on the social process; and (4) ACP does not occur solely within the context of the physician-patient relationship but also within relationships with close loved ones.

Adult↗
PubMed1998

Can raters consistently evaluate the content of focus groups?

Focus groups are increasingly being used to provide insights to researchers and policy makers. These data complement quantitative approaches to understanding the world. Unfortunately, quantitative and qualitative methodologies have often been viewed as antithetical, rather than complementary, strategies. While focus groups can clearly generate rich information that is unobtainable through other quantitative methods, it is important to determine the degree to which different raters can consistently extract information from transcripts. Thus, our goal was to quantify agreement in the interpretation of transcripts from patient and physician focus groups, using decision-making in ischemic heart disease as a model. We used data from focus groups with both patients and physicians that sought to identify factors affecting diagnostic and treatment decisions in ischemic heart disease. Three raters independently reviewed transcribed audiotapes from focus groups of patients with ischemic heart disease, as well as focus groups of physicians who care for these patients. We found that raters could not distinguish between major and minor factors reliably. More troubling, however, is that consistency regarding the apparently straightforward judgment as to the mere presence or absence of a factor was difficult to achieve. In particular, the three raters of each transcript failed to agree on between one third and one half of the factors. This reasonably high level of disagreement occurred despite the raters: (1) having generated the individual factors themselves based upon their reading a random sample of actual transcripts and (2) being trained in the use of rating forms (including standard definitions of themes). These data suggest that if a single rater evaluates focus group transcripts, as is commonly done, judgments may not be reproducible by other raters. Moreover, a single rater may not extract all important information contained in the transcripts.

Female↗