Evaluation by second-year medical students of their computer-aided instruction.
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Computer-Assisted Instruction↗
Biomedical subjects
G C Xakellis
Publications and source records attributed to G C Xakellis.
Characteristics of skin blood flow over the trochanter under constant, prolonged pressure.
Although laboratory studies have documented that externally applied pressure disrupts circulation, in clinical practice little is known about the characteristics of blood flow over bony prominences as a function of time. The purpose of this study was to describe the pattern of blood flow over the trochanter when subjected to a constant interface pressure for a prolonged period of time. A quasi-experimental design was used to measure skin blood flow over the left trochanter in a sample of 19 healthy adults. With the use of laser doppler flowmetry, the pattern of blood flow was monitored continuously while subjects lay on a supportive air mattress. Measurement of blood flow was described for three periods: preload with subjects supine, loading with subjects in the left lateral position and hyperemia after subjects returned to the supine position. Rate of blood flow under loading showed a gradual increase from preload. There was a marked initial increase in flow during hyperemia that gradually tapered off, but failed to reach preload levels within 30 min. Individual blood flow tracings revealed an inconsistent pattern of response to loading, suggesting the presence of a range of physiological response to compressive surface pressure. Given the individual variation in response to a common external pressure, further research is recommended to evaluate the pattern of blood flow over bony prominences subjected to known interface pressure.
Adult↗
Pressure ulcers.
Pressure sores occur when prolonged pressure or shear is applied to the skin of predisposed patients. Prevention requires identification of patients at risk and institution of thorough surveillance and nursing care. Once pressure ulcers occur, treatment decisions are based on the depth of the ulceration. Management consists of motivating the staff, relieving the pressure, debriding the wound, lowering wound bacterial counts and treating complications.
Anti-Infective Agents, Local↗
Translating pressure ulcer guidelines into practice: it's harder than it sounds.
OBJECTIVE: To determine the cost-effectiveness of a guideline-based pressure ulcer prevention protocol over time. DESIGN: Retrospective and prospective quasi-experimental longitudinal design. Costs are presented from the long-term-care facility perspective. Data collection occurred for 3 periods: the first 6 months of 1994 (prior to protocol implementation), the first 6 months of 1995 (immediately following implementation) and the first 6 months of 1997 (2 years following implementation). SETTING: 77-bed long-term-care facility PATIENTS/PARTICIPANTS: Subjects were ulcer-free facility residents at the start of each data collection period. There were 69 subjects in the 1994 sample, 63 in the 1995 sample, and 71 in the 1997 sample. INTERVENTIONS: A guideline-based pressure ulcer prevention protocol was implemented during the last 3 months of 1994. The protocol consisted of specific policies for pressure ulcer prevention and treatment, intensive staff education on pressure ulcer care, and monitoring with regular performance feedback to staff. MEASUREMENTS AND MAIN RESULTS: Time to ulcer development varied among the 3 groups (log rank = 8.81, P = .01), with longer time to ulcer development in 1995 compared with 1994; no difference was seen between 1997 and 1994. The time for ulcers to heal decreased over the 3 years (log rank = 9.49, P <.01), with ulcer healing time being shorter in 1995 and 1997 compared with 1994. Total costs were unchanged during the 3 years (F = 0.2, P =.81). Costs of treatment declined significantly from 1994 to 1995 and 1997 (F = 5.5, P <.01) and costs of prevention increased significantly from 1994 to 1995 and 1997(F = 15, P <.01). From 1994 to 1997, the cost for 1 day of ulcer-free life was $3.50. CONCLUSIONS: Implementation of a pressure ulcer prevention protocol showed mixed results. Initial reductions in pressure ulcer incidence were lost over time. Clinical results of ulcer treatment, however, improved and treatment costs fell during the 3 years. Implementation of preventive programs poses a major leadership challenge.
Aged↗
Improving clinic efficiency of a family medicine teaching clinic.
BACKGROUND: Teaching clinics are the heart of training programs in family practice. It is in these training clinics where residents develop their ambulatory practice habits. Yet, little is known about the efficiency of these teaching clinics. METHODS: We conducted a time-and-motion study of patient flow in a residency teaching clinic. RESULTS: During each half-day session, 7.8 +/- 1.9 providers were scheduled in clinic, and 55.5 +/- 12.9 patients were seen. First-year residents saw 3.55 patients per half-day session, second-year residents saw 4.75 patients, third-year residents saw 8.0 patients, faculty saw 8.22 patients, and urgent care saw 8.35 patients. The number of patients scheduled was highly correlated with the number of providers in clinic. Of the patients scheduled, 25% failed to keep their appointment, and 31% arrived late. Neither rates of no-show patients nor rates of late patients varied by level of provider. The mean time patients spend in the clinic was 80.5 +/- 30 minutes, with 17 +/- 10 minutes spent registering, 18 +/- 17 minutes spent being roomed, and 19 +/- 16 minutes spent waiting for the provider. The physician spent 27 +/- 16 minutes with the patient, including both face-to-face time and precepting time. Patients who arrived on time waited significantly longer than those who arrived late. Waiting time did not vary significantly by level of physician. The time patients spent with their doctor did vary significantly by level of physician; first-year residents spent more time with their patients than upper-level residents or faculty. CONCLUSIONS: Significant variation exists in the patient flow through the clinic. Patient volumes are significantly correlated to the number of providers in clinic. Long waiting times are due in part to long processing times and in part to long waits in the exam room. Concerted multidimensional efforts are needed to smooth out patient flow and improve clinic efficiency.
Appointments and Schedules↗
Initial medication selection for treatment of hypertension in an open-panel HMO.
BACKGROUND: During the past 25 years recommendations for treating hypertension have evolved from a stepped-care approach to monotherapy or sequential monotherapy as experience has been gained and new antihypertensive agents have been introduced. In an effort to develop a disease management strategy for hypertension, we investigated the prescribing patterns of initial medication therapy for newly treated hypertensive patients. METHODS: We examined paid claims data of an open-panel HMO located in the midwest. Charts from 377 patients with newly treated hypertension from a group of 12,242 hypertensive patients in a health insurance population of 85,066 persons were studied. The type of medication regimen received by patients newly treated for hypertension during an 18-month period was categorized into monotherapy, sequential monotherapy, stepped care, and initial treatment with multiple agents. With monotherapy, the class of medication was also reported. Associations between use of angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, or beta-blockers and presence of comorbid conditions were reported. RESULTS: Fifty-five percent of patients received monotherapy, 22 percent received stepped care, and 18 percent received sequential monotherapy. Of those 208 patients receiving monotherapy, 30 percent were prescribed a calcium channel blocker, 22 percent an ACE inhibitor, and 14 percent a beta-blocker. No customization of treatment for comorbid conditions was noted. CONCLUSIONS: Physicians attempt to treat patients' hypertension with monotherapy. In the majority of cases, they have used either a calcium channel blocker or ACE inhibitor as initial monotherapy. Costs for treating hypertension could be reduced and care improved if thiazide diuretics, a combination of potassium-sparing and thiazide diuretics, or beta-blockers were used more frequently as initial monotherapy.
Adrenergic beta-Antagonists↗
Template for pressure ulcer research.
Synthesizing scientific information from the literature, even in a well-defined area, is difficult because not all studies report similar information. A template was developed by the authors to abstract information from articles reviewed for the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline on Pressure Ulcer Treatment. The research template specifies content to be included in a study reprot (e.g. variables, methods, endpoints, statistics, and conclusions). The authors also propose the use of the template to guide researchers so that future studies include important elements and provide greater methodologic consistency.
Humans↗
Using an optical scanner and data base program to manage a family medicine teaching program.
This article describes the value of optically scannable forms and off-the-shelf software in improving administration of a required multi-site, third-year family medicine preceptorship. Formerly, a small preceptorship administrative staff manually handled nearly 1,000 evaluation forms per year. The process was slow, cumbersome, expensive, and inflexible. Optically scannable forms are now used and data bases are created, from which a series of administrative reports are easily generated. This system has reduced management time and cost, eliminated errors, and allowed staff to create both standardized and specialized reports as needed.
Database Management Systems↗
Medical student evaluation of self-selected learning modules.
BACKGROUND: The purposes of this study were to determine the self-directed learning needs of second-year medical students, the resources they selected to address their learning needs, and the effectiveness of those resources. METHODS: Students in an Introduction to Clinical Medicine course were required to devote 24 hours to the study of self-directed learning activities. Although options were provided, students could create their own study modules. Students evaluated each module used. RESULTS: Major needs identified were history and physical examination skills, diagnosis, emergency procedures, psychosocial issues in medicine, and issues concerning physicians as people. The most selected module types were videotapes (52%), computer-aided instruction, labs, and seminars. Overall ratings (5 = high) indicated four clusters of modules: self-directed learning, 4.3; labs, 4.0; seminars, slide-tapes, and computers, 3.65; and videotapes and books, 3.25. Videotapes, the most frequently used module, received low overall ratings. CONCLUSIONS: Self-directed learning allowed students to use a great array of educational opportunities. Students appeared to recognize needs, identify resources, and use those resources to address their learning needs.
Computer-Assisted Instruction↗
Guidelines for the prediction and prevention of pressure ulcers. The Agency for Health Care Policy and Research.
Of the 26 recommendations made by the panel, only six (23 percent) have sufficient research data to warrant a level A or B strength of evidence rating. Thus expert opinion, while traditionally valuable for filling the gaps where research-based information is missing, is used more extensively than data to support the recommendations of this guideline. The literature on pressure ulcers is voluminous but of variable quality. After reviewing this literature, I am not surprised at the confusion and frustration that physicians feel when trying to prevent pressure ulcers. More research is needed to confirm or refute expert opinion on prevention of pressure ulcers. The guideline does, however, provide physicians five specific steps that can be used to prevent pressure ulcers in their patients: (1) perform a risk assessment on all bed- and chair-bound patients, (2) keep the pressure off the bony prominences of at-risk patients by using a turning schedule, (3) use a pressure-reducing mattress in the treatment of all at-risk patients, (4) avoid massage of bony prominences, and (5) encourage the development of institutional educational programs or skin care teams for the prevention and treatment of pressure ulcers. The remaining 20 recommendations are reasonable and can be applied selectively, but they are based on expert opinion and have not been shown to reduce the rate of pressure ulcers in well-designed research studies.
Education, Medical, Continuing↗
The cost-effectiveness of interventions for preventing pressure ulcers.
BACKGROUND: While there is scientific evidence to support the efficacy of preventive interventions for pressure ulcers, few empirical data are available on their cost-effectiveness. The aim of this study was to determine the cost-effectiveness of interventions to prevent pressure ulcers. METHODS: Cost of preventive interventions and days of ulcer-free survival were compared for two groups of patients. One group consisted of 250 patients from a geriatric unit of a British hospital (Norton sample). At the time of the study, no preventive measures were used. Data from the original report of the study were used to determine patients' attainment of one of three end points--ulcer formation, death, or discharge--from which a disease-free survival table was constructed. The second cohort of 420 patients consisted of residents of a long-term care facility in Iowa, where aggressive preventive measures were used (Iowa sample). Data were collected at the study onset and 3 months later. The types of preventive interventions used on each patient were assessed and their costs calculated. Cost of treatment for pressure ulcers was estimated from previous research performed at the Iowa facility. The cost-effectiveness of the preventive intervention was calculated by dividing the mean difference in cost between the two groups by mean difference in ulcer-free days. RESULTS: Survival analysis of days to ulcer development showed the Norton (no prevention) sample had a significantly shorter time to ulcer development than did Iowa sample (patients receiving preventive measures) (P < 0.0001). The mean cost for prevention and treatment of an ulcer was $167 +/- $307 for the Norton sample and $245 +/- $379 for the Iowa sample. The mean number of ulcer-free days was 21.0 -/+ 17.4 for the Norton sample and 78.5 +/- 11.0 for the Iowa sample. The cost per day of ulcer-free life gained was $1.36. CONCLUSION: The use of aggressive preventive measures in the long-term care setting is effective in reducing pressure ulcers and requires a relatively low level of institutional expenditures.
Aged↗
The cost of healing pressure ulcers across multiple health care settings.
The reported costs of treating pressure ulcers have varied widely from study to study. Previous studies have focused on single health care settings and computed only the costs occurring while the patient was a resident in that facility. The purpose of this study was to assess the cost of managing pressure ulcers from their initial occurrence in long-term care through their natural history, including hospital treatment of complications. The 30 patients in this year-long study developed 45 ulcers. The mean length of treatment for an ulcer was 116 days (SD = 127). The mean cost of treatment, including long-term care and hospital costs, was $2,731 per ulcer (SD = 12,184); excluding hospital costs, the mean cost of treatment was $489 per ulcer (SD = 629). The mean cost of treatment per patient was $4,647 (SD = 15,102); excluding hospital costs, the mean treatment cost was $1,284 per patient (SD = 1,380). Eighty percent of the total cost of pressure ulcer treatment was generated by the 4% of patients who required hospitalization for their pressure ulcers. In the absence of complications, pressure ulcers can be treated successfully and cost-effectively in long-term care.
Aged↗
Cost-effectiveness of an intensive pressure ulcer prevention protocol in long-term care.
Conducted in a 77-bed long-term-care facility, this study compared the costs of implementing an intensive pressure ulcer prevention protocol plus the calculated costs of treatment before and after implementing the protocol. A total of 69 patients comprised the preprotocol sample; 16 of them developed 26 ulcers. The postprotocol sample consisted of 63 patient, 3 of whom developed 5 ulcers. The 6-month pressure ulcer incidence was 23% in the preprotocol sample and 5% in the postprotocol sample. Mean cost for prevention and treatment of pressure ulcers was $113 +/- $345 per subject for the preprotocol sample and $100 +/- $157 per subject for the postprotocol sample (t = 0.27, df = 130, p = .79). Mean time to ulcer development was 146 +/- 61 days for the preprotocol subjects and 158 +/- 53 days for the postprotocol subjects (log rank = 8.63, p = .003 Implementation of a protocol that emphasized pressure ulcer prevention significantly reduced the incidence of pressure ulcers and cost per day of ulcer-free life.
Aged↗