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M J Barry

Publications and source records attributed to M J Barry.

At least 109 records · Page 6Linked to original sources
PubMed1994

Advance directives: can patients' stated treatment choices be used to infer unstated choices?

Advance directives have been widely endorsed as a method to match medical interventions to patients' preferences. However, applying advance directives to unspecified future decisions may be problematic. We wondered how well scenario-based treatment choices in advance directives can be used to infer other choices specified by the same patients. We asked 495 out-patients from the Massachusetts General Hospital to state 11 treatment choices in each of four illness scenarios. We calculated likelihood ratios (LRs) to see how well one choice could predict another. Predictions within a given scenario were strong and followed a pattern that reflected the invasiveness of the treatment. Thus, decline of antibiotics predicted decline of major surgery, in the same scenario (LR 36.0-108.3). Requests for major surgery strongly predicted requests for antibiotics (LR 90.4-244.1). Requests for major surgery and decline of antibiotics were the two most predictive preferences; more traditionally considered decisions about cardiopulmonary resuscitation and mechanical ventilation ranged from the third to ninth most predictive among the 11 interventions. Predictions between scenarios were weaker, but still potentially useful, and followed a pattern that reflected the prognoses of the scenarios. Declining treatment in the best prognosis scenario (coma-with-a-chance) predicted declining the same treatment in other scenarios with LRs of 2.5-6.1. Requests for treatment in the worst prognosis scenario (dementia-with-terminal-illness) predicted the same request in the other scenarios with LRs of 5.2-30.5. These data suggest that patients' advance scenario-based treatment choices can provide potentially useful information to apply to unspecified decisions if inferences follow considerations of prognosis and treatment invasiveness. For maximal predictive power, treatment directives should use a range of illness scenarios and include choices, among several others, on antibiotic use and major surgery.

Adult↗
PubMed1994

Serum prostate-specific antigen discriminates weakly between men with benign prostatic hyperplasia and patients with organ-confined prostate cancer.

To determine if serum prostate-specific antigen (PSA) can identify those patients harboring an organ-confined prostate cancer prior to treatment for symptomatic benign prostatic hyperplasia (BPH), we examined retrospectively the preoperative serum PSA level for two groups of men. Group 1 consisted of 187 consecutive patients with a histologic diagnosis of BPH as determined from complete pathologic analysis of the transurethral resection of the prostate (TURP) specimen. Group 2 included 198 consecutive patients with histologically confirmed organ-confined prostate cancer as determined from step-section analysis of the retropubic radical prostatectomy specimen. The median serum PSA value for group 1 was 3.9 ng/ml (range 0.2-55 ng/ml), whereas the median serum PSA level for group 2 was 5.9 ng/ml (range 0.4-58 ng/ml). Although this difference was statistically significant (p < 0.001), the distribution of serum PSA values for group 1 overlapped considerably with the distribution for group 2. For both groups, there was a clustering of PSA values below 10.0 ng/ml (group 1: 90%; group 2: 73%). The area under the receiver operating characteristic curve for log PSA values to discriminate men with BPH from patients with organ-confined prostate cancer was 0.66 (95% confidence interval: 0.60-0.72); a 'perfect' test has an area of 1.0, whereas a test with 'no information value' has an area of 0.5. These findings suggest that serum PSA has only a modest ability to distinguish men with BPH from patients with organ-confined prostate cancer. As a result, some symptomatic BPH patients choosing a non-TURP therapy may harbor a clinically significant prostate cancer despite being evaluated with a serum PSA determination.

Aged↗
PubMed1994

Benign prostatic hyperplasia: diagnosis and treatment. Agency for Health Care Policy and Research.

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline of Benign Prostatic Hyperplasia: Diagnosis and Treatment. The Benign Prostatic Hyperplasia Guideline Panel, a private-sector panel of health care providers, developed the guideline after comprehensively analyzing the research literature. As a result, this guideline comprises the most current scientific knowledge of the development, diagnosis, and treatment of benign prostatic hyperplasia (BPH). The guideline makes specific recommendations to identify both the most effective methods for diagnosing BPH and the most appropriate treatments for BPH based on patient preference and clinical need. BPH affects quality of life and is very rarely a life-threatening disease. Motivation to seek active treatment will, for most patients, depend on how much their symptoms bother them. Many patients choose a regimen of "watchful waiting." The guideline details the relative benefits and harms associated with all diagnostic and treatment approaches. Treatment options discussed include watchful waiting, alpha blocker and finasteride medications, balloon dilation, and the surgical options of transurethral incision, transurethral resection, and open prostatectomy.

Adrenergic alpha-Antagonists↗
PubMed1993

A decision analysis of alternative treatment strategies for clinically localized prostate cancer. Prostate Patient Outcomes Research Team.

OBJECTIVE: To model the impact of initial therapy on outcomes for men with localized (clinical stage A or B) prostatic carcinoma. DESIGN: A decision analysis modeling three strategies: radical prostatectomy, external-beam radiation therapy, and watchful waiting, with delayed hormonal therapy if metastatic disease develops. We modeled the main benefit of treatment as a reduction in the chance of death or disutility from metastatic disease. These benefits were offset in the model by the risks of treatment-related morbidity and mortality. The model was used to analyze expected outcomes by tumor grade (well, moderately, and poorly differentiated) for men 60 to 75 years of age. DATA: Probabilities and rates for important clinical events, obtained through review of the literature for prostatic carcinoma and analysis of Medicare claims data. MAIN RESULTS: Several patterns emerged within the range of uncertainty about the risks and benefits of treatment for prostatic carcinoma. In patients with well-differentiated tumor grades, based on clinical staging, treatment at best offers limited benefit in terms of quality-adjusted life expectancy and may result in harm to the patient. Among patients with moderately or poorly differentiated tumors, if we use the most optimistic assumptions about treatment efficacy, then patients aged 60 to 65 years would benefit from either radical prostatectomy or external-beam radiation therapy, compared with watchful waiting. However, in most other cases, treatment offers less than a 1-year improvement in quality-adjusted life expectancy or decreases the quality-adjusted life expectancy compared with watchful waiting. Invasive treatment generally appears to be harmful for patients older than 70 years. CONCLUSIONS: Radical prostatectomy and radiation therapy may benefit selected groups of patients with localized prostate cancer, particularly younger patients with higher-grade tumors. However, our model shows that in most cases the potential benefits of therapy are small enough that the choice of therapy is sensitive to the patient's preferences for various outcomes and discounting. The choice of watchful waiting is a reasonable alternative to invasive treatment for many men with localized prostatic carcinoma.

Aged↗
PubMed1993

Patient-reported complications and follow-up treatment after radical prostatectomy. The National Medicare Experience: 1988-1990 (updated June 1993).

To estimate the probabilities of complications and follow-up treatment, a sample of Medicare patients who underwent radical prostatectomy (1988 through 1990) was surveyed by mail, telephone, and personal interview. Respondents reported their current status with respect to continence and sexual function as well as post-surgical treatments they had had to treat residual or recurrent cancer or surgical complications. Over 30 percent reported currently wearing pads or clamps to deal with wetness; over 40 percent said they drip urine when they cough or when their bladders are full; 23 percent reported daily wetting of more than a few drops. About 60 percent of patients reported having no full or partial erections since their surgery, and only 11 percent had any erections sufficient for intercourse during the month prior to the survey. Six percent had surgery after the radical prostatectomy to treat incontinence; 15 percent had treatments or used devices to help with sexual function; 20 percent report having had post-surgical treatment for urethral strictures. In addition 16 percent, 22 percent, and 28 percent reported follow-up treatment for cancer (radiation or androgen deprivation therapy) at two, three, and four years after radical prostatectomy. These estimates of complication and follow-up treatment rates are generally higher, and almost certainly more representative for older men, than estimates previously published. Patients and physicians may want to weight heavily the complications and need for follow-up treatments when considering radical prostatectomy for prostate cancer.

Aged↗
PubMed1993

Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia.

In previous studies the severity of symptoms of prostatism in men with benign prostatic hyperplasia have not correlated well with prostate size, degree of bladder trabeculation, uroflowmetry or post-void residual volume. As part of a prospective cohort study of benign prostatic hyperplasia treatment effectiveness in 4 university-based urology practices, we correlated symptom severity and these commonly used measures of disease severity. Symptom severity was quantified using the American Urological Association symptom index. Analyses were based on 198 outpatients completing a standardized evaluation (84 of these men have completed 6 months of followup after treatment with prostatectomy, balloon dilation, terazosin or watchful waiting). At baseline, symptom severity was not correlated with uroflowmetry, post-void residual, prostate size and degree of bladder trabeculation. However, symptom severity was much more strongly related to overall health status than the other measures. Reduction in symptoms with treatment did correlate with improvements in uroflowmetry. This poor baseline correlation with symptoms may reflect unreliability in measurement of the physiological/anatomical variables. Alternatively, these parameters may be measuring different pathophysiological phenomena.

Aged↗
PubMed1993

Quality of life assessment for evaluating benign prostatic hyperplasia treatments. An example of using a condition-specific index.

546 patients enrolled in a prospective study of patient treatment choices for benign prostatic hyperplasia (BPH) completed a self-administered questionnaire that included a symptom index, two general measures of quality of life, and a condition-specific measure of the impact of BPH symptoms on patient quality of life. As expected, differences in symptoms of BPH were significantly associated with general measures of quality of life and the condition-specific impact score. However, the condition-specific impact score was more sensitive to differences in symptoms than the general measures. Hence, such measures are likely to be more responsive to treatment effects, may provide more power for statistical analysis, and hence should be considered along with general quality of life measures for use in treatment outcome studies.

Aged↗
PubMed1993

Diagnosis of superior sulcus tumors: a further use of the thoracoscope.

Most irradiation therapists require a tissue diagnosis of a superior sulcus tumor prior to initiating preoperative irradiation. In the rare case, obtaining a tissue diagnosis via the normally used procedures proves challenging. A technique for obtaining a tissue diagnosis using a thoracoscope in this circumstance is presented.

Carcinoma, Non-Small-Cell Lung↗
PubMed1992

Indications for treatment of benign prostatic hyperplasia. The American Urological Association Study.

BACKGROUND: In 1990, a pilot study was begun that evaluated benign prostatic hyperplasia (BPH) at five clinical institutions. Data management and coordination of this study was performed at the Medical Practices Evaluation Center at Massachusetts General Hospital. Because of decreased patient enrollment, one institution was dropped. This was a randomized, prospective, clinical study that provided an initial overview of the trial and a rationale for the project. METHODS: Patients with clinically significant signs and symptoms of BPH were enrolled in this study. A symptom index consisting of seven items was used to document patient complaints of prostatic enlargement. Prostate size was determined using ultrasonography. Uroflowmetry (peak flow and mean flow) and residual urine volumes were documented. Abdominal ultrasonography was performed to rule out the presence of a dilated upper urinary tract. Cystoscopy was completed to determine the extent of prostatic and bladder neck obstruction. Trabeculations or cellules in the bladder, if present, were also documented. Conclusions. Preliminary results were obtained. The operative and nonoperative options depending on prostate size are shown in the figures of this article. The use of an interactive video disc has been beneficial in explaining the risks and benefits of each treatment option applicable to the patient in this randomized, controlled study.

Aged↗
PubMed1992

Hard measures of subjective outcomes: validating symptom indexes in urology.

Scientifically validated (accurate), and reproducible (precise) methods of assessing the frequency and severity of patient symptoms are becoming more widely used in medicine. Such a symptom index has been developed for patients with benign prostatic hyperplasia, and may find use in clinical practice and research. The criteria for developing and validating such indexes are presented, using the new benign prostatic hyperplasia symptom index as an example. The same approach can be applied to many other disease entities in urology that demand a quantitation of the illness experience from the perspective of the patients.

Humans↗
PubMed1992

The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association.

A symptom index for benign prostatic hyperplasia (BPH) was developed and validated by a multidisciplinary measurement committee of the American Urological Association (AUA). Validation studies were conducted involving a total of 210 BPH patients and 108 control subjects. The final AUA symptom index includes 7 questions covering frequency, nocturia, weak urinary stream, hesitancy, intermittence, incomplete emptying and urgency. On revalidation, the index was internally consistent (Cronbach's alpha = 0.86) and the score generated had excellent test-retest reliability (r = 0.92). Scores were highly correlated with subjects' global ratings of the magnitude of their urinary problem (r = 0.65 to 0.72) and powerfully discriminated between BPH and control subjects (receiver operating characteristic area 0.85). Finally, the index was sensitive to change, with preoperative scores decreasing from a mean of 17.6 to 7.1 by 4 weeks after prostatectomy (p < 0.001). The AUA symptom index is clinically sensible, reliable, valid and responsive. It is practical for use in practice and for inclusion in research protocols.

Adult↗
PubMed1992

Correlation of the American Urological Association symptom index with self-administered versions of the Madsen-Iversen, Boyarsky and Maine Medical Assessment Program symptom indexes. Measurement Committee of the American Urological Association.

We correlated the American Urological Association (AUA) symptom index with other indexes that have been used to measure symptoms for benign prostatic hyperplasia (BPH) and compared their psychometric properties. A self-administered questionnaire that allowed derivation of AUA, Maine Medical Assessment Program, Madsen-Iversen and Boyarsky symptom scores was completed by 76 men with clinically defined BPH, 59 younger control subjects, and 27 men before and after prostatectomy. The scores from the 4 indexes were strongly correlated (r = 0.77 to 0.93). All 4 indexes had good internal consistency and test-retest reliabilities. All indexes were predictive of patient global ratings of the degree of bother from the urinary condition. The AUA index discriminated BPH patients from controls significantly better than the Maine Medical Assessment Program index, and equivalently to the Madsen-Iversen and Boyarsky indexes (despite having fewer items). All 4 indexes were responsive when BPH patients underwent prostatectomy, although the AUA and Madsen-Iversen indexes were significantly more sensitive.

Humans↗
PubMed1991

Advance directives for medical care--a case for greater use.

UNLABELLED: BACKGROUND. Advance directives for medical care and the designation of proxy decision makers to guide medical care after a patient has become incompetent have been widely advocated but little studied. We investigated the attitudes of patients toward planning, perceived barriers to such planning, treatment preferences in four hypothetical scenarios, and the feasibility of using a particular document (the Medical Directive) in the outpatient setting to specify advance directives. METHODS: We surveyed 405 outpatients of 30 primary care physicians at Massachusetts General Hospital and 102 members of the general public in Boston and asked them as part of the survey to complete the Medical Directive. RESULTS: Advance directives were desired by 93 percent of the outpatients and 89 percent of the members of the general public (P greater than 0.2). Both the young and the healthy subgroups expressed at least as much interest in planning as those older than 65 and those in fair-to-poor health. Of the perceived barriers to issuing advance directives, the lack of physician initiative was among the most frequently mentioned, and the disturbing nature of the topic was among the least. The outpatients refused life-sustaining treatments in 71 percent of their responses to options in the four scenarios (coma with chance of recovery, 57 percent; persistent vegetative state, 85 percent; dementia, 79 percent; and dementia with a terminal illness, 87 percent), with small differences between widely differing types of treatments. Specific treatment preferences could not be usefully predicted according to age, self-rated state of health, or other demographic features. Completing the Medical Directive took a median of 14 minutes. CONCLUSIONS: When people are asked to imagine themselves incompetent with a poor prognosis, they decide against life-sustaining treatments about 70 percent of the time. Health, age, or other demographic features cannot be used, however, to predict specific preferences. Advance directives as part of a comprehensive approach such as that provided by the Medical Directive are desired by most people, require physician initiative, and can be achieved during a regular office visit.

Advance Directives↗
PubMed1990

Medical outcomes research and benign prostatic hyperplasia.

Increasing health care costs and growing interest in quality care have focused attention on medical outcomes research. With regard to symptomatic BPH, patients deciding between different treatment choices need to know the likely outcomes of these alternatives, including chances for symptom responses and improved functional health and well-being. There is a paucity of high-quality outcomes research in medicine, including research that would clarify treatment outcomes for BPH. The relationship between physiologic and anatomic bladder outlet obstruction due to BPH and its symptoms, as well as quality of life, needs further study to elucidate how BPH affects health. A number of ongoing studies should provide information on the outcomes of alternative treatment strategies for BPH, the relationship between anatomic and physiologic BPH, and higher-level outcomes, such as symptom levels and quality of life.

Health Status↗