Biomedical subjects

J D Dickens

Publications and source records attributed to J D Dickens.

5 recordsLinked to original sources

PubMed2000

Relation between operator and hospital volume and outcomes following percutaneous coronary interventions in the era of the coronary stent.

CONTEXT: Studies have found an association between physician and institution procedure volume for percutaneous coronary interventions (PCIs) and patient outcomes, but whether implementation of coronary stents has allowed low-volume physicians and centers to achieve outcomes similar to their high-volume counterparts is unknown. OBJECTIVE: To assess the relationship between physician and hospital PCI volumes and patient outcomes following PCIs, given the availability of coronary stents. DESIGN, SETTING, AND PARTICIPANTS: Analysis of data from Medicare National Claims History files for 167 208 patients aged 65 to 99 years who had PCIs performed by 6534 physicians at 1003 hospitals during 1997. Of these procedures, 57.7% involved coronary stents. MAIN OUTCOME MEASURES: Rates of coronary artery bypass graft (CABG) surgery and 30-day mortality occurring during the index episode of care, stratified by physician and hospital PCI volume. RESULTS: Overall unadjusted rates of CABG during the index hospitalization and 30-day mortality were 1.87% and 3.30%, respectively. After adjustment for case mix, patients treated by low-volume (<30 Medicare procedures) physicians had an increased risk of CABG vs patients treated by high-volume (>60 Medicare procedures) physicians (2.25% vs 1.55%; P<.001), but there was no difference in 30-day mortality rates (3.25% vs 3.39%; P =.27). Patients treated at low-volume (<80 Medicare procedures) centers had an increased risk of 30-day mortality vs patients treated at high-volume (>160 Medicare procedures) centers (4.29% vs 3.15%; P<. 001), but there was no difference in the risk of CABG (1.83% vs 1. 83%; P =.96). In patients who received coronary stents, the CABG rate was 1.20% vs 2.78% for patients not receiving stents, and the 30-day mortality rate was 2.83% vs 3.94%. Among patients who received stents, those treated at low-volume centers had an increased risk of 30-day mortality vs those treated at high-volume centers, whereas those treated by low-volume physicians had an increased risk of CABG vs those treated by high-volume physicians. CONCLUSION: In the era of coronary stents, Medicare patients treated by high-volume physicians and at high-volume centers experience better outcomes following PCIs.

Aged↗

PubMed1997

Do physicians do what they say? The inclination to test and its association with coronary angiography rates.

OBJECTIVE: Efforts to evaluate variations in cardiac procedures have focused on patient factors and differences in health care delivery systems. We wanted to assess how physicians' inclination to test patients with coronary artery disease influences utilization patterns. SETTING AND SUBJECTS: Physicians and the populations of Maine, New Hampshire, and Vermont. DESIGN: We conducted a survey of 263 family practitioners, internists, and cardiologists residing in 57 hospital service areas in Maine, New Hampshire, and Vermont. Using patient scenarios, we assessed the clinicians' inclinations to test during the evaluation of patients with coronary artery disease. Self-reported testing intensities were used to create three indices: a Catheterization Index, an Imaging Exercise Tolerance Test (ETT) Index, and Nonimaging ETT Index. Using administrative data, age- and gender-adjusted population-based coronary angiography rates were calculated. Physicians were assigned to low (2.9/1,000), average (4.2/1,000), and high (5.8/1,000) coronary angiography rate areas, based on where they practice. Analysis of variance techniques were used to assess the relation of the index scores to the population-based coronary angiography rates and to physician specialties. RESULTS: There was a positive relationship between the population-based coronary angiography rates and the self-reported scores of the Catheterization Index (p < .005) and the Imaging ETT Index (p = .01), but none was found for the Non-imaging ETT Index (p = .10). These relationships were evident in subanalyses of cardiologists and internists, but not of family practitioners. CONCLUSIONS: Self-reported testing intensity by physicians is related to the population-based rates of coronary angiography. This relationship cuts across specialties, suggesting that there is a "medical signature" for the evaluation of patients with coronary artery disease.

Adult↗

PubMed1996

The association between local diagnostic testing intensity and invasive cardiac procedures.

OBJECTIVE: To determine the extent to which geographic variation in invasive cardiac procedures can be explained by the variable use of diagnostic testing. DESIGN: A population-based cohort study using Medicare Part B data (physician services). SETTING AND SUBJECTS: Procedure data for all Medicare beneficiaries in northern New England. MAIN OUTCOME MEASURES: Twelve coronary angiography service areas were constructed for Medicare beneficiaries in northern New England. Age- and sex-adjusted utilization rates were developed for three procedure categories: total stress test, coronary angiography, and revascularization. Total stress tests were further stratified into nonimaging and imaging procedures (eg, thallium). Tests performed in follow-up to invasive procedures were excluded (eg, stress test following revascularizations). Linear regression was used to assess the relationship between procedure categories. RESULTS: A tight positive relationship was found between total stress test rates and the rates of subsequent coronary angiography (R2=0.61, P<.005). Most of the variance was explained by imaging stress tests (R2=0.50, P<.02). A strong relationship was found between coronary angiography and revascularization (R2=0.82, P<.001). Finally, a clear relationship between total stress tests and subsequent revascularizations was also found (R2=0.55, P<.006). CONCLUSION: The population-based rates of diagnostic testing largely explained the variance associated with subsequent therapeutic interventions. Our results suggest that local testing intensity is an important determinant of the variable use of invasive cardiac procedures.

Cardiovascular Diseases↗

PubMed1996

Changing physician behavior in ordering digoxin assays.

OBJECTIVE: To assess the ability to modify physicians' use of serum digoxin assays in a sustained fashion through (1) an educational intervention by a clinical pharmacist, and (2) changes in the computerized medical information system. DESIGN: A before/after methodology was used to compare test use by hospital staff physicians in two phases. Phase 1 was an educational intervention conducted by a clinical pharmacist with an 8-month follow-up. Phase 2 was a medical information system intervention with a 12-month follow-up. PATIENTS: Adult inpatients from July 1990 through December 1993 who received either digoxin therapy or at least one serum digoxin assay. MAIN OUTCOME MEASURE: Digoxin assays per patient day while receiving digoxin (assays/digoxin day), in-hospital mortality, and length of stay were compared before and after implementation of the interventions. RESULTS: A total of 9468 patients received a digoxin and/or serum digoxin assay. Baseline use of serum digoxin assays was 0.178 assays/digoxin day. Following phase 1, the educational intervention, use declined 20.2% to 0.142 assays/digoxin day (p < 0.03). After phase 2, the implementation of changes in the medical information system, digoxin assay use was maintained at 16.3% less than that at baseline (p < 0.03). Patient mortality was unaffected. CONCLUSIONS: A low-intensity educational intervention by a clinical pharmacist supplemented by medical information system modification resulted in an important decrease in the use of digoxin assays. The change in physician behavior was sustained for more than 18 months. The model presented is not labor intensive, does not require continuous maintenance by healthcare personnel for a sustained effect, and may be widely applicable to healthcare providers.

Aged↗

PubMedDate not supplied

Antibiotic optimization. An evaluation of patient safety and economic outcomes.

BACKGROUND: Although numerous reports have described interventions designed to influence antibiotic utilization, to our knowledge none have been evaluated in a randomized study. METHODS: Adult inpatients receiving 1 or more of 10 designated parenteral antibiotics for 3 or more days during a 3-month period were randomized to an intervention (n = 141) and a control (n = 111) group using an unblocked, computer-generated random number table. Obstetric patients and those seen in infectious disease consultation were excluded. The intervention group received antibiotic-related suggestions from a team consisting of an infectious disease fellow and a clinical pharmacist. Both groups were evaluated for clinical and microbiological outcomes as well as antibiotic utilization via prospective chart reviews and analysis of the hospital's administrative database. RESULTS: Sixty-two (49%) of the intervention group patients received a total of 74 suggestions. Sixty-three (84%) of these suggestions were implemented; the majority involved changes in antibiotic choice, dosing regimen, or route of administration. Per patient antibiotic charges were nearly $400 less in the intervention group vs controls (P = .05). Almost all the savings were related to lower intravenous antibiotic charges. Clinical and microbiological response, antibiotic-associated toxic effects, in-hospital mortality, and readmission rates were similar for both groups. Multiple linear regression analysis identified randomization to the intervention group and female sex as the sole predictors of lower antibiotic charges. There was a trend toward a shorter length of stay for the intervention group (20 vs 24.7 days, P = .11). CONCLUSIONS: This is the first randomized study to evaluate whether antibiotic choices can be influenced in a cost-effective fashion without sacrificing patient safety. We demonstrate that 50% of patients initially treated with expensive parenteral antibiotics can have their regimens refined after 3 days of therapy and that these modifications result in good clinical outcomes with a substantial reduction in antibiotic expense.

Administration, Oral↗