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Biomedical subjects

J E Paul

Publications and source records attributed to J E Paul.

At least 19 recordsLinked to original sources
PubMed2001

Two-year results from the asthma self-management program: long-term impact on health care services, costs, functional status, and productivity.

Participants in a variety of health plans, clinics and employer groups were invited to participate in the Asthma Self-Management Program (ASMP), an education program designed to improve self-management skills and daily functioning in individuals with asthma. The ASMP is an 8-week classroom program that provides information on the respiratory system, trigger avoidance, use of monitoring techniques and asthma medications. After program completion, graduates were contacted at scheduled intervals to reinforce performance of behaviors that are important to asthma self-management and to collect outcomes data. This paper reports the results of 2 years of follow-up with these individuals.

Absenteeism↗
PubMed1998

Utilities for major stroke: results from a survey of preferences among persons at increased risk for stroke.

BACKGROUND: Patient beliefs, values, and preferences are crucial to decisions involving health care. In a large sample of persons at increased risk for stroke, we examined attitudes toward hypothetical major stroke. METHODS AND RESULTS: Respondents were obtained from the Academic Medical Center Consortium (n = 621), the Cardiovascular Health Study (n = 321 ), and United Health Care (n = 319). Preferences were primarily assessed by using the time trade off (TTO). Although major stroke is generally considered an undesirable event (mean TTO = 0.30), responses were varied: although 45% of respondents considered major stroke to be a worse outcome than death, 15% were willing to trade off little or no survival to avoid a major stroke. CONCLUSIONS: Providers should speak directly with patients about beliefs, values, and preferences. Stroke-related interventions, even those with a high price or less than dramatic clinical benefits, are likely to be cost-effective if they prevent an outcome (major stroke) that is so undesirable.

Adult↗
PubMed1998

The role of cost-consequence analysis in healthcare decision-making.

A greater understanding of value associated with new pharmaceutical products should lead to better decision-making. Most commonly cost-effectiveness ratios (CERs) are used to indicate value; however, researchers have recently shown that CER estimates are rarely used by decision-makers in making formulary decisions. In this article, a cost-consequence approach to estimating the value for money of a new treatment for a specific disease is described. Using a cost-consequence approach, the impact of the new treatment on lifetime resource use and costs (including specific healthcare service use and costs, and productivity losses) and health outcomes (including disease symptoms, life expectancy and quality of life) for an individual or group of individuals is estimated and presented in a tabular format. The cost-consequence format is more likely to be approachable, readily understandable and applied by healthcare decision-makers than a simple CER. The decision-maker may use selected items from the cost-consequence analysis to compute composite measures of drug value, such as cost per life-year gained or cost per quality-adjusted life-year (QALY) gained. In general, the cost-consequence approach, by making the impact of the new treatment as comprehensive and transparent as possible, will enable decision-makers to select the components most relevant to their perspective and will also give them confidence that the data are credible to use as the basis for resource allocation decisions.

Cost-Benefit Analysis↗
PubMed1997

Accuracy of administrative data for assessing outcomes after knee replacement surgery.

OBJECTIVE: To assess the accuracy of information in an administrative database (Canadian Institute for Health Information; CIHI) compared with the hospital record for patients undergoing knee replacement (KR). METHODS: A stratified random sample of 185 KR recipients from 5 Ontario hospitals were chosen. Their hospital records and corresponding CIHI files were compared to assess percent complete agreement, false negative (FN) and false positive (FP) rates for demographic data, procedures, and diagnoses. RESULTS: Of 185 records, 175 (95%) were reviewed. Percent complete agreement was greater than 94% for each of patient demographics and procedures (mean FN rates: 0%; mean FP rates: 0-5%). For comorbidities and complications, although mean percent complete agreement was high, and FP rates were low, mean FN rates were 63% for specific comorbid conditions and 70% for organ systems. CONCLUSIONS: High FN rates have been found in documentation of comorbidities and in-hospital complications for CIHI data compared with the hospital record. Under-coding of comorbidities and in-hospital complications has potential implications for researchers using administrative databases.

Comorbidity↗
PubMed1996

Economic impact of treatment of HIV-positive pregnant women and their newborns with zidovudine. Implications for HIV screening.

OBJECTIVES: To estimate the economic impact of (1) treating pregnant women who are human immunodeficiency virus (HIV)-positive with zidovudine and (2) voluntary screening programs for pregnant women for HIV infection and offering treatment with zidovudine to those found to be HIV-positive. MAIN OUTCOME MEASURES: Number of cases of pediatric HIV infection and costs of screening, zidovudine treatment, and pediatric HIV infection treatment. DESIGN: Health care costs associated with treatment of HIV-positive pregnant women and their newborns are estimated as the costs of zidovudine and its administration and the reduction in costs of treating pediatric HIV infection. The lifetime costs of pediatric HIV infection are derived from the published literature. Estimates of the reduction in maternal-to-fetal transmission rates are taken from the AIDS [acquired immunodeficiency syndrome] Clinical Trials Group (ACTG) Protocol 076. Costs of a voluntary screening program include costs of screening tests and counseling. Sensitivity and threshold analyses are performed to determine the impact of changes in input parameter values including zidovudine treatment costs, efficacy of treatment, costs of pediatric HIV infection, prevalence of HIV infection in pregnant women, screening test sensitivity and specificity, and pregnancy termination rates on the results. RESULTS: Assuming transmission rates are reduced from 25.5% to 8.3% as found in the ACTG 076 trial, treatment costs of $104,502 for 100 HIV-positive pregnant women and their newborns are offset by the reduction of $1,701,333 associated with fewer cases of pediatric HIV infection for a net savings of $1,596,831. The sensitivity and threshold analyses show that overall cost savings from treatment of HIV-positive pregnant women and their newborns are achieved for a wide range of possible maternal treatment costs, efficacy rates, and lifetime pediatric HIV treatment costs. In the base-case analysis for the voluntary screening program, overall cost savings are seen when HIV prevalence rate among pregnant women is greater than 4.6 per 1000. However, this threshold prevalence rate is sensitive to changes In parameter value-especially pediatric HIV treatment costs, counselling costs, efficacy of treatment, and years of additional HIV treatment for the pregnant women. CONCLUSIONS: Offering zidovudine treatment to pregnant women known to be HIV-positive will decrease the number of cases of pediatric HIV infection and reduce health care costs. Voluntary screening programs for pregnant women will further decrease the number of cases of pediatric HIV infection. The effect of a screening program on health care costs varies according to HIV prevalence and the costs associated with the screening program.

AIDS Serodiagnosis↗
PubMed1996

Variations in practice patterns: antiviral drug use in hospitalized patients with herpes infections.

This study describes patterns of antiviral drug use for patients hospitalized with chickenpox, herpes simplex, and herpes zoster infections, and also for a subgroup of herpes patients with severe infections (systemic infections, eye infections, encephalitis, hemorrhagic pneumonitis, and other severe conditions). Our findings demonstrate that there is great deal of variation in the use of antiviral drugs for these herpes patients, and that much of this variation is apparently unrelated to medical indications for antiviral drug use. Instead, patterns of use are associated with patient characteristics (age, race) and with hospital characteristics (location, teaching status, number of beds). Because these drugs are effective when used properly, treatment guidelines and protocols may be needed so that improved drug use will produce better patient outcomes.

Adolescent↗
PubMed1996

Full-cost determination of different levels of care in the intensive care unit. An activity-based costing approach.

We applied an activity-based costing methodology to determine the full cost of intensive care service at a community hospital, a university hospital and a health maintenance organisation (HMO)-affiliated hospital. A total of 5 patient care units were analysed: the intensive care unit (ICU) and surgical ICU (SICU) at the university setting, the ICU at the community setting, and the SICU and cardiac care unit at the HMO setting. The selection of the different ICU types was based on the types of critical care units that were found in each setting (e.g. the HMO did not have an ICU). Institution-specific cost data and clinical management parameters were collected through surveys and site visits from the 3 respective organisation types. The analysis revealed a marked increase in patient-minute cost associated with mechanical ventilation. Higher costs associated with prolonged neuromuscular blockade have important economic implications with respect to selection of an appropriate neuromuscular blocking agent.

Coronary Care Units↗
PubMed1996

Sudden death from asthma in 108 children and young adults.

To identify factors that may contribute to asthma mortality, 108 acute asthma deaths were reviewed. Information was obtained from medical records, next-of-kin, and autopsy records. The fatal asthmatic was characterized by early-onset asthma, severe disease requiring systemic corticosteroids, and prior hospitalization. Risk factors associated with gender, season, employment, and region were also identified. The fatal attack was characterized by an identifiable trigger, delay in seeking medical attention, and rapid deterioration in clinical status. Death due to asthma was confirmed in 95% of autopsied cases. Adrenal cortical abnormalities were recorded for 18.7% of cases. We conclude that, in addition to established risk factors, complications associated with the use of systemic steroids may contribute to the risk for sudden death in this age group.

Adolescent↗
PubMed1996

Demographic variation in the rate of knee replacement: a multi-year analysis.

OBJECTIVE: The aim of this study is to describe the practice variation of knee replacements (KRs) in the elderly ( > or = 65) over time from 1985-1990 in terms of the number of primary, bilateral, and revision KRs; the extent of large area variation in performance rates; and the degree to which demographic variables are the determinants of area rates. DATA SOURCES/STUDY SETTING: Data analyzed are from every hospital in the United States that performed a KR on a Medicare patient during the study period. Data were obtained from the MEDPAR, HISKEW, and denominator files of the Medicare Statistical System. STUDY DESIGN: This is a cohort study of all Medicare beneficiaries who received a KR between 1985 and 1990. The dependent variable in the analyses was the count of the KRs performed in each area. DATA COLLECTION/EXTRACTION METHODS: This is a population-based sample of Medicare enrollees in the United States. All hospitalizations for Medicare-reimbursed KRs were included in the initial data set. Exclusion criteria were used to identify the Medicare covered population with a definite KR. These criteria resulted in 7.3 percent exclusions and a final set of 414,079 KR hospitalizations. PRINCIPAL FINDINGS: The number of Medicare-funded KRs increased in each of the study years corresponding to an annual rate of increase of 18.45 percent. The likelihood of receiving a KR was a function of age, gender, and race. For each year, KRs were almost-twice as likely to be performed on women than on men. The odds of whites getting the surgery were over 1.5 times greater than for blacks. Even after adjusting for demographic factors, significant regional variation remained. CONCLUSIONS: Much about area variation and the rate of growth in KR rates remains unexplained. For answers to emerge, better data and different types of studies are required.

Age Factors↗
PubMed1995

US national survey of physician practices for the secondary and tertiary prevention of ischemic stroke. Design, service availability, and common practices.

BACKGROUND AND PURPOSE: Stroke is largely a preventable disease. However, there are little data available concerning the use of stroke prevention diagnostic and treatment modalities by practicing physicians. These data are critical for the rational allocation of resources and targeting of educational efforts. The purposes of this national survey were to gather information about physicians' stroke prevention practice patterns and their attitudes and beliefs regarding secondary and tertiary stroke prevention strategies. METHODS: We conducted a national survey of stroke prevention practices among a stratified random sample of 2000 physicians drawn from the American Medical Association's Physician Masterfile. The survey focused on the availability of services and the use of diagnostic and preventive strategies for patients at elevated risk of stroke. RESULTS: Sixty-seven percent (n = 1006) of eligible physicians completed the survey. Diagnostic studies considered readily available by at least 90% of physicians included carotid ultrasonography, transthoracic echocardiography, Holter monitoring, and brain CT and MRI scans. MR angiography was perceived as being readily available by 68% and transesophageal echocardiography by 74% of respondents. Twelve percent of physicians reported cerebral arteriography and 10% reported carotid endarterectomy as not being readily available. Multiple logistic regression analyses showed that the availability of services varied with physician specialty (noninternist primary care, internal medicine, neurology, surgery), practice setting (nonmetropolitan versus small metropolitan or large metropolitan areas), and for carotid endarterectomy, region of the country (South, Central, Northeast, and West). The odds of carotid endarterectomy being reported as readily available were approximately 2.5 to 3.5 times greater for physicians practicing in the central, northeastern, and western regions compared with those practicing in the South, independent of practice setting and specialty. With regard to stroke prevention practices, 61% of physicians reported prescribing 325 mg of aspirin for stroke prevention, while 33% recommend less than 325 mg and 4% use doses of 650 mg or more. Seventy-one percent of physicians using warfarin reported monitoring anticoagulation with international normalized ratios, and 78% reported monitoring anticoagulated patients at least once a month. Fewer than 20% of physicians reported knowing the perioperative carotid endarterectomy complication rates at the hospital where they perform the operation themselves or refer patients to have the procedure done. CONCLUSIONS: Although all routine and most specialized services for secondary and tertiary stroke prevention are readily available to most physicians, variation in availability exists. The use of international normalized ratios for monitoring warfarin therapy has not yet become universal. Physician knowledge of carotid endarterectomy complication rates is generally lacking. Depending on their causes, these problems may be addressed through targeted physician education efforts and systematic changes in the way in which services are provided.

Aspirin↗
PubMed1994

Waiting times for knee-replacement surgery in the United States and Ontario.

BACKGROUND: Canada, which has universal single-payer health insurance, is often criticized for waiting times for surgery that are longer than those in the United States. We compared waiting times for orthopedic consultations and knee-replacement surgery and patients' acceptance of them in the United States and in the province of Ontario, Canada. METHODS: A stratified random sample of 1486 Medicare recipients (629 from the U.S. national sample, 428 from Indiana, and 429 from western Pennsylvania) and 516 people from Ontario who had been hospitalized for knee replacement between 1985 and 1989 were surveyed by mail in 1992. Patients were asked how long they had waited to see an orthopedic surgeon and to have surgery, the acceptability of these waiting times, and their overall satisfaction with surgery. RESULTS: About 80 percent of the questionnaires were returned, but not all the respondents answered all the questions. The rate of response to specific questions was about 60 to 65 percent in both countries. The median waiting time for an initial orthopedic consultation was two weeks in the United States and four weeks in Ontario. The median waiting time for knee replacement after the operation had been planned was three weeks in the United States and eight weeks in Canada. In the United States, 95 percent of patients in the national sample considered their waiting time for surgery acceptable, as compared with 85.1 percent in Ontario. Overall satisfaction with surgery ("very or somewhat satisfied") was 85.3 percent for all U.S. respondents and 83.5 percent for Canadian respondents. CONCLUSIONS: Waiting times for initial orthopedic consultation and for knee-replacement surgery were longer in Ontario than in the United States, but overall satisfaction with surgery was similar.

Aged↗
PubMed1994

Palatal inlays.

Explore the source record for details and available documents.

Bulimia↗
PubMed1994

Mental-fiscal drag.

There is definitely a mental block in most dentists' minds to asking for a fee, whether it be NHS or private. The process I am describing here is simple and effective, and I hope you find both practical help and comfort before you finish reading this article.

Dentists↗
PubMed1994

Using Medicare claims for outcomes research.

Medicare claims databases have several advantages for use in constructing episodes of care for outcomes research. They are population-based, relatively inexpensive to obtain, include large numbers of cases, and can be used for long-term follow-up. However, the sheer size of these claims databases, along with their primarily administrative (as opposed to clinical) nature, requires that researchers take special care in using them. The 10 PORTs using Medicare claims provided information on their approach to several key issues in working with these data, including: 1) identifying the index cases or patient cohorts to be studied; 2) defining the length of the episode; and 3) measuring outcomes. This paper reports the experience and knowledge gained by these PORTs in using these claims to create and analyze episodes of care.

Databases, Factual↗
PubMed1994

[Constrictive pericarditis--do we need a complete decortication?].

Pericardectomy is an established method for the treatment of various diseases, especially of constrictive pericarditis. Between 1969 and 1991, 212 cases of pericardial diseases were treated surgically. In 72 cases pericardectomy was performed for constrictive pericarditis. Surgical technique and indication for extracorporeal circulation are discussed. Postoperative haemodynamic problems were only seen in cases of preoperative advanced stage myocardial impairment. Extracorporeal circulation is only regarded as necessary in cases of strongly reduced myocardial function or if associated diseases need to be corrected.

Heart-Lung Machine↗
PubMed1993

The Stroke Prevention Patient Outcomes Research Team. Goals and methods.

BACKGROUND AND PURPOSE: The aim of the present study, based at Duke University and involving 14 other institutions, is to identify the most appropriate and cost-effective clinical strategies for prevention of ischemic (thrombotic or embolic) stroke in high-risk individuals and to design and test an intervention to disseminate this information to providers and the public. METHODS: The study uses (1) secondary data from literature review, Medicare claims, and population-based data from three epidemiological studies and (2) primary data generated in national physician and patient surveys and in demonstration trials. Phases I through III involve data collection and analysis using a decision/cost-effectiveness model and consensus development methods. Phase IV includes intervention in physicians' practice patterns. Data is collected by literature survey and abstraction, review of medical records, claims analysis, and patient and physician surveys. CONCLUSIONS: A structured decision model and a well-defined clinical focus provide a successful organization for a PORT on stroke prevention.

Cerebrovascular Disorders↗