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Biomedical subjects

M F Shapiro

Publications and source records attributed to M F Shapiro.

At least 109 records · Page 6Linked to original sources
PubMed1989

Out-of-pocket payments and use of care for serious and minor symptoms. Results of a national survey.

To assess the effect of out-of-pocket payments on use of care for symptoms that physicians consider serious and meriting care, and for minor symptoms, we evaluated data from a 1986 national survey. Among 5412 adults reporting one or more medical visits in the last year, 18.8% had experienced serious symptoms within the previous 30 days, among whom 63.0% sought care, while 31.3% had experienced minor symptoms, among whom 42.8% sought care. Subjects who had paid $15 or less out of pocket for their last medical visit were more likely to seek care for a serious symptom (67.1% vs 52.6%) or for a minor symptom (47.1% vs 32.2%) than were those who paid $30 or more. Large out-of-pocket payments are associated with significant reductions in use of care for both serious and minor symptoms.

Adult↗
PubMed1989

Changing physician test ordering in a university hospital. An intervention of physician participation, explicit criteria, and feedback.

To decrease inappropriate test ordering by medical house staff in a university hospital, we examined the feasibility of an intervention that involved physicians in developing explicit criteria for ordering four specific tests and incorporated feedback of tests ordered. We implemented a time series design with measures at 12 and six months before, during, and three weeks after the intervention. During the intervention, orders for initial or admission chest roentgenograms decreased by 22% and repeated orders for routine urinalyses, chest roentgenograms, and leukocyte differential counts decreased by 23%, 30%, and 46%, respectively, compared with the six-month preintervention period. Orders for prothrombin time and/or partial thromboplastin time did not fall. After the intervention, most test ordering remained at the intervention level. These preliminary results suggest that this intervention may be effective and not overly costly.

Blood Coagulation Tests↗
PubMed1988

Inequities in health services among insured Americans. Do working-age adults have less access to medical care than the elderly?

To determine whether groups other than the elderly and the uninsured have difficulty obtaining access to medical care, we studied 7633 adults nationwide. As we expected, the insured had much greater access than the uninsured, but among the insured there were substantial disparities in access to care. Insured adults of working age were 3.5 times as likely (95 percent confidence interval, 2.7 to 4.4) as the elderly to have needed supportive medical services (including medications and supplies) but not to have received them, and 3.4 times (2.3 to 4.4) as likely to have had major financial difficulties because of illness. Among insured, working-age adults, the poor were 4.4 times (3.5 to 5.3) as likely as those who were not poor to have needed supportive services but not to have received them, and 5.2 times (3.6 to 6.8) as likely to have had major financial problems because of illness. Apart from insurance status and income, blacks were 1.7 times (1.1 to 2.2) as likely as whites to have needed supportive services but not to have received them. Hispanics with a medical illness were 2.2 times (1.3 to 3.2) as likely as whites not to have seen a physician within the past year. We conclude that insured, working-age adults have less access to medical care than the elderly, and that poor, black, or Hispanic persons in this group are at risk for even greater problems with access to care. Current policy strategies are unlikely to improve the ability of these groups to obtain care.

Adult↗
PubMed1988

Who gets screened for cervical and breast cancer? Results from a new national survey.

To evaluate the adequacy of cervical and breast cancer screening in the United States, data were analyzed from a 1986 nationwide telephone survey (n = 4659). Papanicolaou smears within the recommended three- to five-year interval were reported by 79% of women aged 20 years or older. Within the preceding year, 55% of women aged 40 years or older had breast examinations performed by physicians, and 20% of women aged 50 years or older had mammograms. Women who were uninsured or lower in socioeconomic status were less likely to have each of these three preventive measures, independent of the age, health status, and frequency of physician visits of the respondent. In addition, women aged 50 years or older were less likely to have had Papanicolaou smears (63% vs 89%) and breast examinations (52% vs 68%) than those women aged 20 to 49 years. These findings suggest that women who are older, uninsured, or lower in socioeconomic status are at an increased risk for not receiving preventive care, and that screening mammography, although more common than a decade ago, is still markedly underused.

Adult↗
PubMed1987

Laboratory testing on cerebrospinal fluid. A reappraisal.

555 consecutive cases in which cerebrospinal fluid (CSF) was sent for cell count were reviewed to determine which cerebrospinal-fluid tests affect diagnosis or therapy. Among 334 cases (60%) with a normal opening pressure, cell count, and protein, 1385 additional tests were done, but such tests were useful in only 3 patients (0.9%) with multiple sclerosis. Among 148 consecutive cases of bacterial, chronic infectious, and malignant meningitis the opening pressure, cell count, or protein was abnormal in all but 3 (2 childhood bacterial meningitis and 1 cryptococcal meningitis in a patient with the acquired immunodeficiency syndrome). If the opening pressure, cell count, and protein are normal, no additional CSF tests are needed in most instances; however, in immunocompromised patients and in those with possible multiple sclerosis or childhood bacterial meningitis additional tests may be indicated.

Adolescent↗
PubMed1987

Identification of health care problems in a county jail.

The health care needs of prisoners often are not systematically addressed. To evaluate the ability of a questionnaire, that is administered at the time of arrest, to identify inmates' medical problems and to predict subsequent use of care, we reviewed and analyzed medical records and questionnaires for 594 individuals incarcerated in a county jail. Only 54% of subjects had a completed questionnaire filed in a medical record; the questionnaire identified only 48% of persons who eventually sought care for such major problems as drug and alcohol abuse and cardiopulmonary disease. No question screened for psychiatric problems, even though five percent of subjects were diagnosed as having major psychiatric disorders during their incarcerations. On the other hand, many items addressed problems that were far less common. Uniform screening of prison populations may be effective if conducted with greater rigor and better instruments than were employed in the institution studied. Health care for inmates might be served better by universal screening and follow-up, targeted to such important problems as drug and alcohol abuse and psychiatric disorders.

California↗
PubMed1987

The complete blood count and leukocyte differential count. An approach to their rational application.

The complete blood count and leukocyte differential count have no value in screening asymptomatic members of the general population. The complete blood count may be useful for screening infants in the first year of life, institutionalized elderly persons, pregnant women, and recent immigrants from Third World countries, if poor nutrition or inadequate iron intake is suspected. These tests are not useful for hospitalized patients, unless an abnormality is suspected or surgery with major blood loss is anticipated. It is appropriate to obtain the tests when a hematologic or infectious disorder is suspected, but they may not affect decision making if the diagnosis is clinically evident. The leukocyte differential count is unnecessary to confirm an infection in most cases in which leukocytosis is present. Repeat tests should be limited to situations where the clinical course is unclear, and at intervals long enough such that the results might affect clinical decision making.

Ambulatory Care↗
PubMed1986

Effects of cost sharing on seeking care for serious and minor symptoms. Results of a randomized controlled trial.

To estimate the effect of cost sharing on seeking care for serious and minor symptoms, we analyzed data for 3539 persons aged 17 to 61 from the Rand Health Insurance Experiment. Participants were randomly assigned to a free-care group or to insurance plans requiring them to pay part of the costs (cost-sharing group). Annual surveys were administered to determine if participants had serious and minor symptoms during the preceding month and whether they saw a physician. Serious symptoms were judged by a panel of physicians to warrant care in most instances; minor symptoms were judged neither to be severe nor to warrant care in most instances. The cost-sharing group was nearly one third less likely than the free-care group to see a physician when they had minor symptoms (6.3% compared with 9.0%; p less than 0.04). The free-care and cost-sharing groups did not differ significantly in seeking care for serious symptoms (22.3% compared with 17.9%; p = 0.095). However, for participants with low socioeconomic status who began the study in poor health, the prevalence of serious symptoms was higher in the cost-sharing than the free-care group (29.1% compared with 23.8%, p less than 0.004).

Adolescent↗
PubMed1984

Reporting results from chemotherapy trials. Does response make a difference in patient survival?

Patients with many common tumors are treated with chemotherapy despite limited evidence of treatment effectiveness. To determine if chemotherapy trials reporting effectiveness actually demonstrated increased survival in treated patients, we reviewed trials published over a two-year period involving four common solid tumors. Of 80 studies, 95% reported response to chemotherapy as an end point. Of 38 studies demonstrating 15% or greater objective response, 76% reported significantly greater survival of responders than of nonresponders. Of 21 studies containing statements supporting treatment effectiveness, 95% based this claim at least in part on the superior survival of responders compared with nonresponders. Because responders may have lived longer without treatment, such comparisons are not valid and may lead to overly optimistic views of chemotherapy effectiveness. Journal editors should be wary of allowing survival comparisons between responders and nonresponders in published reports.

Clinical Trials as Topic↗
PubMed1984

Cost containment and labor-intensive tests. The case of the leukocyte differential count.

We conducted an analysis of the use of the leukocyte differential count to determine (1) the services ordering the largest numbers of tests, (2) the proportion of differentials that were clinically justifiable and useful, and (3) the potential for real cost savings as opposed to reduction in charges if unjustified differentials could be eliminated. The sources of all laboratory requisitions during three nonconsecutive weeks were determined; criteria for test justifiability were established; an audit of a random sample of medical records was conducted on two services obtaining the most tests; and a time-motion study was undertaken in the hospital hematology laboratory. Forty-seven percent of differentials were obtained on medical and surgical inpatients and only 10% in the medical clinics. Forty-eight percent and 62% of differentials on the medical and surgical services, respectively, were unjustifiable , making up 26% of all differentials done in the hospital laboratory. Test results appear to have affected patient management in less than 3% of patients; no unjustified test altered a patient's diagnosis or therapy. Elimination of only "unjustified" medical and surgical differentials would permit a reduction of 1.8 full-time equivalent positions from the hospital laboratory. The leukocyte differential is over-used, only occasionally useful, and amenable to real cost reduction.

California↗
PubMed1984

Level of care and complications among geriatric patients discharged from the medical service of a teaching hospital.

To assess the effects of hospitalization on the subsequent placement and supportive care of elderly patients, the medical records of 233 consecutive patients aged 75 years or older, admitted to the medical service of a university hospital, were reviewed. The level of care on admission and at discharge, hospital-associated complications, and demographic data were abstracted for each patient. At discharge, 1 per cent returned to a nursing home, 6 per cent were newly placed in a nursing home, 65 per cent returned to the same level of care as on admission, 10 per cent returned home with an increased level of care, and 18 per cent died or were discharged to another acute care facility. Complications occurred in 30 per cent of patients but did not correlate with age, increased level of care at discharge, or increased rate of nursing home placement. Few elderly patients were discharged to nursing homes, and most returned home without arrangements for increased care.

Activities of Daily Living↗
PubMed1983

The diagnosis of depression in different clinical settings. An analysis of the literature on the dexamethasone suppression test.

The dexamethasone suppression test (DST) has performed well as a diagnostic test for depression in many specialized research settings. Clinical epidemiological methodology enables prediction of its diagnostic value in a variety of clinical settings different from those in which the DST has been studied. We reanalyzed the published data on the test's performance as a confirmatory diagnostic test for endogenous depression or major depressive disorder and modeled target populations, taking into consideration available data on the epidemiology of depression and variations in the test's performance according to clinical characteristics of the patients evaluated. The problems with which patients present in different settings will contribute to lower prevalence of the disorder and lower sensitivity and specificity of the test on general psychiatry wards, in psychiatric office practices, and in medical outpatient departments. As a result, the positive predictive value of the test, which is high on research wards (92 per cent), is likely to be lower on general psychiatric wards (82 per cent) and much lower in psychiatric office practice (52 per cent) and in general medical settings (29 per cent). Clinicians who use the DST in the diagnosis of depression should be aware of clinical and epidemiological variables that will affect its diagnostic value in different settings.

Depressive Disorder↗