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Biomedical subjects

D W Molloy

Publications and source records attributed to D W Molloy.

At least 19 recordsLinked to original sources
PubMed1995

Physician characteristics and prescribing for elderly people in New Brunswick: relation to patient outcomes.

OBJECTIVE: To examine the relation between physician characteristics, prescribing behaviour and patient outcomes. DESIGN: Descriptive study linking four provincial databases. SETTING: New Brunswick. PARTICIPANTS: All 366 general practitioners (GPs) (accounting for 40% of all physicians with a general licence in New Brunswick) who ordered at least 200 prescriptions for elderly beneficiaries of the New Brunswick Prescription Drug Program and saw at least 20 elderly patients in an office setting between Apr. 1, 1990, and Mar. 31, 1991. Physicians with palliative care practices were excluded. OUTCOME MEASURES: GPs' personal, professional and practice characteristics, their prescribing patterns, and mortality, morbidity (number of days in hospital per patient) and hip-fracture rates among their elderly patients. RESULTS: Compared with the GPs who had a lower mortality rate, those with a higher mortality rate prescribed more drugs overall (p < 0.001), specifically antidepressants, bronchodilators, cholesterol-lowering agents, gastrointestinal drugs, neuroleptics and nonsteroidal anti-inflammatory drugs (NSAIDs). They also were more likely to be male (p < 0.01), had larger practices (p < 0.001), saw more patients per day (p < 0.05) and billed more per year (p < 0.001). Compared with the GPs who had a lower morbidity rate, those with a higher morbidity rate prescribed more drugs overall (p < 0.005), specifically bronchodilators, gastrointestinal drugs and NSAIDs. They also were more likely to be younger (p < 0.005) and male (p < 0.01), had fewer years in practice (p < 0.001), saw more patients per day (p < 0.05) and billed more per patient (p < 0.01). The GPs who had a higher hip-fracture rate prescribed more drugs overall (p < 0.001), notably antihypertensives, bronchodilators, cholesterol-lowering agents, gastrointestinal drugs and NSAIDs, than those who had a lower hip-fracture rate. They also had a larger practice (p < 0.001), practised more days per year (p < 0.005), had more patient visits per year (p < 0.05) and billed more per year (p < 0.001). Younger male GPs who practised with relatively more intensity and prescribed more drugs per patient had practices with higher morbidity, mortality and hip-fracture rates among their elderly patients than the other GPs. CONCLUSIONS: There is a significant relation between certain physician characteristics, their prescribing behaviour and patient outcomes. Further study is required to determine what physician characteristics and prescribing behaviours for specific illnesses contribute to patient outcomes. Regional differences should also be examined, as should incentives in this fee-for-service system. Linkage of these types of provincial databases may help in the evaluation of physicians' performance and in the development of strategic interventions and practice guidelines.

Adult↗
PubMed1995

Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill. Canadian Critical Care Trials Group.

OBJECTIVE: To examine the attitudes of health care workers regarding the withdrawal of life support. DESIGN: Cross-sectional survey. PARTICIPANTS: Attending staff, house staff, and intensive care unit (ICU) nurses in 37 Canadian university-affiliated hospitals. MAIN OUTCOME MEASURES: Health care workers' ratings of the importance of 17 factors considered in the decision to withdraw life support, and their ratings of five levels of care ranging from comfort measures to intensive care in two of 12 different clinical scenarios. RESULTS: We surveyed 1361 respondents (149 of 167 potentially eligible ICU attending staff, 142 of 173 ICU house staff, and 1070 of 1455 ICU nurses, with response rates of 89%, 82% and 74%, respectively). The most important factors were likelihood of surviving the current episode, likelihood of long-term survival, premorbid cognitive function, and age of the patient. In choosing the level of care for the patient scenarios, the same option was chosen by more than 50% of respondents in only one of 12 scenarios; opposite extremes of care were chosen by more than 10% of the respondents in eight of 12 scenarios. Respondent characteristics affecting choices included the number of years since graduation, the city and province in which they worked, the number of beds in their ICU, and their assessment of the likelihood that they would withdraw life support in comparison with their colleagues (P < .001 for all comparisons). CONCLUSIONS: While ICU health care workers consistently identify a number of patient factors as important in decisions to withdraw care, there is extreme variability, which may be explained in part by the values of individual health care providers.

Adult↗
PubMed1995

Measuring patient and relative satisfaction with level or aggressiveness of care and involvement in care decisions in the context of life threatening illness.

The objective of the study was to develop valid and reliable discriminative indices which measure patient and relative satisfaction with two closely related aspects of medical care: the level of care received and their involvement in decisions regarding care. We generated items by literature review and interviews with patients, relatives, and health care providers. In the final questionnaires, we included the items identified most frequently as sources of dissatisfaction and rated most important by 102 patients and 153 relatives. To measure reliability and validity we administered the instruments to 105 patients and 75 relatives of competent patients and 89 relatives of incompetent patients. We constructed three questionnaires: the Patient Satisfaction Index with 23 items, the Relative of Competent Patient Satisfaction Index with 34 items, and the Relative of Incompetent Patient Satisfaction Index with 29 items. We found mean scores of 75-80% of the maximum possible score, with a wide range of scores. The intraclass correlation for the instruments varied from 0.86 to 0.94. Correlations with global ratings were high (0.59-0.75) and similar to predictions. Correlations with caregiver ratings were lower than predicted (0.18-0.22). For both patients and relatives, our instruments discriminate between those with higher and lower satisfaction with the level of medical care and with their involvement with decision-making.

Aged↗
PubMed1995

Clinical trials in cognitively impaired older adults: home versus clinic assessments.

OBJECTIVE: To compare the reliability of instruments used in clinical trials involving cognitively impaired older adults when the instruments are administered in-home rather than in-clinic and to compare withdrawal rates is these two groups. DESIGN: This study was part of a larger n-of-1 clinical trial to investigate the efficacy and safety of a MAO/A inhibitor (Brofaromine) in patients with Alzheimer's disease. Participants were initially assessed at the clinic (baseline) and then randomly allocated to in-home or in-clinic assessments for the remainder of the trial. The baseline and second assessment (performed before initiation of the treatment) were used for the reliability analysis. Withdrawal rates were examined over the course of the 6-month trial. SETTING: Assessments took place at a geriatric clinic in an urban university teaching hospital and at residences of some of the patients. PARTICIPANTS: Forty-six Alzheimer's disease patients participated in the study, of which, 22 were randomized to in-home assessments and 24 to in-clinic assessments. MEASUREMENTS: Test-retest reliability was measured for all five instruments used in the study and was based on the first two assessments. Sample size requirements, based on within-group variance, were calculated. Withdrawal rates were obtained for the total duration of the trial. RESULTS: Test-retest reliability of the instruments, as determined by intraclass correlations, was good in both groups but favored in-clinic for all but one instrument (range: 0.47-0.90 for in-home vs 0.57-0.92 for in-clinic). Sample size requirements based on reliability assessment data were found to be larger for some instruments when administered in-home. Only four in-home patients withdrew before completion of the study, compared with eight in-clinic patients. CONCLUSION: The results suggest the in-home assessments in cognitively impaired older adults may result in lower withdrawal rates but may necessitate larger sample sizes to offset larger test-retest variability.

Aged↗
PubMed1995

Disabling encephalopathy during 5-fluorouracil and levamisole adjuvant therapy for resected colorectal cancer: a report of two cases.

We observed leukoencephalopathy in 1 patient, and progressive dementia in another, during the administration of 5-fluorouracil (5-FU) and levamisole. A retrospective search, among 80 other patients with resected colorectal cancer receiving 5-FU and levamisole as adjuvant therapy, 166 resected malignant melanoma patients receiving adjuvant levamisole, and 254 advanced colorectal cancer patients receiving 5-FU often combined with leucovorin, for other cases of encephalopathy was negative. The frequency of this neurotoxicity is low (about 2% of patients receiving 5-FU and levamisole), but it appears specific for this combination of drugs. The lack of complete reversibility on stopping the drugs is worrisome, as this therapy is used to improve the curability of resected colon cancer.

Adenocarcinoma↗
PubMed1994

Relation between physician characteristics and prescribing for elderly people in New Brunswick.

OBJECTIVE: To determine whether there is a relation between physician characteristics and prescribing for elderly patients. DESIGN: Descriptive study linking two provincial databases. SETTING: New Brunswick. PARTICIPANTS: All general practitioners (GPs) in New Brunswick who ordered at least 200 prescriptions for elderly beneficiaries of the New Brunswick Prescription Drug Program between Apr. 1, 1990, and Mar. 31, 1991; eligible GPs accounted for 376 (40%) of all physicians with a general licence in New Brunswick. MAIN OUTCOME MEASURES: GPs' personal and professional characteristics (age, sex, family practice accreditation, country of training and number of years in practice), practice characteristics (number of practice days, number of patients seen and medical services provided per day, average amount of billing per patient, total number of patients seen and their average age, and total amount of billings) and number of prescriptions by category of drug. RESULTS: High prescribers and low prescribers did not differ significantly in age, number of years in practice, mean practice size or patient age. Compared with the low prescribers the high prescribers were more likely to be male, have been trained in Canada and be qualified by the Canadian College of Family Physicians. Also, they had more practice days, saw more patients per day, performed more services per day, billed more per patient and billed on average 30% more during the study period. Overall, the high prescribers ordered on average 45% more prescriptions than the low prescribers. CONCLUSION: There is a significant relation between certain physician characteristics and prescribing behaviour. Further study is required to examine the relation between these variables and patient outcomes.

Accounting↗
PubMed1994

New treatments for dementia. Myth, magic, and science.

Dementia could affect 778,000 Canadians by the year 2031. While current treatment is mainly supportive, a race to find new treatments for this dreaded disease takes varied approaches and currently accounts for 10% of drug company resources. Tacrine is the first drug licensed by the US Food and Drug Administration for use in Alzheimer's disease. New treatments raise several ethical issues and involve society's attitude toward death and dying.

Acetylcarnitine↗
PubMed1994

Alzheimer's disease. Physician-patient communication.

The number of cognitively impaired elderly in Canada has increased greatly during the past two decades; nearly all have Alzheimer's disease (AD). The memory problems and changes in language and communication of these patients place tremendous strain on physicians who are searching for a differential diagnosis and are trying to communicate with them. Reviewing the salient language and communication features of AD patients leads to strategies for improving effective physician-patient communication.

Aged↗
PubMed1993

Effect of a new nootropic agent, CGS 5649B, on cognition, function, and behavior in dementia.

To determine the efficacy of CGS 5649B, the authors conducted a series of randomized, double-masked, single-subject studies using pairs of treatment periods, each pair including four weeks of active drug administration and four weeks of placebo administration. Thirty-two moderately demented patients completed three treatment pairs, receiving doses of 90, 200, or 600 mg of CGS 5649B during the active periods. Two patients met criteria for individual response in the behavioral measures. In the group analysis none of the differences achieved statistical significance. The authors conclude that CGS 5649B had a favorable impact on behavior for two of 32 patients.

Adult↗
PubMed1991

Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study.

OBJECTIVES: To determine what treatment decisions physicians will make when faced with a hypothetical incompetent elderly patient with life-threatening gastrointestinal bleeding and to examine the relative importance of physician characteristics and factors (legal and ethical concerns, hospital costs, level of dementia, patient's age, physician's religion, patient's wishes and family's wishes) in making those decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. MAIN OUTCOME MEASURES: A self-administered questionnaire describing the elderly patient. Respondents were asked to choose one of four levels of care and to identify the level of importance factors had in making that decision. Older physicians, those less concerned about litigation, those for whom the level of dementia was important and those for whom the patient's age was important were expected to give less aggressive care than the other physicians. MAIN RESULTS: Supportive care was chosen by 8.1% of the respondents, limited therapeutic care by 41.5%, maximum therapeutic care without admission to the intensive care unit (ICU) by 32.2% and maximum care with admission to the ICU by 18.2%. The patient's wishes were reported by 91.0% as being extremely or very important in choosing the treatment. Stepwise logistic regression analysis revealed that the following variables independently predicted the level of treatment: level of dementia, country of residence, duration of practice, legal concerns, patient's age and ethical concerns. These factors were significantly correlated with the physicians' treatment choices (p less than 0.05). CONCLUSIONS: The importance that the physicians placed on the level of dementia was the strongest predictor of the level of care that would be provided. A societal consensus on the influence of cognitive function on the appropriate level of care as well as training of physicians in ethical issues are required.

Adult↗
PubMed1991

A comprehensive health care directive in a home for the aged.

OBJECTIVES: To examine the use of and compliance with a new comprehensive health care directive by residents of a home for the aged and to determine the effect of the directive on the use of health care services. DESIGN: Descriptive study with a before-after design. SETTING: A home for the aged providing residential care to women. PARTICIPANTS: All 119 residents (ages 71 to 103 years, mean age 87.5 years). INTERVENTION: Introduction of a comprehensive health care directive and follow-up at 1 year. OUTCOME MEASURES: Residents' treatment choices, compliance with the directive, number of hospital admissions and length of hospital stay, number of deaths and places where deaths occurred. RESULTS: Ninety (76%) of the residents completed the directive. In the event of reversible life-threatening illness 34, 24, 11 and 21 residents requested supportive, limited, maximum and intensive care respectively. For irreversible illness the numbers were 75, 12, 3 and 0 respectively. In case of cardiac arrest 88% requested that cardiopulmonary resuscitation not be done. In the year before the introduction of the directive there were nine deaths, one in the home and eight in hospitals. In the year after there were 17 deaths, 11 in the home and 6 in hospitals. The mean length of hospital stay was significantly lower in that year than in the year before implementation (p less than 0.001). CONCLUSIONS: This innovative health care directive seems to be feasible, practical and well supported by residents, their families and health care professionals. Further studies are required to establish the generalizability and reproducibility of the data to other elderly people in institutions, to chronically ill patients and to the community at large.

Advance Directives↗
PubMed1991

Variability in physicians' decisions on caring for chronically ill elderly patients: an international study.

OBJECTIVES: To determine what treatment decisions physicians will make when faced with an incompetent elderly patient with life-threatening gastrointestinal bleeding and to identify the factors that affect their decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. OUTCOME MEASURE: A self-administered questionnaire containing three case vignettes. Each provided the same details on an incompetent elderly patient; however, one gave no information about the wishes of the patient and his family (no directive), the second provided a do-not-resuscitate (DNR) request, and the third included a detailed therapeutic and resuscitative effort chart (DTREC) requesting maximum therapeutic care without admission to the intensive care unit (ICU). The four treatment options were supportive care only, limited therapeutic care, maximum therapeutic care without admission to the ICU and maximum care with admission to the ICU. MAIN RESULTS: Treatment decisions varied and were systematically related to age, level of training and country (p less than 0.001). The older physicians and those in family medicine were less likely than the others to choose aggressive treatment options. Brazilian and US physicians were the most aggressive; Australian physicians were the most conservative. The DNR request resulted in a significant decrease in the number of physicians choosing aggressive options (p less than 0.001). The DTREC resulted in a move toward more aggressive treatment, as outlined in the directive (p less than 0.001). Overall, however, about 40% of the physicians chose a level of care different from what had been requested. Furthermore, over 10% would have tried cardiopulmonary resuscitation despite the DNR request. CONCLUSION: Treatment of incompetent elderly patients with life-threatening illness varies widely within and between countries. Uniform standards should be developed on the basis of societal values and be communicated to physicians.

Advance Directives↗
PubMed1991

Effect of tetrahydroaminoacridine on cognition, function and behaviour in Alzheimer's disease.

OBJECTIVE: To determine the efficacy of tetrahydroaminoacridine (THA) in Alzheimer's disease. DESIGN: Randomized, double-blind, multiple crossover trial with three treatment periods, each consisting of 3 weeks of active drug therapy and 3 weeks of placebo administration. SETTING: Referral-based geriatric practice in a community hospital. PATIENTS: Thirty-four patients with moderate to severe Alzheimer's disease. Subjects were included if they had stage 3 to 6 disease (as determined by the Reisberg scale) and had not been taking psychotropic drugs for at least 1 month and if informed consent had been obtained from the patients and their next of kin. INTERVENTIONS: Fifty to 100 mg of THA daily and matched placebo. RESULTS: Of the initial 34 patients 14 experienced liver toxicity and 3 gastrointestinal side effects during the study; however, all 22 who completed the study were able to tolerate at least the minimum dose. For the 22 patients there was no clinically or statistically significant effect of THA on cognition, functional status or behaviour. The results for individual patients showed no subgroup of THA-responsive patients. CONCLUSION: THA has no clinically important benefits in Alzheimer's disease and is associated with appreciable toxic effects.

Activities of Daily Living↗