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Biomedical subjects

E A Balas

Publications and source records attributed to E A Balas.

At least 37 records · Page 2Linked to original sources
PubMed1997

Electronic communication with patients. Evaluation of distance medicine technology.

OBJECTIVE: To evaluate controlled evidence on the efficacy of distance medicine technologies in clinical practice and health care outcome. DATA SOURCES: Systematic electronic database and manual searches (1966-1996) were conducted to identify clinical trial reports on distance medicine applications. STUDY SELECTION: Three eligibility criteria were applied: prospective, contemporaneously controlled clinical trial with random assignment of the intervention; electronic distance technology application in the intervention group and no similar intervention in the control group; and measurement of the intervention effect on process or outcome of care. DATA EXTRACTION: Data were abstracted by independent reviewers using a standardized abstraction form and the quality of methodology was scored. Distance technology applications were described in 6 categories: computerized communication, telephone follow-up and counseling, telephone reminders, interactive telephone systems, after-hours telephone access, and telephone screening. DATA SYNTHESIS: Of 80 eligible clinical trials, 61 (76%) analyzed provider-initiated communication with patients and 50 (63%) reported positive outcome, improved performance, or significant benefits, including studies of computerized communication (7 of 7), telephone follow-up and counseling (20 of 37), telephone reminders (14 of 23), interactive telephone systems (5 of 6), telephone access (3 of 4), and telephone screening (1 of 3). Significantly improved outcomes were demonstrated in studies of preventive care, management of osteoarthritis, cardiac rehabilitation, and diabetes care. CONCLUSIONS: Distance medicine technology enables greater continuity of care by improving access and supporting the coordination of activities by a clinician. The benefits of distance technologies in facilitating communication between clinicians and patients indicate that application of telemedicine should not be limited to physician-to-physician communication.

Communication↗
PubMed1997

In search of controlled evidence for health care quality improvement.

The purpose of this study was to measure the efficiency of simple searches in retrieving controlled evidence about specific primary health care quality improvement interventions and their effects. Searches were conducted to retrieve evidence on seven interventions and seven effect variables. Specific words and the closest Medical Subject Headings (MeSH) recommended by professional librarians were used to search the MEDLINE database. Searches were restricted to the MeSH publication type "randomized controlled trial." Two reviewers independently judged retrieved citations for relevancy to the selected interventions and effects. In selecting MeSH terms, the average agreement among librarians was 64.3% (+/-26.1) for interventions and 57.1% (+/-19.9) for effects. Analysis of the 755 retrieved reports showed that MeSH term searches had an overall recall rate of 58% while the same rate for textword searches was significantly lower (11%, p < .001). The difference in overall precision rates was nonsignificant (26% versus 33%, p = .15). In the group of MeSH searches, overall precision and recall was significantly lower for effects than for interventions (12% versus 52%, p < .001 and 41% versus 69%, p < .001). Two textwords appeared in more than 25% of the benchmark collection: reminder (25.7%) and cost (25.0%). The results of this study indicate that information needs for health care quality improvement cannot be met by simple literature searches. Certain MeSH terms and combinations of textwords yield moderately efficient recall and precision in literature searches for health care quality improvement. Clinicians and physician executives gaining direct access to bibliographic database could probably be better served by structured indexing of critical aspects of randomized controlled clinical trials: design, sample, interventions, and effects.

Abstracting and Indexing↗
PubMed1997

Clinical trials of interactive computerized patient education: implications for family practice.

A systematic review of randomized clinical trials was conducted to evaluate the acceptability and usefulness of computerized patient education interventions. The Columbia Registry, MEDLINE, Health, BIOSIS, and CINAHL bibliographic databases were searched. Selection was based on the following criteria: (1) randomized controlled clinical trials, (2) educational patient-computer interaction, and (3) effect measured on the process or outcome of care. Twenty-two studies met the selection criteria. Of these, 13 (59%) used instructional programs for educational intervention. Five studies (22.7%) tested information support networks, and four (18%) evaluated systems for health assessment and history-taking. The most frequently targeted clinical application area was diabetes mellitus (n = 7). All studies, except one on the treatment of alcoholism, reported positive results for interactive educational intervention. All diabetes education studies, in particular, reported decreased blood glucose levels among patients exposed to this intervention. Computerized educational interventions can lead to improved health status in several major areas of care, and appear not to be a substitute for, but a valuable supplement to, face-to-face time with physicians.

Adolescent↗
PubMed1997

Technique for efficient information retrieval in outpatient systems.

In the era of managed care, quality of medical care standards continue to materialize. Most of these standards have long, cumbersome, and complex rules. In light of such problematic rules, efficient ways of retrieving information for a computerized score card are needed. A technique for making such rules less difficult to use is to create Boolean expressions for each quality of care indicator. These Boolean expressions partition the indicators into key words and phrases so that information can be retrieved readily from a system. This study incorporates an outpatient clinical information system of a major university hospital. The technique used to retrieve information and related issues are discussed in the following text.

Ambulatory Care↗
PubMed1996

The clinical value of computerized information services. A review of 98 randomized clinical trials.

OBJECTIVE: To review all randomized clinical trials addressing the efficacy of clinical information systems and to determine the clinical settings, types of interventions, and effects studied. DATA SOURCES: Extensive and systematic MEDLINE searches were conducted using a combination of medical subject headings (MeSH) and textword terms to collect trial reports. Manual searches of books and monographs as well as informal contacts were also used. STUDY SELECTION: The eligibility criteria were (1) randomized controlled clinical trial, (2) computerized information intervention in the study group, and (3) effect measured on the process or outcome of care. DATA EXTRACTION: Two research assistants independently abstracted from the selected reports the following structured information: trial sites, computerized interventions, effect variables, and outcomes. Three investigators evaluated the combined list of trial features for setting, intervention, and effect. The statistical analysis included an evaluation of agreement in developing classifications and an analysis of the ratio of positive trial outcomes. DATA SYNTHESIS: Most information services were tested in outpatient care (82%), particularly in primary care (66%). The information intervention targeted the provider in 64% of the trials. The effect was primarily measured for the process of care (76%). Provider prompt/reminder, computer-assisted treatment planner, interactive patient education/therapy, and patient prompt/reminder were significantly successful interventions (sign test, P < .05). CONCLUSIONS: Randomized clinical trials confirm that four generic information interventions are active ingredients of computer systems and can make a significant difference in family medicine (physician and patient reminders, treatment planner, and patient education). To manage care and improve quality, primary care computer systems should incorporate these effective information services.

Information Systems↗
PubMed1996

Effect of physician profiling on utilization. Meta-analysis of randomized clinical trials.

OBJECTIVES: An American Medical Association survey reported that more than half of physicians are subjects of either clinical or economic profiling. This multilevel meta-analysis was designed to assess the clinical effect of peer-comparison feedback intervention (profiles) in changing practice patterns. METHODS: Systematic computerized and manual searches were combined to retrieve articles on randomized controlled clinical trials testing profiling reports. Eligible studies were randomized, controlled clinical trials that tested peer-comparison feedback intervention and measured utilization of clinical procedures. To use all available information, data were abstracted and analyzed on three levels: (1) direction of effects, (2) p value fro the statistical comparison, and (3) odds ratio (OR). MAIN RESULTS: In the 12 eligible trials, 553 physicians were profiled. The test result was p < .05 for the vote-counting sign test of 12 studies (level 1) and p < .05 for the z-transformation test of 8 studies (level 2). There were 5 trials included in the OR analysis (level 3). The primary effect variable in two of the 5 trials had a nonsignificant OR. However, the overall OR calculated by the Mantel-Haenszel method was significant (1.091, confidence interval: 1.045 to 1.136). CONCLUSIONS: Profiling has a statistically significant, but minimal effect on the utilization of clinical procedures. The results of this study indicate a need for controlled clinical evaluations before subjecting large numbers of physicians to utilization management interventions.

Confidence Intervals↗
PubMed1996

Developing quality indicators as educational tools to measure the implementation of clinical practice guidelines.

Our objective was to explore expectations and recommendations for the development of measurable quality indicators as educational tools to implement clinical practice guidelines. A survey using structured personal interviews with a stratified sample of 20 health professionals was made. Questions analyzed preferences in evaluating quality of care, measuring discrepancies between clinical guidelines and actual practice patterns, and the development of quality indicators. All of our participants (100%) reported that the compliance with established and widely accepted clinical guidelines is an important quality indicator. Health professionals indicated 1.8 (+/- 1.1) overall preference of our developed quality indicators for the management of depression. Although most currently used quality indicators focus either on the process or on the outcome of care, health professionals strongly prefer indicators that measure both. Our measurable quality indicators were found to have wide acceptance without major differences among primary care physicians, medical directors, and health benefit managers.

Adult↗
PubMed1996

Contrasting RCC, RVU, and ABC for managed care decisions. A case study compares three widely used costing methods and finds one superior.

To obtain cost data needed to improve managed care decisions and negotiate profitable capitation contracts, most healthcare provider organizations use one of three costing methods: the ratio-of-costs-to-charges method, the relative value unit method, or the activity-based costing method. Although the ratio-of-costs to charges is used by a majority of provider organizations, a case study that applied these three methods in a renal dialysis clinic found that the activity-based costing method provided the most accurate cost data. By using this costing method, healthcare financial managers can obtain the data needed to make optimal decisions regarding resource allocation and cost containment, thus assuring the longterm financial viability of their organizations.

Capitation Fee↗
PubMed1995

Financial effect of clinical decisions: case study of a dialysis center.

The purpose of this study was to specify the financial effect of clinical decisions in a dialysis center. A consecutive sample of 14,343 outpatient hemodialysis treatments (OHD), 16,111 continuous ambulatory peritoneal dialysis (CAPD), and 4,513 chronic cycler-assisted peritoneal dialysis (CCPD) days of treatment was analyzed. An activity-based cost calculation method was applied to the analysis of alternative treatments (service bundles). The weekly cost of OHD was higher ($338 versus $241/$242), and the contribution margin (reimbursement minus total cost) of CAPD/CCPD was much greater ($.48 versus $148/$147 per patient week). Clinical decision-making had an influence on less than 6.8% of OHD and 45.4%/46.6% of CAPD/CCPD related expenses. In comparison to activity-based cost calculation, conventional methods overestimated the overhead expense of CAPD by 3-48%. This study documented that most cost control opportunities reside in the usual process of care and less can be influenced by a direct interference with the patient-physician contacts. Paying for 1 week of renal replacement (capitation) could simplify the process of reimbursement and cost tracking.

Ambulatory Care Facilities↗
PubMed1995

Methods of randomized controlled clinical trials in health services research.

The randomized controlled clinical trial is an increasingly used method in health services research. Analysis of methodology is needed to accelerate practical implementation of trial results, select trials for meta-analysis, and improve trial quality in health services research. The objectives of this study are to explore the methodology of health services research trials, create and validate a streamlined quality evaluation tool, and identify frequent quality defects and confounding effects on quality. The authors developed a quality questionnaire that contained 20 evaluation criteria for health services research trials. One hundred one trials from the Columbia Registry of Controlled Clinical Trials were evaluated using the new quality tool. The overall agreement between independent reviewers, Cohen's kappa, was 0.94 (+/- 0.01). Of a possible score of 100, the trials received an average score of 54.8 (+/- 12.5). Five evaluation criteria indicated significant quality deficiencies (sample size, description of case selection, data on possible adverse effects, analysis of secondary effect variables, and retrospective analysis). The quality of study characteristics was significantly weaker than the quality of reporting characteristics (P < 0.001). The total average scores of Medline-indexed journals were better than the non-Medline-indexed journals (P < 0.001). There was a positive correlation between the overall quality and year of publication (R = 0.21, P < 0.05). The authors conclude that the new quality evaluation tool leads to replicable results and there is an urgent need to improve several study characteristics of clinical trials. In comparison to drug trials, site selection, randomization, and blinding often require different approaches in health services research.

Evaluation Studies as Topic↗
PubMed1995

Multipurpose practice guideline modules for clinical decision analysis and quality improvement.

This study aimed to measure the loss of information in communication between clinical researchers and information system developers, to design a tool for sharing clinical practice guidelines, and to test the feasibility of this tool in knowledge base development. The analysis of a sample of 101 randomized controlled clinical trials indicated that exact numeric results were published in only 64 percent of the trials. While structured abstracts were associated with improved total quality scores (p0.001), there was no significant improvement in reporting numeric results (p=0.31). Based on the documented loss of information and the needs of various parties involved, the concept of a multipurpose knowledge module was developed for sharing clinical practice recommendations. Such clinical practice guideline modules were applied in developing the knowledge base of a quality feedback expert system (QFES).

Abstracting and Indexing↗
PubMed1994

How to structure clinical practice guidelines for continuous quality improvement?

The purpose of this study was to evaluate the relevance of available practice guidelines to clinical quality improvement programs. A sample of 19 guidelines was evaluated in four prominent primary care areas. Two research assistants independently coded the clinical conditions and recommended/not recommended procedures abstracted from the guidelines (Cohen's kappa .67 and .50, respectively). An average of 35.1 (+/- 25.8) medical conditions and 48.4 (+/- 41.5) clinical procedures were defined by the guidelines. Most conditions were defined by using ICD-9-CM, age/sex group, or therapy, but 29% of definitions included symptoms which are not coded routinely. CPT codes alone were unable to identify most procedures. AHCPR guidelines mentioned significantly more procedures (p < .001) and fewer symptoms (p < .001) per clinical condition than other guidelines. The difficulty of finding codes for conditions and procedures, the high rate of non-codable items, and the lack of recommended measures limit the applicability of published clinical practice guidelines to continuous quality improvement programs.

Age Factors↗
PubMed1994

Effect of physician reminders on preventive care: meta-analysis of randomized clinical trials.

The objective of this study was to assess the clinical value of the physician reminder, an information intervention, in increasing compliance for selected preventive health care measures. Meta-analysis was used to combine the quantitative evidence from randomized controlled clinical trials meeting the eligibility criteria. The trials included in this meta-analysis were conducted in a family or internal medicine clinic. Physician reminders were used in the trials to influence utilization and compliance of preventive health care activities. The use of physician reminders for preventive health care activities resulted in a homogeneous effect for the subcategories of cervical cancer screening (test for heterogeneity X2(2) = 4.122, non-significant) and tetanus immunization (test for heterogeneity X2(2) = 3.139, non-significant). Similarly, the odds ratio from the combination of evidence from the three cervical cancer screening trials was significant (1.180, 95 percent CI: 1.020 to 1.339). The resulting odds ratio from the combination of evidence from the three tetanus immunization trials was significant (2.819, 95 percent CI: 2.664 to 2.975). The results of the meta-analyses for cervical cancer screening and tetanus immunizations indicate that physician reminders are an effective information intervention and can improve compliance for these two preventive health care procedures. Based on the results of this meta-analysis, further trials testing the effect of physician reminders on tetanus immunization would be unnecessary and probably unethical.

Female↗
PubMed1994

A decision-support system for the analysis of clinical practice patterns.

Several studies documented substantial variation in medical practice patterns, but physicians often do not have adequate information on the cumulative clinical and financial effects of their decisions. The purpose of developing an expert system for the analysis of clinical practice patterns was to assist providers in analyzing and improving the process and outcome of patient care. The developed QFES (Quality Feedback Expert System) helps users in the definition and evaluation of measurable quality improvement objectives. Based on objectives and actual clinical data, several measures can be calculated (utilization of procedures, annualized cost effect of using a particular procedure, and expected utilization based on peer-comparison and case-mix adjustment). The quality management rules help to detect important discrepancies among members of the selected provider group and compare performance with objectives. The system incorporates a variety of data and knowledge bases: (i) clinical data on actual practice patterns, (ii) frames of quality parameters derived from clinical practice guidelines, and (iii) rules of quality management for data analysis. An analysis of practice patterns of 12 family physicians in the management of urinary tract infections illustrates the use of the system.

Artificial Intelligence↗
PubMed1994

Decision support systems: fact and fiction.

Computers perform tasks daily that aid people in the completion of their duties; computers help drive cars, cook food, entertain, and support our decision making processes. Often a silent partner, the computer is involved in tasks that a health professional provides. Modern ECG machines, infusion pumps, blood analyzers, ventilators, and imaging machines contain computers that aid in the use of these devices. Though not traditionally considered decision support systems, these diagnostic systems support the decision making process in health care. Shortliffe EH et al define the kinds of decision support systems by the roles they play in the decision making process. The authors state that any computer system that deals with clinical data or medical knowledge is intended to provide decision support. This article will discuss fact and fiction regarding decision support systems beginning with information systems that support the decision making process to more sophisticated knowledge based systems that provide interpretation and analysis of data.

Decision Support Systems, Management↗
PubMed1993

Quality evaluation of controlled clinical information service trials.

Randomized controlled clinical trials are increasingly accepted as tools of computer technology assessment and, therefore, quality evaluation of trials has great theoretical and practical significance. The purpose of this study was to assist the design of evaluation studies and synthesis of published results by developing and validating an easy-to-use quality scoring method. The development of the new scoring system was based on the available quality evaluation methods and the analysis of 19 trial reports registered in the Columbia Registry of Controlled Clinical Information Service Trials. First critical aspects and afterwards the levels of quality were defined. In spite of the fact that all quality requirements were met by some trials, the average overall quality score was 52.6 (+/- 8.7) per cent. The minimum score was 37 and the maximum was 72 per cent. Data collection and site/sample definition were better in the good quality trials, but improvement in statistical analysis was erratic. The quality scoring method was validated by using another sample of 20 registered trials. While the number of published controlled clinical trials is increasing in medical informatics, the analysis was unable to demonstrate a significant positive correlation between the quality and year of publication.

Evaluation Studies as Topic↗
PubMed1993

Computerized medical records. Dream or reality?

For over 25 years many clinicians and others working in health-related fields have envisioned the day when physicians will use a computer on their desk or at the bedside to enter and retrieve the medical records and other information needed to care for their patients. Pioneers in medical informatics have been working during this time to develop the concepts and systems to make this possible, but so far, with only a few exceptions, this has been still mostly a dream. However, we may now be on the threshold of the time when these systems will be implemented on a large scale and become an integral part of the practice of clinical medicine, making the vision no longer a dream but a reality.

Humans↗