Search PubMed⌕ Search

Biomedical subjects

E B Bass

Publications and source records attributed to E B Bass.

90 records · Page 5Linked to original sources
PubMed1993

Factors influencing third party payer costs for allogeneic BMT.

To assess how payer costs for allogeneic BMT relate to patient characteristics and clinical complications, a retrospective cohort study of 402 persons undergoing allogeneic BMT between 1980 and 1987 at a university-based BMT center was designed to determine total inpatient payer costs, including hospital and physician costs, and number of days hospitalized during the first 180 days following BMT. The average total inpatient payer cost (in 1990 dollars) during the first 180 days following BMT was $208,410. Inflation-adjusted inpatient payer costs increased from $227,806 in 1980 to $308,545 in 1983, and then decreased to $156,163 by 1987. In multivariate analysis, inpatient payer costs were strongly associated with occurrence of CMV infection (increase of $53,517; p = 0.0001) or acute GVHD (increase of $46,500; p = 0.001), and significantly associated with malignant (versus non-malignant) disease (decrease of $36,633; p = 0.05), even after adjusting for length of survival and year of BMT. Inpatient payer costs were not related to patient age, sex or race. Despite recent reductions in inpatient payer costs for BMT, CMV infection and acute GVHD continue to be associated with tremendous costs to third party payers. Further reductions in the costs of BMT may require improved prevention of CMV infection and GVHD.

Adolescent↗
PubMed1991

A phenomenology of scut.

OBJECTIVE: To identify, describe, and quantify the night-call duties that residents in internal medicine call "scutwork" and to compare faculty and residents' perceptions of scutwork. DESIGN: Prospective, cross-sectional study. SETTING: General internal medicine training program at a university-affiliated tertiary care hospital. PARTICIPANTS: Forty-eight residents who spent 3 months or more on an internal medicine teaching unit during the previous year and 41 faculty members who spent 2 months or more on one of these units. INTERVENTIONS: Postcall surveys and night-call diaries were used to analyze residents' activities, to derive a definition of scutwork, and to estimate its prevalence. Residents and faculty then completed a detailed questionnaire that included ratings of the educational value, "scut content," and residents' responsibility for 20 specific tasks. MAIN RESULTS: Eighty-three percent of residents found scutwork and education to be mutually exclusive for the 20 tasks, although 20% indicated that scutwork was an appropriate task for residents. Residents' ratings of tasks as scut varied according to the context of the task. For example, obtaining routine consent from someone else's patient was considered scutwork by 98% of residents, whereas obtaining such consent from the residents's own patient was rated as scutwork by only 52% (P less than 0.01). Similarly, performing intravenous cannulation at the request of ward staff was rated as scut by 94% of residents, whereas performing cannulation at another resident's request was rated as scut by 56% (P less than 0.01). Night-time admission of a patient for an elective procedure was rated as scut by 75% of residents, whereas admission of such a patient after discussion with a faculty member was labeled scut by only 44% (P less than 0.01). Faculty ratings of such admissions did not show the same variation (24% for both). Faculty were more likely than residents to assess tasks as educational (50% compared with 26%, P less than 0.01) but were less likely to consider tasks as scutwork (47% compared with 62%, P = 0.12) or as work that should be done by nonresidents (35% compared with 46%, P greater than 0.2). CONCLUSIONS: Our results suggest that the characteristics of scutwork can be identified, that the perception of scut varies between faculty and residents, and that the context of a task often determines whether residents perceive it as scut.

Alberta↗
PubMed1991

The use of angioplasty, bypass surgery, and amputation in the management of peripheral vascular disease.

BACKGROUND: Percutaneous transluminal angioplasty has been adopted widely as a treatment for patients with peripheral vascular disease of the lower extremities. However, the effect of this procedure on the overall management of peripheral vascular disease and on the outcomes of patients has not been clearly delineated. In particular, it is not known whether angioplasty has replaced other treatments for peripheral vascular disease. METHODS: To assess the extent to which angioplasty is used and the associated changes in the surgical management of peripheral vascular disease of the lower extremities, we used data on hospital discharges in Maryland to identify all angioplasty procedures, peripheral bypass operations, and lower-extremity amputations performed for peripheral vascular disease in Maryland hospitals between 1979 and 1989. RESULTS: We estimated that from 1979 to 1989 the annual rate of percutaneous transluminal angioplasty for peripheral vascular disease of the lower extremities, adjusted for age and sex, rose from 1 to 24 per 100,000 Maryland residents (P less than 0.0001 by linear regression). Despite this increase in the use of angioplasty, the adjusted annual rate of peripheral bypass surgery also rose substantially, from 32 to 65 per 100,000 (P less than 0.001), whereas the adjusted annual rate of lower-extremity amputation remained stable at about 30 per 100,000. Total charges for hospitalizations during which a peripheral revascularization procedure was performed increased from $14.7 million in 1979 (in 1989 dollars) to $30.5 million in 1989. CONCLUSIONS: In Maryland, the adoption of percutaneous transluminal angioplasty for peripheral vascular disease of the lower extremities has been associated with an increase in the use of peripheral bypass surgery and with no decline in lower-extremity amputations. These results could be due to increased diagnosis of peripheral vascular disease, expanded indications for procedural interventions, or an increased number of repeat procedures performed in patients with peripheral vascular disease of the lower extremities.

Aged↗
PubMed1991

Cost-effectiveness of extracorporeal shock-wave lithotripsy versus cholecystectomy for symptomatic gallstones.

To evaluate the cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy for symptomatic gallstones, a model was constructed that projects charges and survival for both treatments. For a 45-year-old woman with one small stone, treatment with extracorporeal shock-wave lithotripsy rather than cholecystectomy is projected to result in an average gain of only 3 days of life and an average increase in direct medical charges of $1729 over 5 years of follow-up. The resulting marginal cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy is $216,000 of extra charges per year of life gained with extracorporeal shock-wave lithotripsy. Extracorporeal shock-wave lithotripsy is projected to be much more cost-effective for elderly than for young patients (10-20-fold difference), but considerably less cost-effective for multiple stones than a single stone (2-4-fold difference), and less cost-effective for women than men (twofold difference). Adjusting for effects of morbidity on quality of life, extracorporeal shock-wave lithotripsy is projected to have slightly better quality-adjusted survival than cholecystectomy for the small subset of patients with one stone (by 8 to 43 days at 5 years) but not for young patients with multiple stones. It is concluded that decisions about appropriate use of extracorporeal shock-wave lithotripsy should consider the effects of patient characteristics on clinical and economic outcomes.

Aged↗
PubMed1990

The duration of Holter monitoring in patients with syncope. Is 24 hours enough?

To determine the incremental yield of ambulatory monitoring in the evaluation of syncope, three serial 24-hour Holter recordings were obtained in a consecutive series of 95 patients with syncope, the cause of which was not explained by history, physical examination, or 12-lead electrocardiogram. The mean age of patients was 61 years and 41% were men. Major electrocardiographic abnormalities were found in 26 patients (27%), including unsustained ventricular tachycardia (19 patients), pauses of at least 2 seconds (8 patients), profound bradycardia (1 patient), and complete heart block (1 patient). The first 24-hour Holter recording had at least one major abnormality in 14 patients (15%) (95% confidence interval, 8.3% to 23.4%). Of the 81 patients without a major abnormality on the first Holter recording, the second Holter recording had major abnormalities in 9 (11%) (95% confidence interval, 5.1% to 20.0%). Of the 72 patients without a major abnormality on the first two Holter recordings, only 3 patients (4.2%) had a major abnormality on the third Holter recording (95% confidence interval, 0.8% to 11.7%). Four factors were significantly associated with an increased likelihood of a major abnormality on 72 hours of monitoring: age above 65 years (relative risk, 2.2), male gender (relative risk, 2.0), history of heart disease (relative risk, 2.2), and an initial nonsinus rhythm (relative risk, 3.5). These results suggest that 24 hours of Holter monitoring is not enough to identify all potentially important arrhythmias in patients with syncope. Monitoring may need to be extended to 48 hours if the first 24-hour Holter recording is normal.

Adolescent↗
PubMed1989

Comparison of a supplemented Rose Questionnaire to exercise thallium testing in men and women.

The Rose Questionnaire has had high specificity and variable sensitivity when compared to physician identification of the symptom complex of angina pectoris. We assessed the accuracy of a supplemented Rose Questionnaire in a series of 198 patients by comparing the Questionnaire to exercise thallium test evidence of coronary artery disease. The Rose diagnosis of angina had 26% sensitivity, 79% specificity, 42% positive predictive value, and 65% negative predictive value. The Rose diagnosis of myocardial infarction had 26% sensitivity and 90% specificity. The Rose diagnosis of angina or infarction yielded a sensitivity of 44%, specificity of 72%, positive predictive value of 67%, and negative predictive value of 50%. Supplemental questions designed to identify atypical ischemic pain led to increased sensitivity of up to 68% that was offset by decreased specificity. While the Questionnaire's sensitivity for coronary disease was greater for women than men (57 vs 40%), the overall accuracy was the same because specificity was lower (63 vs 80%).

Angina Pectoris↗
PubMed1989

Epidemiological correlates of diabetic neuropathy. Report from Pittsburgh Epidemiology of Diabetes Complications Study.

The natural history of diabetic neuropathy and its risk factors are not well understood, apart from the recognition that prevalence increases with duration and, in many studies, degree of glycemia. The role of potential risk factors was therefore evaluated in a cross-sectional analysis from the baseline examination of the Pittsburgh Epidemiology of Diabetes Complications Study. We present results from the first 400 subjects seen at baseline examination. Neuropathy was determined by a trained internist with a standardized examination and was defined as the presence of at least two of three criteria: abnormal sensory or motor signs, symptoms consistent with neuropathy, and decreased tendon reflexes. The prevalence of neuropathy in this cohort was 34% (18%, 18-29 yr old, 58% greater than or equal to 30 yr old) with no difference by sex. By focusing on subjects greater than or equal to 18 yr old, all significant univariate variables (e.g., duration, glycosylated hemoglobin [HbA1]) were analyzed in 3 multiple logistic regression models: all subjects greater than or equal to 18 yr old and separating the same subjects into two groups based on age (18-29 and greater than or equal to 30 yr). Duration, HbA1, smoking status, and high-density lipoprotein cholesterol were found to be associated with neuropathy in the models for the greater than or equal to 18-yr-old group and the greater than or equal to 30-yr-old group. In the 18- to 29-yr-old group, duration, HbA1, and hypertension status were found to be significantly associated with neuropathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1989

Measuring diabetic neuropathy. Assessment and comparison of clinical examination and quantitative sensory testing.

The need for a standardized and valid means of assessing diabetic neuropathy has been increasingly recognized. To identify potential components of such an assessment, interobserver variation (neurologist and internist) of a standard neurologic examination and the comparability of this examination with vibratory and thermal sensitivity testing was studied. The study population comprised the first 100 participants in a neuropathy substudy of 25- to 34-yr-old subjects with insulin-dependent diabetes mellitus taking part in a cohort follow-up study. Symptoms of dysesthesias, paresthesias, and burning, aching, or stabbing pain revealed good interobserver agreement. Signs of neuropathy, more prevalent in the great toe than index finger, showed poor interobserver agreement for vibration, but fair interobserver agreement for touch and pinprick. Mean quantitative sensory thresholds differed significantly by clinical category of abnormal vibratory and pinprick sensations. Threshold testing showed twice the prevalence of abnormality compared with clinical examination. It is concluded that components of the clinical examination can be identified that, along with quantitative sensory-threshold testing, may provide a satisfactory core assessment for use both in epidemiologic studies and incorporation into more in-depth protocols required for clinical research and practice. The clinical relevance of the greater prevalence of abnormalities on threshold testing will be established by long-term follow-up.

Adult↗
PubMed1988

Long-term prognosis of patients undergoing electrophysiologic studies for syncope of unknown origin.

Long-term prognosis was determined in 70 patients with unexplained syncope who underwent electrophysiologic testing between April 1981 and April 1986. The electrophysiologic study had positive results in 37 patients--31 with ventricular tachycardia, 3 with supraventricular tachycardia and 3 with abnormal conduction. There was no significant difference in the 3-year actuarial recurrence rate between the positive and negative outcomes (32 vs 24%, respectively). At 3 years, patients with positive outcomes had higher rates of sudden death than patients with negative results (48 vs 9%, respectively, p less than 0.002). The 3-year total mortality rate was also markedly higher in patients with positive results than among those with negative outcomes (61 vs 15%, respectively, p less than 0.001). Multivariate analyses showed mortality to be independently associated with unsustained ventricular tachycardia on prolonged electrocardiographic monitoring. It was concluded that patients with electrophysiologically positive results had high rates of sudden death and total mortality that have not been previously well recognized.

Bundle-Branch Block↗
PubMed1980

Atypical nemaline myopathy with temporomandibular ankylosis.

A young girl who initially presented with jaw hypomobility at age 4 years subsequently developed signs of a slowly progressive myopathy. Rods were found in all sampled muscles, and were associated with fibrous contractures in the temporomandibular joint muscles. Rods in fibers undergoing necrosis displayed a pattern of degradation that was almost identical to the pattern induced by calcium-activated neutral protease in vitro. It appears that this patient had nemaline myopathy, atypical in both clinical presentation and pathologic lesions.

Ankylosis↗
PubMedDate not supplied

Contrasting views of physicians and nurses about an inpatient computer-based provider order-entry system.

OBJECTIVE: Many hospitals are investing in computer-based provider order-entry (POE) systems, and providers' evaluations have proved important for the success of the systems. The authors assessed how physicians and nurses viewed the effects of one modified commercial POE system on time spent patients, resource utilization, errors with orders, and overall quality of care. DESIGN: Survey. MEASUREMENTS: Opinions of 271 POE users on medicine wards of an urban teaching hospital: 96 medical house officers, 49 attending physicians, 19 clinical fellows with heavy inpatient loads, and 107 nurses. RESULTS: Responses were received from 85 percent of the sample. Most physicians and nurses agreed that orders were executed faster under POE. About 30 percent of house officers and attendings or fellows, compared with 56 percent of nurses, reported improvement in overall quality of care with POE. Forty-four percent of house officers and 34 percent of attendings/fellows reported that their time with patients decreased, whereas 56 percent of nurses indicated that their time with patients increased (P < 0.001). Sixty percent of house officers and 41 percent of attendings/fellows indicated that order errors increased, whereas 69 percent of nurses indicated a decrease or no change in errors. Although most nurses reported no change in the frequency of ordering tests and medications with POE, 61 percent of house officers reported an increased frequency. CONCLUSION: Physicians and nurses had markedly different views about effects of a POE system on patient care, highlighting the need to consider both perspectives when assessing the impact of POE. With this POE system, most nurses saw beneficial effects, whereas many physicians saw negative effects.

Attitude to Computers↗
PubMedDate not supplied

Comparison of the rating scale and the standard gamble in measuring patient preferences for outcomes of gallstone disease.

To estimate patient preferences for gallstone-related treatments and outcomes, and assess how preferences vary by patient characteristics and scaling technique, the authors randomly assigned 40 patients without gallstones to interviews based on a rating scale (n = 22) and a standard gamble (n = 18). The patients assigned preference values (possible values 0 to 1) to open cholecystectomy (mean 0.45 by rating scale, 0.78 by standard gamble), laparoscopic cholecystectomy (0.71, 0.91), extracorporeal shock-wave lithotripsy (0.77, 0.89), acute cholecystitis (0.36, 0.77), lifetime biliary colic (0.41, 0.71), postcholecystectomy syndrome (0.43, 0.79), asymptomatic stone necessitating treatment with bile acids (0.76, 0.96), and surgical scar (0.79, 0.998). Preferences varied little by age, gender, or race. Standard gamble values were highly correlated with, but significantly greater than, rating scale values. The authors conclude that patients' preferences for gallstone-related conditions generally are significantly less than one, and differ markedly by the scaling technique used to derive them. These results should be considered when patient preferences are incorporated into analyses of gallstone treatments.

Acute Disease↗
PubMedDate not supplied

Preference values for visual states in patients planning to undergo cataract surgery.

To assess how preference values that cataract surgery patients assign to their preoperative visual states relate to visual acuity and problems in specific aspects of daily life, the authors interviewed 47 patients scheduled to have cataract surgery. Using a rating-scale technique with a scale from 0 (death) to 1 (excellent health), the patients had a mean preference value of 0.68 for their preoperative vision. Patients' preference values for their preoperative vision were more closely related to problems in specific aspects of daily life (especially feelings of depression and problems interacting with people) than to visual acuity in the operative eye, better eye, or worse eye, or a weighted average of visual acuities in both eyes. These results provide a rationale for relying more on patients' views about the effects of visual impairment than on measures of visual acuity when assessing the need for cataract surgery.

Activities of Daily Living↗
PubMedDate not supplied

Use of focus groups to identify concerns about dialysis. Choice Study.

BACKGROUND: Patients with end-stage renal disease (ESRD) may have quality-of-life (QOL) concerns that are not fully appreciated by their providers. The authors conducted focus groups with dialysis patients and dialysis professionals to determine whether this qualitative method would reveal differences between patients' and providers' views about: 1) domains of QOL that are affected by ESRD and dialysis; and 2) aspects of dialysis that affect QOL. METHODS: Separate focus group discussions were held with: 8 adult hemodialysis patients (mean age 50 years; 3 women; mean duration of dialysis 8.5 years), 5 adult peritoneal dialysis patients (mean age 54 years; 3 women; mean duration of dialysis 4.6 years), 8 nephrologists (mean of 12 years of dialysis practice), and 9 other health professionals involved in dialysis care (3 nurses, 2 dietitians, 2 social workers, and 2 technicians; mean of 10 years experience in dialysis care). Discussions were audiotaped, transcribed verbatim, and reviewed independently by three investigators to identify and categorize distinct thoughts. RESULTS: 1,271 distinct thoughts were identified and grouped into 20 related categories, which included ten QOL domains and ten aspects of dialysis that affect QOL. Compared with the professionals, the patients identified one additional relevant QOL domain (10 vs 9), and one additional aspect of dialysis that affects QOL (10 vs 9), and expressed more thoughts per domain (p < 0.05), although the contents of their comments were frequently similar. Among QOL domains, the numbers of related thoughts identified by patients and professionals, respectively, were: freedom/control (60, 89); social relationships (36, 11); anxiety (37, 4); role function (24, 10); energy (12, 10); body image (16, 4); sex (11, 21); mental attitude (21, 0); sleep (15, 1), and cognitive function (13, 7). Among aspects of dialysis that affect QOL, the numbers of thoughts identified by patients and professionals were: general dialysis issues (159, 105); relationships with staff (62, 110); patient education (63, 68); diet (44, 40); scheduling (57, 3); vascular or peritoneal access issues (31, 17), adaptation to dialysis (16, 14); dialysis dose (18, 8); symptoms (25, 0), and self-care (5, 24). CONCLUSIONS: Although health professionals have a good understanding of patient concerns about the effects of ESRD and dialysis, the focus group discussions revealed a breadth and depth of QOL concerns that they may not fully appreciate.

Adaptation, Psychological↗
PubMedDate not supplied

Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery.

CONTEXT: We previously found that length of stay in the intensive care unit (ICU) after abdominal aortic surgery increased when fewer ICU nurses were available per patient. We hypothesized that having fewer nurses increases the risk for medical complications. OBJECTIVE: To evaluate the association between nurse-to-patient ratio in the ICU and risk for medical and surgical complications after abdominal aortic surgery. DESIGN: Observational study. SETTING: All nonfederal acute care hospitals in Maryland. DATA SOURCES: Information about patients came from hospital discharge data on all patients in Maryland with a principal procedure code for abdominal aortic surgery from 1994 through 1996 (n = 2606). The organizational characteristics of ICUs were obtained by surveying ICU medical and nursing directors in 1996 at the 46 Maryland hospitals that performed abdominal aortic surgery. Thirty-nine of the ICU directors (85%) completed the survey. EXPOSURE: Surgery in hospitals with fewer ICU nurses (in which each nurse cared for three or four patients) compared with hospitals with more ICU nurses (in which each nurse cared for one or two patients). OUTCOME: Proportion of patients who developed postoperative complications. RESULTS: Seven hospitals with 478 patients had fewer ICU nurses, and 31 hospitals with 2128 patients had more ICU nurses. Patients in hospitals with fewer nurses were more likely than patients in hospitals with more nurses to have complications: 47% vs. 34% had any complication, 43% vs. 28% had any medical complication, 24% vs. 9% had pulmonary insufficiency after a procedure, and 21% vs. 13% were reintubated (P < 0.001 for all comparisons). After adjustment for patient, hospital, and surgeon characteristics, having fewer versus more ICU nurses was associated with an increased risk for any complication (relative risk, 1.7 [95% CI, 1.3 to 2.4]), any medical complication (relative risk, 2.1 [CI, 1.5 to 2.9]), pulmonary insufficiency after procedure (relative risk, 4.5 [CI, 2.9 to 6.9]) and reintubation (relative risk, 1.6 [CI, 1.1 to 2.5]). CONCLUSION: Having fewer ICU nurses per patient is associated with increased risk for respiratory-related complications after abdominal aortic surgery.

Aged↗