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Biomedical subjects

J F Steiner

Publications and source records attributed to J F Steiner.

At least 37 records · Page 2Linked to original sources
PubMed1998

Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis.

CONTEXT: The spread of antibiotic-resistant bacteria is associated with antibiotic use. Children receive a significant proportion of the antibiotics prescribed each year and represent an important target group for efforts aimed at reducing unnecessary antibiotic use. OBJECTIVE: To evaluate antibiotic-prescribing practices for children younger than 18 years who had received a diagnosis of cold, upper respiratory tract infection (URI), or bronchitis in the United States. DESIGN: Representative national survey of practicing physicians participating in the National Ambulatory Medical Care Survey conducted in 1992 with a response rate of 73%. SETTING: Office-based physician practices. PARTICIPANTS: Physicians completing patient record forms for patients younger than 18 years. MAIN OUTCOME MEASURES: Principal diagnoses and antibiotic prescriptions. RESULTS: A total of 531 pediatric office visits were recorded that included a principal diagnosis of cold, URI, or bronchitis. Antibiotics were prescribed to 44% of patients with common colds, 46% with URIs, and 75% with bronchitis. Extrapolating to the United States, 6.5 million prescriptions (12% of all prescriptions for children) were written for children diagnosed as having a URI or nasopharyngitis (common cold), and 4.7 million (9% of all prescriptions for children) were written for children diagnosed as having bronchitis. After controlling for confounding factors, antibiotics were prescribed more often for children aged 5 to 11 years than for younger children (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.13-3.33) and rates were lower for pediatricians than for nonpediatricians (OR, 0.57; 95% CI, 0.35-0.92). Children aged 0 to 4 years received 53% of all antibiotic prescriptions, and otitis media was the most frequent diagnosis for which antibiotics were prescribed (30% of all prescriptions). CONCLUSIONS: Antibiotic prescribing for children diagnosed as having colds, URIs, and bronchitis, conditions that typically do not benefit from antibiotics, represents a substantial proportion of total antibiotic prescriptions to children in the United States each year.

Adolescent↗
PubMed1998

Factors associated with antibiotic use for acute bronchitis.

OBJECTIVES: To describe the clinical features of adults diagnosed with acute bronchitis, and to identify clinical variables associated with antibiotic treatment of acute bronchitis. DESIGN: Prospective, cohort study. SETTING: Primary care office practices at a group-model HMO in the Denver metropolitan area. PATIENTS/PARTICIPANTS: Patients were adults seeking care for acute respiratory illnesses. Participating clinicians included internists, family medicine physicians, nurse practitioners, physician assistants, and registered nurses. MEASUREMENTS AND MAIN RESULTS: Clinicians voluntarily completed encounter forms for patients presenting with acute respiratory illnesses between February and May, 1996. Acute bronchitis was the primary diagnosis in 16% of acute respiratory illness visits (n = 1,525). The most frequent symptoms of acute bronchitis were cough (92%), phlegm production (63%), "runny nose" (50%), and throat pain (50%). The most frequent physical examination findings were pharyngeal erythema (45%), cervical lymphadenopathy (19%), wheezes (18%), and rhonchi (17%). Antibiotics were prescribed to 85% of patients diagnosed with acute bronchitis. Purulent nasal discharge by patient report, and sinus tenderness on physical examination were moderately associated with antibiotic treatment (p = .06 and .08, respectively). Antibiotic prescription rates did not vary by patient age or gender, duration of illness, days of work lost due to illness, or clinician type. CONCLUSIONS: Acute bronchitis is frequently treated with antibiotics in ambulatory practice. The clinical factors we identified to be associated with antibiotic use for acute bronchitis appear to play a minor role in explaining the excessive use of antibiotics for this condition. These findings suggest that clinicians use the diagnosis of acute bronchitis as an indication for antibiotic treatment, despite clinical trials and expert recommendations to the contrary.

Acute Disease↗
PubMed1998

Managed care for the medically uninsured: the preliminary experience of CU CARE.

Uninsured Americans often face barriers to or lack continuity of care. Care for this population is often fragmented, expensive and undercompensated. University Hospital in Denver, in partnership with Kaiser Permanente of Colorado, sought to address this problem by developing CU CARE, a managed care demonstration program for the medically uninsured within the University of Colorado Health Sciences Center. This paper describes the evolution and preliminary experience of the CU CARE program. Policy implications for the future of health care delivery to this population are also briefly discussed.

Colorado↗
PubMed1998

Rural childhood immunization. Rates and demographic characteristics.

BACKGROUND: Childhood immunization rates are suboptimal, especially in high-risk populations. Rural residents could constitute a population at high risk for childhood underimmunization; little is known about demographic factors associated with childhood underimmunization. This study compared the immunization rates of urban and rural 2-year-olds and examined the association between demographic factors and underimmunization for rural 2-year-olds. METHODS: We analyzed two nationally representative surveys: the 1991 National Maternal and Infant Health Survey (NMIHS) and the 1993 National Health Interview Survey (NHIS). The study population consisted of children in non-metropolitan statistical areas who were 24 to 36 months of age in the NMIHS and 19 months to 5 years of age in the NHIS. The NMIHS sample contained 4425 children (966 in rural areas) and the NHIS sample contained 2505 children (566 in rural areas). RESULTS: There were no significant differences in immunization rates between rural and urban children. In urban areas, immunization rates were 63.3% (NMIHS) and 65.5% (NHIS) compared with 63.0% (NMIHS) and 67.8% (NHIS) in rural areas. Low income, low family education, nonwhite race, unemployment, and being a female child were associated with underimmunization in one or both data sets. These relationships were not modified by residence in a universal purchase state, where the state purchases and distributes vaccine for all children to reduce the cost and thereby improve access to immunization services. CONCLUSIONS: Approximately one third of children in urban and rural areas were underimmunized. The demographic characteristics of underimmunized children were similar in urban and rural areas; however, the special characteristics of rural areas may require that interventions be tailored to rural needs.

Adult↗
PubMed1997

Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians.

CONTEXT: Antibiotic use is associated with increased rates of antibiotic-resistant organisms. A previous study has shown that colds, upper respiratory tract infections, and bronchitis account for nearly one third of all antibiotic prescribing by ambulatory care physicians. How frequently antibiotics are prescribed for these conditions and for and by whom is not known. OBJECTIVES: To measure antibiotic prescription rates and to identify predictors of antibiotic use for adults diagnosed as having colds, upper respiratory tract infections, and bronchitis in the United States. DESIGN: Sample survey of practicing physicians participating in the National Ambulatory Medical Care Survey, 1992. SETTING: Office-based physician practices. SUBJECTS: Physicians (n=1529) completing patient record forms for adult office visits (n=28787). MAIN OUTCOME MEASURES: Antibiotic prescriptions for colds, upper respiratory tract infections, and bronchitis. RESULTS: Office visits for colds, upper respiratory tract infections, and bronchitis resulted in approximately 12 million antibiotic prescriptions, accounting for 21% of all antibiotic prescriptions to adults in 1992. A total of 51 % of patients diagnosed as having colds, 52% of patients diagnosed as having upper respiratory tract infections, and 66% of patients diagnosed as having bronchitis were treated with antibiotics. Female sex (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.05-2.62) and rural practice location (OR, 2.25; 95% CI, 1.33-3.80) were associated with greater antibiotic prescription rates, whereas black race (OR, 0.44; 95% CI, 0.21-0.93) was associated with lower antibiotic prescription rates. Patient age, Hispanic ethnicity, geographic region, physician specialty, and payment sources were not associated with antibiotic prescription rates in the bivariate analysis. Multivariate logistic regression analysis identified only rural practice location (adjusted OR, 2.58; 95% CI, 1.39-4.76) to be independently associated with more frequent antibiotic prescriptions for colds, upper respiratory tract infections, and bronchitis. CONCLUSION: Although antibiotics have little or no benefit for colds, upper respiratory tract infections, or bronchitis, these conditions account for a sizable proportion of total antibiotic prescriptions for adults by office-based physicians in the United States. Overuse of antibiotics is widespread across geographical areas, medical specialties, and payment sources. Therefore, effective strategies for changing prescribing behavior for these conditions will need to be broad based.

Adult↗
PubMed1997

Outcomes and costs after hip fracture and stroke. A comparison of rehabilitation settings.

OBJECTIVE: To assess whether outcomes and costs differ for elderly patients admitted to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes. DESIGN: Inception cohort stratified by provider type and followed prospectively for 6 months. SETTING: A total of 92 hospital-based units and freestanding facilities from 17 states. PATIENTS: A total of 518 randomly selected patients with hip fracture and 485 stroke patients admitted from November 1991 to February 1994. MAIN OUTCOME MEASURES: At 6 months comparing community residence, recovery to premorbid levels in 5 activities of daily living (ADLs), Medicare costs, and the number of therapy and physician visits. Outcomes were adjusted for premorbid residence and function, caregiver availability, comorbid illness, admission function, cognition, depression, sensory deficits, and mobility impairments. RESULTS: On admission, rehabilitation hospital patients were more likely (P<.001) to have caregivers and better cognitive and physical function. Hip fracture patients admitted to rehabilitation hospitals did not differ from patients admitted to nursing homes in returning to the community (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.6) or in the number of ADLs recovered to premorbid level (difference, 0.09 ADL; 95% CI, -0.27-0.44), but stroke patients admitted to rehabilitation hospitals were more likely to return to the community (adjusted OR, 3.3; 95% CI, 1.5-7.2) and recover ADLs (difference, 0.63 ADL; 95% CI, 0.20-1.07). Subacute nursing home patients with stroke were more likely than traditional nursing home patients to return to the community (adjusted OR, 6.8; 95% CI, 2.2-21.4), there was no difference in return to the community for patients with hip fracture (adjusted OR, 1.6; 95% CI, 0.7-3.6), and there were no differences in recovery of ADLs for either condition. Medicare costs were greater (P<.001) for rehabilitation hospital patients than for subacute nursing home patients, and the costs for subacute nursing home patients were greater (P=.03 for stroke and .009 for hip fracture) than for traditional nursing home patients. CONCLUSIONS: Study findings are consistent with enhanced outcomes for elderly patients with stroke treated in rehabilitation hospitals but not for patients with hip fracture. Subacute nursing homes were more effective than traditional nursing homes in returning patients with stroke to the community, despite comparable functional outcomes.

Activities of Daily Living↗
PubMed1997

The assessment of refill compliance using pharmacy records: methods, validity, and applications.

The refill records of computerized pharmacy systems are used increasingly as a source of compliance information. We reviewed the English-language literature to develop a typology of methods for assessing refill compliance (RC), to describe the epidemiology of compliance in obtaining medications, to identify studies that attempted to validate RC measures, to describe clinical features that predicted RC, and to describe the uses of RC measures in epidemiologic and health services research. In most of the 41 studies reviewed, patients obtained less medication than prescribed; gaps in treatment were common. Of the studies that assessed the validity of RC measures, most found significant associations between RC and other compliance measures, as well as measures of drug presence (e.g., serum drug levels) or physiologic drug effects. Refill compliance was generally not correlated with demographic characteristics of study populations, was higher among drugs with fewer daily doses, and was inconsistently associated with the total number of drugs prescribed. We conclude that, though some methodologic problems require further study, RC measures can be a useful source of compliance information in population-based studies when direct measurement of medication consumption is not feasible.

Australia↗
PubMed1997

Do traditional symptoms of hypothyroidism correlate with biochemical disease?

OBJECTIVE: Hypothyroidism often remains undetected because of the difficulty associating symptoms with disease. To determine the relation between symptoms and biochemical disease, we assessed symptoms and serum thyroid function tests, concurrently, for patients with and without hypothyroidism. DESIGN: Cross-sectional study. SETTING/PATIENTS: Seventy-six newly diagnosed case patients with overt hypothyroidism and 147 matched control patients identified through outpatient laboratories in Michigan and Colorado. MEASUREMENTS AND MAIN RESULTS: Patient symptoms were assessed by questionnaire. Case patients reported a higher proportion of hypothyroid symptoms than did control patients (30.2% vs 16.5%, p < .0001). Univariate analysis identified three significant predictors of an elevated level of thyroid-stimulating hormone (TSH) (p < .05), and 13 symptoms which, when they had changed in the past year, were reported more often by case patients with hypothyroidism than by control patients (p < .005). Individuals reporting changes in 7 or more symptoms were significantly more likely to have hypothyroidism (likelihood ratio [LR] = 8.7, 95% confidence interval [CI] 3.8, 20.2); those reporting changes in 2 or fewer symptoms were less likely to have hypothyroidism (LR = 0.5, 95% CI 0.4, 0.7). CONCLUSIONS: In this sample, the number of hypothyroid symptoms reported was directly related to the level of TSH. The association was stronger when more symptoms were reported. Symptoms that had changed in the past year were more powerful than symptoms reported present at the time of testing. This suggests that traditional symptoms are valuable when deciding which patients to test for hypothyroidism.

Adult↗
PubMed1997

Development and validation of a clinical prediction rule for prolonged nursing home residence after hip fracture.

OBJECTIVES: To develop and validate a clinical prediction rule for nursing home residence 6 months after a hip fracture. DESIGN: Two prospective cohort studies, a development study (DS) and a validation study (VS). SETTING: The DS included hip fracture patients admitted to 92 rehabilitation units or skilled nursing facilities; the VS included hip fracture patients from 11 integrated healthcare systems. PARTICIPANTS: A total of 344 community-dwelling hip fracture patients aged 65 and older participated in the DS; 239 similar patients were enrolled in the VS. INTERVENTION: None. MEASUREMENTS: The acute hospital record, nursing evaluations, and patient questionnaires provided information about demographics, physical and neuropsychological function, and comorbidity. Residence 6 months after fracture was determined by phone interview. Multivariate analysis identified predictors for a risk score to assess the likelihood of nursing home residence. RESULTS: 18.7% of patients in the DS resided in nursing homes 6 months after hip fracture. The four independent risk factors for institutionalization were (1) being unmarried (OR = 6.7 [95% CI 2.4 to 19]), (2) incontinence (OR = 2.3 [CI 1.2 to 4.7]), (3) dependence in ambulation (OR = 5.0 [CI 2.1 to 12.3]), and (4) cognitive impairment (OR = 6.6 [CI 3.3 to 13.2]). Of patients with all four risk factors, 73.2% were institutionalized at 6 months, compared with 0% of patients with no risk factors. In the VS, 6.1% of patients resided in nursing homes after 6 months, with a range from 50.0% of patients with four risk factors to 0% of those with no risk factors. Areas under receiver-operating characteristic curves for the prediction rule were 0.84 +/- .03 in the DS, and 0.81 +/- .06 in the VS. CONCLUSION: A clinical prediction rule using four easily measurable characteristics can identify individuals at high or low risk of nursing home residence 6 months after hip fracture.

Aged↗
PubMed1996

Exercise training improves functional status in patients with peripheral arterial disease.

PURPOSE: In patients with intermittent claudication (IC) a structured walking exercise program improves exercise performance. However, few studies have evaluated the effects of exercise training on functional status during daily activities. We hypothesized that a supervised exercise training program would improve functional status in patients with IC, with 24 weeks of training more beneficial than 12 weeks. A secondary aim was to evaluate the effects of strength training and combinations of strength and treadmill training on functional status. METHODS: Twenty-nine men with disabling IC were randomized to 12 weeks of either supervised treadmill training (3 hr/wk at a work intensity sufficient to produce claudication), strength training (3 hr/wk of resistive training of six muscle groups of each leg), or to a nonexercising control group. Functional status was assessed by questionnaires characterizing walking ability (Walking Impairment Questionnaire, WIQ), habitual physical activity level (Physical Activity Recall, PAR), and physical, social, and role functioning, well-being, and overall health (Medical Outcomes Study SF-20, MOS). Patients alos had their activity levels monitored with an activity monitor (Vitalog). RESULTS: After 12 weeks of treadmill training PAR scores increased by 48 metabolic equivalent hr/wk, the MOS physical functioning score by 24 percentage points, and the number of bouts of walking activity measured by the Vitalog by 4.5 bouts/hr (all p < 0.05). No changes were seen in WIQ scores. After 12 additional weeks of treadmill training improvements initially observed in the PAR, MOS, and Vitalog scores were maintained, and in addition the ability to walk distances (WIQ) improved by 31 percentage points, and the IC severity score had improved by 29 percentage points (both p < 0.05). After 12 weeks of strength training patients improved their WIQ walking speed, stair climbing scores, and MOS well-being scores with no other changes in functional status. Subjects in the control group did not improve functional status by any measure. Twelve weeks of treadmill training after the strength training program maintained WIQ walking speed scores, and activity level defined by Vitalog improved. Twelve weeks of combined treadmill and strength training after the control period had no effect on functional status. CONCLUSIONS: A supervised treadmill training program improved functional status during daily activities, with 24 weeks more effective than 12. In addition, treadmill training alone was more effective in improving functional status in patients with IC than strength training or combinations of the training modalities.

Aged↗
PubMed1996

Pharmacotherapy problems in the elderly.

As the elderly population increases, pharmacists will routinely confront aging-related problems in drug therapy. Drug therapy plans must take into account that diseases will present and progress differently in the elderly. Individual variations characterize the aging process, and it is physiologic-versus chronologic-aging that underlies age-related differences in pharmacokinetics and pharmacodynamics. More than one in six elderly Americans are taking prescription drugs whose adverse effects can have serious consequences in this age group.

Aged↗
PubMed1996

Clinical pharmacokinetics and pharmacodynamics of finasteride.

Finasteride is a potent 5 alpha-reductase inhibitor that has shown limited success in men treated for benign prostatic hyperplasia (success is defined as a decrease in the symptoms associated with urinary tract obstruction, and as increases in the urinary flow rate). 5 alpha-reductase is necessary for the prostatic conversion of testosterone to dihydrotesterone (DHT), the specific steroid that stimulates prostate transitional zone growth. Finasteride reduces the size of the prostate gland by 20%, but this does not correlate well with improvement in symptoms. Finasteride is well absorbed after oral administration and, while the rate of absorption may be slowed postprandially, the presence of food has no effect on the total bioavailability. Finasteride is widely distributed, but since its pharmacological effects are very specific to inhibition of 5 alpha-reductase, and since only the prostate gland, the scalp, and the genital skin contain high concentrations of this enzyme, few adverse reactions will be seen in other organ systems. Finasteride undergoes extensive hepatic metabolism to essentially inactive metabolites, which are eliminated through the bile and urine. The terminal elimination half-life (t1/2z) is 4.7 to 7.1 hours; but despite this, slow accumulation occurs with multiple doses. Values of t1/2z are higher in elderly men, but no dosage adjustments are necessary. Likewise, no dosage adjustments are necessary for patients with renal dysfunction, since the metabolites which accumulate are relatively inactive and well tolerated, and because greater faecal excretion of the metabolites occurs in these patients. The effect of hepatic dysfunction on the metabolism of finasteride is unknown. Therapeutic doses of finasteride produce a rapid and pronounced effect in reducing both plasma and prostate tissue levels of DHT. Doses below 0.5 mg/day do not produce much suppression of DHT levels, and doses above 5 mg/day have little additional benefit. A single dose of finasteride suppresses serum DHT levels for up to 4 days, longer than would be expected from the serum terminal elimination half-life (t1/2z) of the drug: this is probably due to the high affinity that finasteride has for the 5 alpha-reductase enzyme. Serum testosterone levels increase in patients receiving finasteride, but are not normally outside the upper limits of the normal range. Serum prostate-specific antigen (PSA) levels decrease with finasteride administration; the baseline for investigation of prostate cancer with elevated PSA levels should be one-half of the normal range. In responders to finasteride, the prostate gland shrinks in volume by about 20%, urinary flow rate improves by approximately 3 ml/s, and symptoms are relieved. The response to finasteride appears to be maximal at doses of 5 mg/day. For most men receiving finasteride, these effects will persist for at least the 5 years that long term studies have been conducted. Serum DHT levels increase again when finasteride therapy is discontinued, probably resulting in the return of the hyperplasia, decreased urine flow and obstructive symptoms. Finasteride is well tolerated, with loss of libido and sexual potency being the most commonly reported adverse reactions. No drug interactions with finasteride have been reported.

Drug Interactions↗
PubMed1995

Safety belt nonuse by internal medicine patients: a missed opportunity in clinical preventive medicine.

BACKGROUND: The United States Preventive Services Task Force recommends that physicians routinely counsel all patients to wear safety belts. We undertook this study to determine the prevalence of the nonuse of safety belts among internal medicine patients, to measure the association of nonuse with other health risk factors, and to ascertain the safety belt counseling practices of physicians. PATIENTS AND METHODS: A total of 492 consecutive patients attending a university-based general medicine clinic were given a validated, self-administered questionnaire, and 94% responded. A medical chart review was performed in a blinded fashion on 94% of the eligible charts. RESULTS: Of the 454 patients who provided safety belt information, 243 (54%) did not wear safety belts. Nonusers were more likely to be problem drinkers, inactive, obese, and to have a low income (adjusted odds ratios 1.8 to 2.0). Of patients with all four of these characteristics, 91% did not use safety belts. The leading reasons for safety belt nonuse were discomfort (35%), short driving distances (24%), and forgetfulness (13%). Obese patients were more likely to report discomfort as their reason for nonuse (odds ratio 2.4; 95% confidence limit 1.4 to 4.3). Eighteen patients (3.9%) reported that a physician had ever counseled them about safety belt use. Only two of 314 medical records (0.6%) noted physician questioning or counseling about safety belt use. CONCLUSIONS: The majority of patients attending an internal medicine clinic do not wear safety belts. Nonusers are more likely to be problem drinkers, inactive, obese, and to have a low income. Patients with multiple health risk factors are at significant risk of nonuse. The most common reason for nonuse is physical discomfort, especially among obese patients. Finally, physicians rarely counsel patients to use safety belts.

Alcoholism↗
PubMed1995

Quality of care in teaching nursing homes: findings and implications.

This article explores policy implications and selected methodological topics relating to long-term care (LTC) quality. We first discuss the Teaching Nursing Home Program (TNHP), in which quality of care in teaching nursing homes (TNHs) was found to be superior to the quality of care in comparison nursing homes (CNHs). A combination of outcome and process/structural measures was used to evaluate the effects of care and underlying reasons for superior TNH outcomes. Second, we explore policy and analytic ramifications. Conceptual, methodological, and applied issues in measuring and improving the quality of LTC are discussed in the context of TNH research and related research in home care.

Education, Nursing↗
PubMed1994

Finding temporal patterns--a set-based approach.

We created an inference engine and query language for expressing temporal patterns in data. The patterns are represented by using temporally-ordered sets of data objects. Patterns are elaborated by reference to new objects inferred from original data, and by interlocking temporal and other relationships among sets of these objects. We found the tools well-suited to define scenarios of events that are evidence of inappropriate use of prescription drugs, using Medicaid administrative data that describe medical events. The tools' usefulness in research might be considerably more general.

Artificial Intelligence↗
PubMed1994

A prospective study of heparin-induced osteoporosis in pregnancy using bone densitometry.

OBJECTIVE: Our purpose was to evaluate the subclinical occurrence of heparin-induced osteoporosis in pregnancy, by means of bone densitometry. STUDY DESIGN: A prospective, consecutive cohort of 14 pregnant women requiring heparin therapy and 14 pregnant controls matched for age, race, and smoking status was identified by 20 weeks' gestation at a university medical center. Proximal femur bone density measurements were taken at baseline, immediately post partum, and 6 months post partum in the cases and controls. Vertebral measurements were also obtained on both groups immediately post partum and 6 months post partum. Bone density as a function of heparin dosing and duration was examined. Nonparametric statistical tests were used for all comparisons. RESULTS: Five of 14 cases (36%) had a > or = 10% decrease from the baseline proximal femur measurements to immediate postpartum values versus none of the 14 matched controls (p = 0.04). Mean proximal femur bone density measurements also decreased in the cases (p = 0.01); this difference continued to be statistically significant 6 months post partum (p = 0.03). No dose-response relationship could be demonstrated. CONCLUSION: Heparin adversely affected bone density in about one third of exposed patients.

Absorptiometry, Photon↗