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Biomedical subjects

J E Billi

Publications and source records attributed to J E Billi.

29 records · Page 2Linked to original sources
PubMed1987

Evaluation of a minimal-contact smoking cessation intervention in an outpatient setting.

We examined the ability of a provider-initiated, minimal-contact intervention to modify the smoking behavior of ambulatory clinic patients. Smokers at two outpatient sites were assigned to one of three groups: provider intervention only (PI); provider intervention plus self-help manual (PI/M); and usual care (control) group (C). The physician message emphasized the patient's personal susceptibility, the physician's concern, and the patient's ability to quit (self-efficacy). The nurse consultation concentrated on benefits and barriers associated with stopping, and on strategies for cessation. Telephone interviews were conducted with the 250 participants within a few days of their clinic visit and again at one and six months. Both PI and PI/M proved to be superior to usual care in motivating attempts to quit at both one-month and six-month follow-ups, and logistic regression analyses indicated that participants receiving the self-help manual in addition to the health provider message were between two and three times more likely to quit smoking during the study period than were participants in either of the other study groups.

Adult↗
PubMed1987

Phenothiazine-induced cholestatic jaundice.

Proposed mechanisms, clinical features, prevalence, and treatment of phenothiazine-induced cholestatic jaundice are reviewed, and interactions between phenothiazines and other drugs that could theoretically alter the risk of cholestasis are described. Phenothiazine-induced jaundice is classified as a form of cholestatic hepatocanalicular hepatotoxicity and as an acute liver disease. Occasionally cholestatic jaundice may progress to chronic liver disease. The mechanism of hepatotoxicity is not completely understood but may involve a combination of physiochemical, immune, and direct toxic effects. Based on proposed mechanisms, concomitant use of drugs that alter microsomal hepatic enzyme function or have metabolic pathways that interfere with or overlap with those of the phenothiazines could be expected to potentiate or reduce the risk of cholestasis. The estimated prevalence of jaundice with chlorpromazine is 1-2%. The prevalence of jaundice with other phenothiazines is probably similar. The onset of jaundice usually occurs during the first one to four weeks of therapy. In most cases, discontinuation of the offending drug is the only treatment required. Jaundice usually resolves without sequelae two to eight weeks later. Pruritus can be relieved by topical corticosteroid or analgesic therapies or by oral antihistamines or bile acid sequestrants if topical therapy is ineffective. Whenever possible, reinstitution of neuroleptic therapy should be delayed until the reaction has resolved. Selection of a nonphenothiazine neuroleptic agent may be preferred. Phenothiazine-induced cholestatic jaundice occurs relatively infrequently and is usually self-limited; topical agents and oral antihistamines can alleviate the discomfort associated with the reaction.

Antipsychotic Agents↗
PubMed1985

Differential diagnosis and the competing-hypotheses heuristic. A practical approach to judgment under uncertainty and Bayesian probability.

Evaluating the same diagnostic information across the plausible competing diagnoses is a practical strategy (ie, heuristic) to guide decision making in the face of uncertainty. The prevalence of use of this competing-hypotheses heuristic by 89 first-year house officers was examined in three simulated patient cases. Results indicated that only a minority (24%) of the house officers selected optimal diagnostic information consistent with this Bayesian heuristic across all three cases. Almost all (97%) of the house officers selecting optimal diagnostic information were able to identify the most probable diagnosis specified by Bayes' theorem, while only a chance number (53%) of house officers selecting nonoptimal information were able to identify the most probable diagnosis. The competing-hypotheses heuristic is discussed within the context of diagnostic problem-solving models derived from the literature on medical decision making and clinicopathological conference case records. It is suggested that the heuristic, which does not necessitate any mathematical calculations, may be useful as a complement to clinical judgment.

Bayes Theorem↗
PubMed1984

Cardiopulmonary resuscitation: an update.

We are currently witnessing the emergence of a physiologic approach to cardiopulmonary resuscitation. The algorithms and recommendations provided by the AHA provide an excellent framework for managing cardiac emergencies. As new knowledge becomes available, these recommendations should be modified and expanded. Continued assessment of the patient is a critical factor in managing cardiac arrest. As more complex technology and newer medications crowd the resuscitation scene, it is extremely important not to lose sight of the patient and the basics of good resuscitation: airway, breathing, and circulation. Technology provides helpful adjuncts to our assessment but cannot replace direct contact with the patient and the information gathered by direct observation. Students often fix their attention on the cardiac monitor, treating the electrical activity but ignoring the patient. Only by bringing together our observations from the patient, the laboratory, and our diagnostic tools will our knowledge of resuscitation develop to the point where we can improve survival from cardiac arrest.

Airway Obstruction↗
PubMedDate not supplied

The effects of a cost-education program on hospital charges.

An educational intervention designed to change physicians' use of inpatient services was implemented on two general medical services for a year. The intervention consisted of a brief orientation to cost containment issues, a pamphlet that outlined practical cost containment strategies and listed the charges for commonly ordered tests and services, and access to detailed interim patients' bills generated during the hospitalization. Two concurrent control services received no intervention. Over 1,600 admissions were evaluated. The geometric mean length of stay was 0.61 days shorter on intervention services compared with control (5.15 vs. 5.76 days, p less than 0.01). The geometric mean hospital charges were $388 less for intervention patients ($3,199 vs. $3,587, p less than 0.005). Neither patients' demographic characteristics nor case mix could explain the reductions. The authors conclude that a simple program utilizing information already in existence in most hospitals can result in a significant and meaningful reduction in length of stay and charges.

Cost Control↗
PubMedDate not supplied

The effects of a low-cost intervention program on hospital costs.

OBJECTIVE: To assess the impact of a low-cost education and feedback intervention designed to change physicians' utilization behavior on general medicine services. DESIGN: Prospective, nonequivalent control group study of 1,432 admissions on four general medicine services over 12 months. Two services were randomly selected to receive the intervention. The other two served as controls. Admissions alternated between control and intervention services each day. Results were casemix-adjusted using diagnosis-related groups (DRGs). Three internists blinded to patient study group assignment assessed quality of care using a structured implicit instrument. SETTING: Four general medicine services at a university hospital. INTERVENTIONS: A brief orientation, a pamphlet of cost strategies and common charges, detailed interim bills, and information about projected length of stay and usual hospital reimbursement for each patient. PATIENTS/PARTICIPANTS: Each service was staffed by a full-time internal medicine faculty member, one third-year and two first-year internal medicine houseofficers, three medical students, and a clinical pharmacist. Physicians were assigned to services for one-month periods by a physician unaware of the study design. To prevent crossover, houseofficers assigned to a service returned to the same service for all subsequent general medical inpatient assignments. MEASUREMENTS AND MAIN RESULTS: Geometric mean length of stay was 0.44 days (7.8%) shorter for the intervention services than for the control services (p less than 0.01), and geometric mean charges were $341 (7.1%) less (p less than 0.01). Effects persisted despite using a more precise cost estimate or casemix adjustment. Intervention houseofficers demonstrated superior cost-related attitudes but no difference in knowledge of charges. Audits of quality of care detected no significant difference between groups. CONCLUSION: This low-intensity intervention reduced length of stay and charges, even under the cost-constrained context of the prospective payment system.

Cost Control↗
PubMedDate not supplied

Information gathering and integration as sources of error in diagnostic decision making.

This research examined the relative importance of information gathering versus information utilization in accounting for errors in diagnostic decision making. Two experiments compared physicians' performances under two conditions: one in which they gathered a limited amount of diagnostic information and then integrated it before making a decision, and the other in which they were given all the diagnostic information and needed only to integrate it. The physicians: 1) frequently failed to select normatively optimal information in both experimental conditions; 2) were more confident about the correctness of their information selection when their task was limited to information integration than when it also included information gathering; and 3) made diagnoses in substantial agreement with those indicated by applying normative procedures to the same data. Physicians appear to have difficulties recognizing the diagnosticity of information, which often results in decisions that are pseudodiagnostic or based on diagnostically worthless information.

Bayes Theorem↗
PubMedDate not supplied

Clinical practice guidelines: quality improvement tools versus legal norms.

The role of clinical guidelines in malpractice litigation has been controversial. The primary purpose of guidelines as a quality improvement tool must be sustained, and applications of guidelines beyond this purpose must be done carefully, with full recognition of inherent limitations.

Humans↗