Search PubMed⌕ Search

Biomedical subjects

F J Fowler

Publications and source records attributed to F J Fowler.

70 records · Page 4Linked to original sources
PubMed1988

Watchful waiting vs immediate transurethral resection for symptomatic prostatism. The importance of patients' preferences.

The rate of resection for benign prostatic hypertrophy shows considerable variability among small geographic areas. To help inform the decision to recommend prostatectomy to men with prostatism without signs of chronic retention, we performed a decision analysis to compare the expected outcomes with immediate transurethral resection and watchful waiting. Data used in the model originated from the medical literature, Medicare claims data, and patient interview studies. In our base-case analysis for 70-year-old men, immediate surgery resulted in the loss of 1.01 months of life expectancy, but when adjustments were made for quality of life, immediate surgery was favored with a net utility benefit of 2.94 quality-adjusted life-months. However, the analysis was particularly sensitive to the degree of disutility attributed to the index symptoms of prostatism. We conclude that patient preferences should be the dominant factor in the decision whether to recommend prostatectomy.

Age Factors↗
PubMed1988

Symptom status and quality of life following prostatectomy.

When prostatectomy is proposed as treatment for the symptoms of prostatism, the decision to operate should depend on how patients evaluate their symptoms and on objective information about the outcomes. We undertook a health interview study to determine the probabilities for symptom relief, improvement in the quality of life, and complications following surgery and to evaluate patient concern about the symptoms of prostatism. The operation was effective in reducing symptoms: 93% of severely and 79% of moderately symptomatic patients experienced improvement; however, a statistically significant improvement in indices of quality of life occurred only among patients with acute retention or severe symptoms prior to surgery. Short-term complications of varying severity occurred in 24% of patients; in addition, 4% reported persistent incontinence and 5%, impotence. Patients with similar symptoms reported considerable difference in the degree to which they were bothered by their symptoms. The result emphasizes the importance of patient participation in the decision to undergo prostatectomy.

Aged↗
PubMedDate not supplied

The influence of patient smoking status on therapeutic decisions.

STUDY OBJECTIVE: To assess the effect of patient smoking status on internists' inclinations to recommend certain types of therapy for conditions that are and conditions that are not related to smoking. DESIGN, SETTING, AND PARTICIPANTS: Five hundred ninety-eight internists identified systematically from the Directory of Medical Specialists (first entry on each page of text) were asked to complete a questionnaire about how their treatment decisions for five therapies differed as a function of patient smoking status. RESULTS: The responses of the 320 internists who completed and returned the questionnaire showed that smoking status had little effect on physicians' inclinations to recommend herniorrhaphy, hemodialysis, or bronchodilator therapy. However, physicians were considerably less inclined to recommend coronary artery bypass grafting or peripheral arterial surgery to patients who smoked. Reduced efficacy and greater risk of therapy were the most frequent reasons given for the observed decrease. Reduced entitlement by smokers to complex therapies for smoking-related diseases and the withholding of therapy as a bargaining tool to induce smokers to quit were also cited as reasons. CONCLUSIONS: Some internists believe they are less likely to recommend complex therapies for smoking-related diseases to patients who continue to smoke. Some of this decrease may be attributable to the notion that smokers are less entitled to complex therapies or that withholding therapies is a permissible way to influence patients to adopt more healthful lifestyles. Whether these physician attitudes reflect actual practice is yet to be shown.

Angina Pectoris↗
PubMedDate not supplied

The role of reluctance to give up life in the measurement of the values of health states.

Questions that involve willingness to risk or give up life often are used to measure the values of health states. In the Boston Health Study, interviews with 291 patients who had AIDS included questions about health status and current desire for resuscitation, and a series of hypothetical questions about desire for life-extending efforts if the patients found themselves in undesirable states, such as being chronically nauseous or blind. An index, "reluctance to give up life" was made from five such questions. The desire for resuscitation was related to current health status, but the general reluctance to give up life was not. Desire to be resuscitated was significantly related to current health status only when "reluctance to give up life" was "low." For people reluctant to say they will give up any life at all, questions that involve risking or trading life seem likely to be poor measures of the values of health states.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

The stability of preferences for life-sustaining care among persons with AIDS in the Boston Health Study.

BACKGROUND: Clinicians recognize the importance of eliciting patient preferences for life-sustaining care, yet little is known about the stability of those preferences for patients with serious disease. OBJECTIVES: To examine the stability of preferences for life-sustaining care among persons with AIDS and to assess factors associated with changes in preferences. DESIGN: Two patient surveys and medical record reviews, administered four months apart in 1990-1991. SETTING: Three health care settings in Boston. PATIENTS: 252 of 505 eligible persons with AIDS who participated in both baseline and follow-up surveys. MAIN OUTCOME MEASURES: A single question assessing desire for cardiac resuscitation and a scale of preferences for life-extending treatment conditional on hypothetical health states. RESULTS: Approximately one-fourth of the respondents changed their minds about life-sustaining care during a four-month period. Of patients who initially desired cardiac resuscitation, 23% decided to forego it four months later, and of those who initially said they would decline care, 34% later said they would accept it. Of those who initially desired any of the life-extending treatments, 25% decided to forego them four months later, and of those who initially said they would decline life-extending care, 24% later said they would accept some treatment. Patients reporting changes in physical function, pain, or suicide ideation were more likely to modify their desires to be resuscitated (all p< or =0.05). Patients lacking an advance directive, not completing high school, or becoming more severely ill were more likely to change their preferences on the Life Extension scale (p< or =0.05). Patients who discussed their preferences with at least one physician were just as likely as others to change desires for cardiac resuscitation. Age, gender, race, emotional health, clinical severity, social support, and site of care were not significant correlates of change for either measure. CONCLUSIONS: Health care providers should periodically reassess preferences for life-sustaining care, particularly for patients with progressive disease, given the instability in patient preferences. However, predictors of instability may vary with how preferences are measured. In particular, changes in health status may be related to instability of preferences for certain types of treatments.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Model for the integrated network? Rehabilitation makes a good candidate.

Rehabilitation is a good model for an integrated delivery network (IDN). Because it is an integral part of the treatment plans of a diverse group of medical specialties, rehab often plays a pivotal role in patients' recovery. Since its focus is on functional outcomes, rehab is compatible with a capitated payment system. In addition, rehab entered the managed care arena before other "product lines," so rehab providers have experience with diverse reimbursement conditions. And although rehab encompasses all levels of care, it is not too large to function as a model for a full-scale IDN. There are four key stages in the development of a rehab IDN: A strong leader with a clear vision organizes a working committee composed of the key leaders of each entity involved in rehab: hospitals, nursing homes, home health, and others. The committee begins to design the proposed network. Though the committee may study other IDNs, its focus is on its own organization's needs and objectives. A master plan addressing systems gaps and opportunities throughout the IDN is drawn up. Integral to the plan is a schedule according to which each of the network's components will be integrated. The master plan is implemented. The working committee determines the IDN's final structure and names the members of the management team.

Continuity of Patient Care↗
PubMedDate not supplied

Boosting performance.

Explore the source record for details and available documents.

Benchmarking↗
PubMedDate not supplied

The redesign of the National Health Interview Survey.

Starting in 1997, on its 40th anniversary, the National Health Interview Survey (NHIS) will begin collecting data in a radically redesigned form. The redesign was undertaken because interviews were too long; new or different kinds of information were needed, including better measures of health status and chronic conditions: and the ability to analyze family-level data was limited. A shortened annual core survey will be supplemented with a rotating set of questions designed to provide more detail than the current NHIS with respect to health status, utilization of health care services, and health promotion and disease prevention. One adult from each family will be objectively selected to be the respondent, and a significant portion of the data will be collected by self-report. For several of the most common chronic conditions, additional information will be routinely collected that will improve the clinical relevance and quality of data about those conditions. While there will be some costs associated with these changes, their net result will be to enhance the value of NHIS data in addressing current health policy issues.

Adult↗