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Biomedical subjects

K Grumbach

Publications and source records attributed to K Grumbach.

At least 73 records · Page 4Linked to original sources
PubMed1994

Complications after laparoscopic pelvic lymphadenectomy: CT diagnosis.

OBJECTIVE: Laparoscopic dissection of pelvic lymph nodes has become an accepted alternative to open lymphadenectomy for staging of genitourinary tumors. This study reviews the CT findings in patients with major complications detected after laparoscopic dissection. MATERIALS AND METHODS: Of 85 patients who had laparoscopic dissection of pelvic lymph nodes at our institutions during a 3-year period, complications developed in 12 patients (14%), and eight of these had abdominopelvic CT studies done. CT findings and initial interpretations were correlated with follow-up surgical, clinical, or interventional radiologic findings in all cases. RESULTS: Complications of laparoscopic dissection detected with CT included small-bowel obstruction due to herniation through the trocar site in the abdominal wall (n = 2), extensive hematoma of the abdominal wall or retroperitoneum (n = 2), urinary ascites or multiple urinomas due to ureteral laceration or transection (n = 2), and lymphocele compressing the bladder where the peritoneum was sealed after lymphadenectomy (n = 1). In one case, CT showed pneumoperitoneum but failed to show a perforation of the sigmoid colon. CONCLUSION: Major complications occurred after laparoscopic dissection of pelvic lymph nodes and were diagnosed on the basis of CT findings in seven of eight patients. Recognition of the CT appearances of hernia or hematoma at the insertion sites of the trocars or the laparoscope is important, as is detection of injury to bladder, ureter, bowel, or blood vessels. Symptomatic lymphoceles were infrequently detected, probably because of the use of free drainage into the peritoneal cavity after laparoscopic dissection.

Aged↗
PubMed1994

The role of the Society of Teachers of Family Medicine in health care reform: a membership survey.

BACKGROUND AND OBJECTIVES: We conducted a survey of STFM members to: 1) measure perceived knowledge of and support for four health care reform proposals, 2) rate the members' priorities about specific legislative activities relevant to STFM, health care reform, and STFM general activities, and 3) assess interest in STFM developing a monograph on health care reform. METHODS: A self-administered questionnaire was mailed to a 15% random sample (n = 470) of STFM members. Researchers were blinded to the identity of respondents. RESULTS: Three hundred seven members returned completed surveys (response rate = 65%). Members were largely divided in their support between the pay or play and the single payer plans, with 39% (95% confidence interval (CI) 33%-44%) preferring the former and 34% (95% CI = 31%-37%) preferring the latter. Employer mandate and tax credit plans were rated less favorably. Overall, members rated their perceived knowledge about these plans as fair to good. In terms of rating their priorities about STFM activities, members gave the highest ratings to STFM legislative activities specific to the needs of academic family medicine (eg, faculty development, reimbursement for clinical and teaching activities, and research). These specific legislative activities were rated higher than all of the general categories of STFM activities. CONCLUSION: STFM members want STFM to advocate for specific legislation pertinent to the development of academic family medicine. Although most members support comprehensive health care reform, no single plan is preferred by a majority of members.

Family Practice↗
PubMed1993

Use of coronary artery bypass surgery in the United States and Canada. Influence of age and income.

OBJECTIVE: To compare overall rates of coronary artery bypass surgery (CABS) in several Canadian and US jurisdictions and to compare use by age and income groups in the two countries. DESIGN: Survey, using computerized hospital discharge abstracts. SETTING: All nonfederal hospitals in New York, California, Ontario, Manitoba, and British Columbia between 1983 and 1989. PATIENTS: All adult residents of the five jurisdictions who underwent CABS in a hospital in their jurisdiction. RESULTS: Between 1983 and 1989, the CABS rates were consistently highest in California and lowest in the Canadian jurisdictions. In 1989, the age-adjusted rate of CABS in California (112.5/100,000 adults) was 27% higher than in New York (88.4/100,000) and 80% higher than in the three Canadian provinces combined (62.4/100,000). The CABS rates increased for those aged 65 years and older and decreased for those aged 20 to 54 years in all five jurisdictions. In 1989, CABS rates were three times higher in California than in Canada for those aged 75 years and older, and the higher rates for those aged 65 years and older accounted for 75% of the overall difference in rates between California and Canada. In Canada, CABS rates for the nonelderly varied little by income of area of residence, but in New York and California, rates increased steadily with the income of area of residence. CONCLUSION: Control over the supply of resources in Canada is associated with markedly lower CABS rates for the elderly than found in the United States. While overall rates are lower in Canada, the Canadian universal health insurance system reduces the influence of income on access to CABS found in the United States. However, even without universal health insurance, CABS rates for the nonelderly living in the poorest areas in California are similar to the rates for those living in the poorest parts of Canada.

Adult↗
PubMed1993

Primary care and public emergency department overcrowding.

OBJECTIVES: Our objective was to evaluate whether referral to primary care settings would be clinically appropriate for and acceptable to patients waiting for emergency department care for nonemergency conditions. METHODS: We studied 700 patients waiting for emergency department care at a public hospital. Access to alternative sources of medical care, clinical appropriateness of emergency department use, and patients' willingness to use nonemergency services were measured and compared between patients with and without a regular source of care. RESULTS: Nearly half (45%) of the patients cited access barriers to primary care as their reason for using the emergency department. Only 13% of the patients waiting for care had conditions that were clinically appropriate for emergency department services. Patients with a regular source of care used the emergency department more appropriately than did patients without a regular source of care. Thirty-eight percent of the patients expressed a willingness to trade their emergency department visit for an appointment with a physician within 3 days. CONCLUSIONS: Public emergency departments could refer large numbers of patients to appointments at primary care facilities. This alternative would be viable only if the availability and coordination of primary care services were enhanced for low-income populations.

Adult↗
PubMed1993

Variation in physicians' recommendations about revisit interval for three common conditions.

BACKGROUND: The appropriate revisit interval for most conditions is uncertain. This survey was done to gather information about physicians' recommendations on revisit intervals for three common conditions. METHODS: Data were gathered in a mailed survey of 116 primary care physicians in the University of California at San Francisco Collaborative Research Network. Physicians were given descriptions of three hypothetical patients, one with diabetes mellitus, one with angina, and one with hypertension, and were asked when they would recommend a follow-up visit for the condition. RESULTS: There were great variations in physicians' recommendations about revisit intervals for each hypothetical patient. Internists were significantly more likely than family physicians to recommend a longer revisit interval for the hypothetical patient with diabetes mellitus; a similar revisit pattern was found for the patient with hypertension. There were no significant associations with recommended revisit interval and many other physician characteristics. CONCLUSIONS: As interest in containing the cost and improving the efficiency of medical care increases, knowing how often patients ought to be seen will be a topic of increasing importance. A rational, information-based approach to the choice of revisit interval for common conditions could yield substantial savings in medical care costs. The existence of great variation in recommended revisit interval suggests that physicians are uncertain about what interval is best.

Aged↗
PubMed1993

Collecting data to evaluate the effect of health policies on vulnerable populations.

Public health policies often have disproportionate effects on the poor and other vulnerable groups. Standard survey techniques are often difficult to apply to these vulnerable populations, and many data bases systematically omit such individuals. The purpose of this paper is to review our experience in collecting primary survey data from public hospital, mentally ill, HIV-infected, and non-English-speaking patients. Important issues in conducting research on these populations include proper selection of subjects and comparison groups and difficulties involved in recruitment and enrollment of subjects. Maintaining longitudinal data on these populations is difficult and often requires tracking, secondary contacts, home visits and community outreach, and the use of organizations, institutions, and networks. Investigators must also pay careful attention to ethical issues involved in conducting research on vulnerable populations.

Data Collection↗
PubMed1992

Financing universal health insurance: taxes, premiums, and the lessons of social insurance.

In a society with strong antitax sentiment and large government deficits, the enactment of universal health insurance is blocked by an impasse over financing. The two chief mechanisms for funding universal health insurance are taxes and insurance premiums. Taxes and premiums are not distinct entities; rather, a spectrum of financing methods exists with varying tax-like and premium-like features. Premium-like financing tends to be voluntary and earmarked for health care, with coverage contingent upon making payments and payments going to private insurance firms. Tax-like financing, in contrast, tends to be mandatory and not earmarked for health care, with coverage not dependent upon making payments and payments going to governments. Over the past century, most industrialized nations have developed highly popular social insurance programs to cover periods of retirement, disability, unemployment, and payment for medical care. Social insurance constitutes a blend of tax-like and premium-like features, offering lessons that might assist in breaking the current impasse over universal health insurance financing.

Fees and Charges↗
PubMed1991

Consequences of queuing for care at a public hospital emergency department.

OBJECTIVE: To determine whether the length of a queue at a public hospital emergency department was associated with increased likelihood of patients' leaving without being seen by a physician and whether leaving adversely affected patients' health or affected their subsequent use of health care services. DESIGN: Observational cohort. Patients were surveyed during 1 week in July 1990 and received a follow-up survey 7 to 14 days later. The responses of patients who left without being seen by a physician were compared with those who were seen by a physician. SETTING: Emergency department at San Francisco (Calif) General Hospital. PATIENTS: All English-, Spanish-, and Cantonese-speaking adults waiting for emergency care were eligible. Of 882 eligible individuals, 700 agreed to participate; 85% of enrolled subjects saw a physician and 15% left without being seen. Demographic characteristics of patients who were and who were not seen were not significantly different. MAIN OUTCOME MEASURES: Emergency department waiting time and changes in patients' self-reported health. RESULTS: Patients were more likely to leave as waiting times increased. At follow-up, patients who left without being seen were twice as likely as those who were seen to report that their pain or the seriousness of their problem was worse. Only 4% of patients who left required subsequent hospitalization, but 27% returned to an emergency department. CONCLUSION: Many patients can appropriately decide whether their problem is truly urgent and make alternative plans in the face of long waits, but the health of some patients may be jeopardized by long queues for emergency care.

Acute Disease↗
PubMed1991

Liberal benefits, conservative spending. The Physicians for a National Health Program proposal.

The Physicians for a National Health Program proposes to cover all Americans under a single, comprehensive public insurance program without copayments or deductibles and with free choice of provider. Such a national health program could reap tens of billions dollars in administrative savings in the initial years, enough to fund generous increases in health care services not only for the uninsured, but for the underinsured as well. We delineate a transitional national health program budget that would hold overall health spending at current levels while accommodating increases in hospital and physician utilization. Future national health program spending would be indexed to the growth in gross national product adjusted for demographic, epidemiologic, and technologic shifts. Financing for the national health program would transfer funds into the public program without disrupting the general pattern of current revenue sources. We suggest a funding package that would augment existing government health spending with earmarked health care taxes. Because these new taxes would replace employer-employee insurance premiums and substantial portions of current out-of-pocket expenditures, they would not increase health costs for the average American.

Budgets↗
PubMed1991

How many physicians can we afford?

We project physician costs for the year 2,000 under several alternative scenarios, using different assumptions about the future supply of physicians and gross income (or expenditures) per physician. The supply of active, posttraining patient-care physicians is projected to increase from a ratio of 144 per 100,000 population in 1986 to 176 per 100,000 in 2,000. Depending on whether expenditures per physician increase at the rate of the consumer price index, the gross national product, or the historical 1982 through 1987 expenditure trends, there will be an additional cost (in constant 1986 dollars) of $21 billion, $30 billion, or $40 billion, respectively, compared with projected physician costs under a scenario of a constant physician-to-population ratio. The disproportionate growth of costs for practice overhead will pose a particular problem for efforts to restrain inflation of expenditures per physician.

Fee Schedules↗
PubMed1991

National health insurance and the problems of American medicine.

The problems of inequitable access to care, health care inflation, and reduced physician autonomy confront physicians and health care reformers with a dilemma. Piecemeal measures attempting to alleviate one problem in isolation simply exacerbate the others. A logical approach to addressing these problems together is a national health program based on a single payer of health services. By reducing administrative waste and emphasizing global budgetary strategies, the single-payer system could promote more efficient health care spending. While single-payer systems create more explicit political conflict over resource allocation, they also have demonstrated an ability to maintain quality of care and reduce bureaucratic intrusions into clinical practice.

Canada↗
PubMed1990

Disorders of the fetal thorax and abdomen.

Many disorders of the fetal thorax and abdomen can be evaluated using ultrasound. Even when a definitive diagnosis cannot be made prenatally, sonography can provide valuable clinical information regarding the nature and location of the abnormality, associated anomalies, and the presence of secondary complications. An awareness of these disorders and their sonographic appearance is important to impact upon obstetrical management and overall prognosis.

Digestive System Abnormalities↗
PubMed1990

Supplemental emergent chest computed tomography in the management of blunt torso trauma.

The efficacy of conventional chest X-ray (CXR) in comparison to chest computed tomography (CCT) in acutely injured blunt trauma patients was examined. Over a 21-month period, 50 patients underwent CXR and CCT according to a standard protocol, and their films and records were reviewed retrospectively. Hemo- and/or pneumothorax (HPTX) was noted in 12 patients (five by CXR, 12 by CCT). Pulmonary contusion (PC) was identified in ten patients (four by CXR, ten by CCT). Three additional false positive PC were diagnosed by CXR. Therapy changes based upon CCT findings occurred in seven of seven HPTX and five of six PC. The two imaging techniques were complementary in detecting fractures. Atelectasis was a common CCT finding (58% incidence). Chest X-ray is less sensitive than chest computed tomography in the detection of HPTX (42% vs. 100%) and PC (40% vs. 100%). Emergent chest computed tomography is recommended in stable patients with: 1) blunt high-energy torso trauma, 2) "cross-body" injury pattern, and/or 3) a mechanism of injury suggestive of chest trauma.

Adult↗
PubMed1990

Non-Hodgkin lymphoma of the small intestine.

The authors present a simplified radiographic classification of non-Hodgkin lymphoma involving the small intestine. The classification system is based on radiographic findings in 22 pathologically proved cases of lymphoma involving the small bowel and consists of three major forms: primary, lymphoma complicating celiac disease, and mesenteric nodal. In this series, small bowel lymphoma was evenly distributed in the jejunum and ileum. The most common radiographic patterns were circumferential lesion (seven cases), cavitary lesion (four cases), and mesenteric nodal disease invading the small bowel (seven cases). Obstructive symptoms were usually encountered with the mesenteric nodal form. Lymphoma complicating celiac disease was typified by multiple, thickened, nodular folds involving a segment of proximal small intestine.

Adult↗