Biomedical subjects
Publications and source records attributed to I Jacoby.
Three strategies for timely detection of common duct stones are examined by decision analysis: the use of intraoperative cholangiography (IOC) in ALL, NONE, or in SOME of the cases that are selected by the estimated probability of a common duct stone. Selective use of IOC is the most cost-effective option and offers a slightly lower mortality risk.
The Graduate Medical Education National Advisory Committee (GMENAC) projected the need for and supply of physicians and other providers, recommended time and access standards for health care services, and developed guidelines for the geographic distribution of physicians. Since this study, analysts have given scant attention to national problems of physician geographic distribution. The issue deserves additional scrutiny in light of the current continuing problems of underservice in rural areas. The emergence of geographic information systems offers a unique opportunity to acquire data on provider distribution and provide a framework for developing and testing redistribution policy.
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Programs that disseminate information to health care practitioners often do so partly to encourage appropriate changes in practice. However, merely providing information is seldom enough to accomplish such changes. If information transfer programs are to influence practice, they must be designed to maximize the conditions facilitating change. Reliance on a diffusion model for thinking about how information reaches practitioners has led researchers to over-emphasize the importance of exposure to information and ignore other factors that determine whether change will occur, such as practitioners' motivation to change, the context in which clinical decisions are made, and how information is presented. The fact that successful dissemination will not necessarily produce change also has implications for how information transfer programs should be monitored and evaluated.
The purpose of this paper is to present an update on biomedical technology assessment activities from a United States perspective. In 1985, I described in detail (a) a primary vehicle for technology assessment--the Consensus Development Program (CDP) of the National Institutes of Health (NIH)--and also discussed, in a second paper, (b) the transfer of consensus-enhanced scientific information and some of its impact on U.S. medical practice. Here, I focus on what has transpired during the past year: the changes in the climate in which U.S. technology assessment efforts are being conducted, the consequences of these changes, and the challenges that they pose for all concerned with the provision of quality health care. The first part of this paper centers on the broader framework within which technology assessment plays a role in the United States. Later, it addresses the specific technology assessment and transfer activities in which the NIH is engaged.
The Office of Medical Applications of Research of the National Institutes of Health conducted a survey to evaluate the effectiveness of mass mailing of consensus statements as compared with traditional dissemination methods. The consensus statement on osteoporosis, published earlier in JAMA, was selected for study. Physicians (N = 695) within each of five relevant specialties in two comparable metropolitan areas were surveyed. Findings suggest that while a small but significant increase of awareness resulted from direct mailing, this increase should be weighed against costs and effectiveness of other methods.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Of 210 women who were experiencing dysuria, frequent urination, pyuria, and significant bacteriuria and who were treated with a single 3-g dose of amoxicillin, 165 (79%) were cured of their original infections. Patients with infections that were negative by antibody-coated-bacteria assay were cured at a significantly higher rate than those with infections that were positive by antibody-coated-bacteria assay (90 versus 59%; P less than 0.001). Similarly, those with infections caused by amoxicillin-susceptible organisms were cured at a significantly higher rate than those with infections caused by resistant organisms (85 versus 50%; P less than 0.001). Of 27 patients who had infections caused by amoxicillin-susceptible organisms and who had relapses after single-dose therapy, 14 (52%) had relapses again after a conventional 10-day course of therapy, although all responded to a 6-week course. An additional 27 patients experiencing dysuria, frequent urination, and pyuria but who had a lower number of uropathogens in the urine (10(2) to 10(4.5)/ml of urine) were treated with single-dose therapy, with a 100% eradication of organisms and an 89% rate of symptomatic relief.
A model was developed that describes the flow of residents through the graduate medical education (GME) system (derived from anonymous GME histories of the 160,000 US medical school graduates [1960 to 1977] on the American Medical Association's physician's master file in 1979). The model showed ultimate specialty distribution among practitioners as a function of specialty distribution among residents at entry to GME indicating that an increase in family practice residents will probably yield an increase in primary care practitioners, owing to the lower level of attrition from family practice residencies as opposed to specialists in internal medicine and pediatrics. Increases in first-year family medicine residencies led to decreases in primary care residencies as a whole led to increases in internal medicine subspecialists but to decreases in surgical subspecialists.
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To determine which demographic factors favor rural communities obtaining physicians, county characteristics of National Health Service Corps sites are analyzed. Through the use of a difference of means test, sites which were staffed at least once are compared with sites which were never able to obtain physicians. Since a major portion of the sites never staffed were located in the Southeast, the effect of "southeast location" as a separate, binary variable is considered. Five factors related to income, employment and education significantly (p less than 0.01) distinguish the staffed from the "never-staffed" sites. A function derived from discriminant analysis correctly classifies more than 70 per cent of the sites as staffed or never-staffed; inclusion of the southeast variable increases the number of correctly classified sites by 6 per cent. Given the presence of both socioeconomic and nondemographic constraints on rural communities, significant improvements in physician distribution may require that programmatic interventions be intensified.
Cryptococcal meningitis and a cerebral cryptococcoma developed in a patient with pulmonary cryptococcosis ("coin lesion") shortly after infected area of lung was removed. Treatment with amphotericin B and flucytosine failed to clear the organisms and antigen from the spinal fluid or alter the neurologic manifestations related to the cerebral lesion. Therapy with miconazole cured the meningitis and led to disappearance of the lesion in the brain (serial computed tomographic scan). Study of the patient over the next 5 years disclosed no evidence of relapse of infection and completely normal findings on neurologic examination.