Biomedical subjects

Jon D Lurie

Publications and source records attributed to Jon D Lurie.

6 recordsLinked to original sources

PubMed2003

Rates of advanced spinal imaging and spine surgery.

STUDY DESIGN: Small area analysis. OBJECTIVES: To determine the association between the rates of advanced spinal imaging and spine surgery across geographic areas. SUMMARY OF BACKGROUND DATA: The rates of spine surgery in the United States have increased along with a concurrent rise in the use of advanced spinal imaging: CT and MRI. Spine surgery rates vary six-fold across geographic areas of the United States. Differences in patient populations and health care supply have explained only about 10% of this variation. METHODS: We used a random 5% sample of Medicare's National Claims History Part B files for 1996 and 1997 to determine procedure rates across 306 Hospital Referral Regions. We analyzed the association between spinal imaging and spine surgery using linear regression. Main outcome measures were rates of procedures and coefficients of determination (R2). RESULTS: The rates of advanced spinal imaging (CT and MRI combined) varied 5.5-fold across geographic areas. Areas with higher rates of MRI had higher rates of spine surgery overall (r = 0.46) and spinal stenosis surgery specifically (r = 0.37). The rates of advanced spinal imaging accounted for 22% of the variability in overall spine surgery rates (R2 = 0.22, P < 0.001) and 14% of the variability in lumbar stenosis surgery rates (R2 = 0.14, P < 0.001). A simulation model showed that MRIs obtained in the patients undergoing surgery accounted for only a small part of the correlation between MRI and total spine surgery rates. CONCLUSIONS: A significant proportion of the variation in rates of spine surgery can be explained by differences in the rates of advanced spinal imaging. The indications for advanced spinal imaging are not firmly agreed on, and the appropriateness of many of these imaging studies has been questioned. Improved consensus on the use and interpretation of advanced spinal imaging studies could have an important effect on variation in spine surgery rates.

Aged↗

PubMed2003

Is a condition-specific instrument for patients with low back pain/leg symptoms really necessary? The responsiveness of the Oswestry Disability Index, MODEMS, and the SF-36.

STUDY DESIGN: Analysis of longitudinal data collected prospectively from patients seen in 27 National Spine Network member centers across the United States. OBJECTIVE: To evaluate the responsiveness of the Oswestry Disability Index, MODEMS scales, and all scales and summary scales of the MOS Short-Form 36 (SF-36) for patients with low back pain/leg symptoms. SUMMARY OF BACKGROUND DATA: The responsiveness of general and condition-specific health status instruments is a key concept for clinicians and scientists. Various authors have explored responsiveness in common surveys used to assess spine patients. Although it is generally believed that condition-specific measures are more responsive to change in the condition under study, in the case of low back pain, most authors agree that further exploration is necessary. METHODS: Patients with diagnoses of herniated disc, spinal stenosis, and spondylosis from the National Spine Network database who completed baseline and 3-month follow-up surveys were analyzed. Patient-provider consensus regarding improvement, worsening, or no change in the condition was selected as the external criterion. Responsiveness was evaluated using ROC curve analysis and effect size calculations. RESULTS: Nine hundred and seventy patients had complete data at baseline and 3 months. At follow-up, 68% of the patients had consensus improvement. Based on ROC analysis, scales assessing pain were significantly more responsive than scales assessing function. There were no significant differences between the condition-specific scales and their equivalent general-health counterpart. The scales with the highest probabilities of correctly identifying patient's improvement were: the condition-specific pain scale from MODEMS (PAIN, ROC = 0.758); the combined pain and function scale from MODEMS (MPDL, ROC = 0.755); the general pain scale from the SF-36 (BP, ROC = 0.753); the combined pain and function scale from the SF-36 (PCS, ROC = 0.745); the condition-specific function measure from the Oswestry (ODI, ROC = 0.723); and the physical function measure from the SF-36 (PF, ROC = 0.721). A similar rank order was typically maintained with effect size calculations. Results were nearly identical in patients with multiple non-spine-related comorbidities and in patients with high degrees of perceived disability. The BP scale was most responsive to worsening of symptoms. CONCLUSION: For studies of patients with low back problems, the general SF-36 may be a sufficient measure of health status and patient function, without the need for additional condition-specific instruments. Pain scales appear to be the most responsive measures in patients with low back pain.

Cohort Studies↗

PubMed2002

Computerized questionnaires and the quality of survey data.

STUDY DESIGN: A retrospective data quality analysis was conducted. OBJECTIVE: To compare missing response rates and internal consistency between computerized and paper surveys administered to spine patients. SUMMARY OF BACKGROUND DATA: Computerized patient surveys have been shown to offer numerous advantages over traditional paper surveys. It has been assumed that computerized surveys also improve data quality, but quantitative comparisons have not been made. METHODS: Between January 1998 and December 2000, approximately 3500 computerized questionnaires and 15,000 paper questionnaires containing the MOS 36-Item Short-Form Health Survey (SF-36) and the Oswestry Low Back Pain Disability Questionnaire were administered in the National Spine Network. Missing response rates and the Response Consistency Index (RCI) were compared between computerized and paper questionnaire data. RESULTS: Computer surveys had approximately half the missing response rate of paper surveys. For the SF-36, the computer survey had 1.7% missing, as compared with 3.3% missing on paper (P < 0.001). For the Oswestry, the computer survey had 2.9% missing, as compared with 6% missing on paper (P < 0.001). Whereas 84% of the SF-36 surveys and 85% of the Oswestry surveys collected by computer were completely filled out (no missing responses), only 68% of the SF-36 surveys (P < 0.001) and 77% of the Oswestry surveys (P < 0.001) collected on paper were completely filled out. The SF-36 data collected by computer had better internal consistency than the paper-form data, with average Response Consistency Index scores of 0.12 and 0.16, respectively (P = 0.001). CONCLUSIONS: Superior response rates and higher internal consistency suggest that computerized survey systems improve data quality, and may enhance instrument validity for commonly used measures of spine patient health.

Cohort Studies↗

PubMed2002

Design of the Spine Patient outcomes Research Trial (SPORT).

SUMMARY OF BACKGROUND DATA: The Spine Patient Outcomes Research Trial (SPORT) was designed to assess the relative efficacy and cost-effectiveness of surgical and nonsurgical approaches to the treatment of common conditions associated with low back and leg pain. OBJECTIVES: To describe the rationale and design of the SPORT project and to discuss its strengths and limitations. STUDY DESIGN: Descriptive. METHODS: First, the authors explain the rationale for embarking on SPORT, i.e., deficiencies in the existing scientific knowledge base for treatment of these conditions. Second, the authors describe the design of SPORT, including topics such as specific aims, participating sites, study population, recruitment and enrollment, study interventions, follow-up, outcomes, statistical analysis, and study governance and organization. Finally, issues that complicate the performance of randomized trials in surgery as they relate to the design and conduct of SPORT are discussed. RESULTS: The SPORT project is being conducted at 11 clinical centers around the United States. It involves the simultaneous conduct of three multicenter, randomized, controlled clinical trials. The study includes patients with the three most common diagnoses for which spine surgery is performed: intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis, and it compares the most commonly used standard surgical and nonsurgical treatments for patients with these diagnoses. By the end of enrollment the authors anticipate a total of 500 patients with intervertebral disc herniation, 370 patients with spinal stenosis, and 300 patients with degenerative spondylolisthesis in the randomized trials. Patients who meet the eligibility criteria but decline to be randomized are invited to participate in an observational cohort study. Patients are being followed for a minimum of 24 months with visits scheduled at 6 weeks and at 3, 6, 12, and 24 months. CONCLUSIONS: The results of this study will provide high-quality scientific evidence to aid clinical decision-making and improve treatment outcomes for these common, costly, and, in some instances, debilitating conditions.

Cost-Benefit Analysis↗

PubMed2002

An approach to hospital quality improvement.

This study demonstrates many of the important features and challenges of improving hospital care. The unique confluence of software technology advances and increasingly complex clinical needs have made possible a redesign of the process by which discharge documentation is generated and disseminated. Using knowledge of the patients' experience of hospital care, a multidisciplinary team identified communication at the time of discharge as a key interaction point in the system of care. With this need in mind, the team identified an aim of improving the accuracy and timeliness of discharge data and their dissemination. The project leveraged existing information technology to help satisfy the general aims of recording only useful information only once and reducing wait times for information [14]. The ability to manage structured medication data and translate this information and specialized care instructions into patient-directed language facilitated the creation of a document that would ensure that patients knew what was expected of them after discharge. Implementation of a discharge form requires understanding all of the constituencies within a medical center. It was therefore necessary to put together a team that included representation from all the groups who interact with this discharge information. The authors proceeded with a small-scale test of change during which they identified training and education needs that would be useful as the new process expands to other areas of the hospital. The case illustrates how in one project a team needs to address all of the challenges to improving hospital quality. The discharge form clearly required understanding the patient's perspective. The approach taken by the team to change the discharge form also showed detailed understanding of the process of discharging a patient from the hospital. Many microsystems are involved in this process and the change that was implemented took into account the needs of each of those subsystems and drew on resources from the macroorganization (computer information system). Measurement was embedded into the system for monitoring. Organizational culture was addressed in that the organization itself was moving in the direction of greater use of electronic information for better patient care. Finally, multiple staff members needed to come together to accomplish this task, all working together as a team. They created an implementation plan that allowed them to do the work in staged, planned efforts, and to learn from each endeavor. Was the change an improvement? The team was able to implement successively a change in the discharge process as measured by utilization of the new form. Will the quality of care improve? Probably, although that remains to be seen. Improvements in care do not need to be sophisticated, they do not need to be elaborate, and they do not need to involve new devices or new technologies. Improvements start with thinking about the way work is done and reflecting on how the work might be done differently to meet and exceed patients' needs and expectations.

Algorithms↗

PubMedDate not supplied

Benchmarking the future generalist workforce.

CONTEXT: Previous workforce analyses by the Council on Graduate Medical Education (COGME) have concluded that the United States has too few, or just enough, generalists. However, recent trends suggest that more physicians are entering primary care, raising the possibility of a future surplus. OBJECTIVE: To project the future supply of generalists relative to future requirements. DESIGN: We developed a model that projects the supply of generalists into the future on the basis of the annual number of physicians entering and leaving the workforce. We calculated the number of clinically active generalists from the physician master-files of the American Medical Association and American Osteopathic Association. The number of graduating trainees entering the generalist workforce was calculated from the 1999 to 2000 AMA Annual Survey of GME. The number leaving was calculated by using age- and sex-specific rates or physician death and retirement provided by the Bureau of Health Professions. MEASUREMENTS: Projected per capita number of clinically active generalists to the year 2025, relative to physician requirements suggested by COGME and several regional benchmarks of physician supply. RESULTS: The supply of generalists is projected to grow from its current level of 69 per 100,000 to nearly 88 per 100,000 by the year 2025. Adjusting for the changing age-sex structure of the physician workforce decreases the "effective" supply to 85 generalists per 100,000. By the year 2025, the effective supply of generalists will exceed COGME's upper estimate of generalist requirements (80 per 100,000), resulting in an excess of about 18,000 full-time equivalent generalists. The future supply of generalists will also exceed most current regional benchmarks of generalist supply. CONCLUSION: At current levels of training, the supply of generalists will grow substantially and soon exceed several benchmarks for generalist requirements.

Benchmarking↗