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Biomedical subjects

H V Fineberg

Publications and source records attributed to H V Fineberg.

At least 55 records · Page 3Linked to original sources
PubMed1983

Shorter length of stay for simple cholecystectomy: cost-effectiveness of alternative strategies.

Patients undergoing simple cholecystectomy during a 12-month period at a Boston teaching hospital were retrospectively divided into two groups: short stay surgery (SSS) patients had a hospital length of stay (LOS) of 5 or 6 days; conventional stay surgery (CSS) patients were hospitalized for more than 6 days. After matching for sex, age, preoperative LOS, and secondary diagnoses, 18 pairs were identified. None of the patients had major complications after the hospital discharge. One to 2 years after surgery, health status was identical in the two groups. Patients in the SSS group reported a larger number of minor complications after hospital discharge and less satisfaction with the adequacy of their length of stay. Shortened length of hospital stay for a subgroup of simple cholecystectomy patients is a promising means of reducing cost with minimal, if any, sacrifice in quality of care and deserves further evaluation.

Adult↗
PubMed1983

Risk-benefit considerations in the management of polymyalgia rheumatica.

Management of the polymyalgia rheumatica syndrome (PMR) is controversial. Gratifying symptomatic response usually occurs after treatment with nonsteroidal antiinflammatory drugs or low doses of corticosteroids. However, some PMR patients are at risk of sudden blindness from an associated disease, giant cell arteritis (GCA). Blindness can be prevented by using higher and more toxic doses of corticosteroids. Temporal artery biopsy can be an aid in diagnosis, though it is not a completely sensitive test for GCA. This study employs decision analysis and derived risk-benefit ratios (equivalent to utility ratios) to evaluate five possible PMR management strategies. The incremental risk-benefit analysis provides a means for weighing intangible trade-offs without a formal utility analysis. Given base case assumptions derived from the literature, empirical treatment with high-dose steroids cannot be justified for PMR patients who have no cranial arteritic symptoms, because the acceptable risk-benefit ratio associated with this strategy is more than 90 cases of severe medication side effects per case of monocular blindness averted.

Adrenal Cortex Hormones↗
PubMed1983

The clinical value of body computed tomography over time and technologic change.

A clinical study of body computed tomography (CT) at Massachusetts General Hospital evaluated 2,619 patients who were prospectively assigned to one of 12 examination protocols. Data obtained from referring physicians and patient records just before CT examination and later in the course of care served as a basis for judging the contribution of CT to diagnostic understanding, use of other tests, and choice of therapy. Fifty-three percent of examinations produced a substantial or unique contribution to diagnostic understanding, and 15% contributed to a change in treatment. Performance in different protocols varied greatly: lymphoma, pancreas, retroperitoneum, lung, and liver ranked in the top half for both diagnostic and therapeutic efficacy; pelvis, urology, and colon fell in the bottom third. Overall, CT reduced surgery by an estimated 14% and angiography by an estimated 11% in the study population. Availability of CT was also associated over time with significant declines in the frequency of sonographic examinations and of lymphangiography, though not of endoscopic retrograde cholangiopancreatography. Compared with an 18-sec scanner, examinations on a 3-sec unit more frequently contributed to improved diagnostic understanding (p less than 0.05) and to increased physician confidence in previously chosen treatment (p less than 0.001). Studies of the diagnostic and therapeutic efficacy of devices like CT can guide clinical expectations and provide a basis for evaluating new imaging methods.

Evaluation Studies as Topic↗
PubMed1982

Exponential increase in age-specific prevalence of ventricular dysrhythmia among males.

Analyzing nine available studies of cardiac dysrhythmia among males shows an exponential increase of the prevalence of dysrhythmia with increased age (16-74 yr). This pattern appears in unselected populations and in populations selected for prior history of myocardial infarction. In 6 of 9 population groups the exponent for the rate of increased prevalence of any ventricular premature contractions (VPCs) with age was statistically indistinguishable from study to study despite variations in length of monitoring, of local interpretations of ECG, or of differences in the composition of these groups. Within each population group the prevalence of "frequent" VPCs or of "complex" VPCs also increased exponentially with age. The precise mathematical expression for the increase suggests an etiologic explanation for cardiac dysrhythmia common to coronary artery disease and myocardial infarctions which exhibit similar behavior.

Adolescent↗
PubMed1982

Implications of alternative strategies to diagnose coronary artery disease.

Strategies to diagnose coronary artery disease were examined for cost-effectiveness in a hypothetical population of 55-year-old men who, alternatively, are asymptomatic, have atypical angina or have definite angina. Strategies considered include various combinations of noninvasive tests (resting ECG, exercise stress test [ETT]. radionuclide scanning [RNS] and coronary angiography). Benefits are estimated in terms of the detection of multivessel disease and years of life gained from coronary artery bypass graft surgery (CABG). Only the direct costs (charges) for diagnostic or treatment procedures are considered. In asymptomatic persons, the average cost-effectiveness for different strategies ranges from $22,600 per year of life gained (ETT followed in positives by RNS) to $60,000 (angiography as primary screening test). Hence, screening is relatively cost-ineffective and would be extremely expensive if implemented widely. For patients with atypical angina, the cost-effectiveness ratio is about $9300 per year of life gained. Strategies involving use of ETT alone or in combination with the ECG or RNS appear to be preferable. For definite angina, the cost-effectiveness ratio is about $8800. Little difference is noted among various strategies for diagnosing definite angina, and the option to proceed directly to angiography appears reasonable.

Angina Pectoris↗
PubMed1981

When doctors meet numbers.

A Statistical Skills Self-Assessment Questionnaire (SAQ) was developed using hypothetical clinical questions to explore respondents' mastery of vocabulary and rules of inference that seem relevant to the use of quantitative information. The SAQ was administered to 281 subjects, including 36 medical students, 45 interns and residents, 49 physicians engaged in research and 151 physicians in full-time practice. All groups of subjects showed frequent lack of consensus on the meaning of terms in common use (e.g., "false-positive rate" and "p values") and unfamiliarity with some important principles in quantitative inference (e.g., the Central Limit Theorem and Regression to the Mean). Subjects often seemed willing to draw conclusions unsupported by available data. Performance on the SAQ was inversely correlated with length of time since graduation from medical school, and practicing physicians tended to err more frequently than the other three groups.

Education, Medical↗
PubMed1980

The case for abandonment of explosive anesthetic agents.

The use of inflammable anesthetics in the United States has been debated widely over the past several years. Those in favor of continued use of these agents argue for educational use, professional freedom, pharmacologic safety, and the need to retain an option. Those in favor of a ban on such agents cite the lack of demonstrated pharmacologic advantage, diminishing physician expertise, risk of fire, and cost. The use of inflammable anesthetics has declined markedly over the past 15 years; in 1978, only 15 per cent of American hospitals were reportedly using them. However, we estimate that the use of inflammable anesthetics adds approximately $9.4 million to the annual cost of surgical care. As their use declines further, the cost per patient increases because most of the costs are fixed. We advocate a ban on inflammable anesthetics. Without definitive action on the part of policy makers, the use of these agents is likely to continue at a very low, and hence a relatively expensive, rate.

Anesthesia, Inhalation↗
PubMed1980

Value of stool cultures.

An evaluation of stool cultures in a large teaching hospital where this test had been requested for 2468 patients in 1977 showed that only 58 patients (2.4%) had positive stool cultures (Salmonella or Shigella). Likelihood ratios computed from data from the medical records of 54 patients with positive stool cultures and a control group of 189 patients with negative cultures suggested that the best clinical predictor of a positive stool culture was the combination of persistent diarrhoea (duration more than 24 h), fever, and either blood in the stool or abdominal pain with nausea or vomiting. These findings were present in 20 of 52 patients with positive cultures, but in no patients with negative cultures. 53 patients had a positive result on the first culture done; 1 patient required 2 cultures. Microscopic examination for faecal leucocytes was not a useful predictor. In only 10 of 227 patients did culture results (positive or negative) lead to appropriate changes in treatment. The requirement that request forms be signed by a doctor, the limitation to no more than 2 stool cultures per illness, and consideration of the clinical predictors and their likelihood ratios for positive stool cultures would promote a more discerning use of this low-cost but low-yield diagnostic test.

Bacteria↗
PubMed1980

Clinical efficacy of computed body tomography, II.

The contribution to diagnostic understanding and therapeutic decision making by computed body tomography (CT) was measured in 623 patients using prospective and retrospective inquiry of referring physicians. CT improved diagnostic understanding in 52% of patients, reassured the physician about previously planned therapy in 43%, improved precision of previously planned treatment in 23%, and contributed to a change in therapy in 14%. There was a significant increase over time in reports of improved diagnostic understanding which was probably related to increasing clinical experience with the technique. However, this improvement in diagnostic understanding did not correspondingly increase the frequency of beneficially altered therapy. CT contributed to a substantial decrease in preplanned invasive imaging tests and a decision not to perform surgery in 19% of patients in whom an operation had been previously planned. The value of a CT examination to patient care varied considerably with the clinical problem; the most consistent contributions were observed in patients with diseases suspected in the mediastinum and retroperitoneum.

Attitude of Health Personnel↗
PubMed1980

Evaluating efficacy.

Explore the source record for details and available documents.

Evaluation Studies as Topic↗
PubMed1980

Evaluation of computed tomography in pancreatic cancer.

A study of the clinical efficacy of computed body tomography (CBT) is ongoing at the Massachusetts General Hospital. This study attempts to measure the contribution of CBT to diagnostic understanding, the use of other diagnostic tests, and the choice of therapy. During the first nineteen months of the study, 185 patients were examined on the pancreas protocol, a number approximating 30 per cent of all patients in the study. Physicians have some suspicion of pancreatic cancer in nearly all patients examined on the pancreas protocol. CBT improved the physician's diagnostic understanding in 54 per cent of patients examined on the pancreas protocol and contributed to a change in therapy in 18 per cent. CBT also contributed to a net reduction of 54 per cent in the number of angiograms performed compared to the number planned prior to CBT examination. In a subset of seventy-three patients, a definitive diagnosis of pancreatic cancer, inflammation, or normal pancreas was reached in each case. For patients with inflammation, CBT was 1.5 times as likely to increase as to decrease the physician's estimate of the correct diagnosis; for cancer patients CBT was 3.5 times as likely to aid as to mislead the physician; for patients with a normal pancreas, CBT was 6 times as likely to help as to hinder correct diagnosis. CBT can be a valuable aid to the diagnosis and treatment of patients suspected of having pancreatic cancer, but the physician should interpret its results in the light of all available clinical information.

Evaluation Studies as Topic↗