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Biomedical subjects

M M Holmes

Publications and source records attributed to M M Holmes.

33 records · Page 2Linked to original sources
PubMed1989

Methods of analyzing physician practice patterns in hypertension.

A principal method of studying physician practice patterns has been to examine physicians' responses to brief written cases. We have compared this method with practice patterns of the same physicians derived from chart audit. Subjects were 98 family practice residents for whom data were available in actual patient encounters for the workup of asymptomatic hypertension. Short, carefully structured case reports using four cues were designed and a checklist similar to the one used for test ordering in practice was employed. Chart reviews and billing encounter forms were used for comparison. Results indicated residents ordered fewer tests in clinical practice, due, in part, to practice constraints not represented in the written cases. Physicians tend to make the diagnosis of hypertension incrementally in practice, with no one visit adequately representing the point of diagnosis. Studies based on data bases using a patient encounter as the unit of analysis in chronic disease such as hypertension may spuriously underestimate the actual number of tests ordered for the workup. Judgment cases may better reflect the patterns of use of information in a well-defined problem. Prediction of number of tests ordered in the clinical setting has not been established in this case.

Adult↗
PubMed1987

Social policy and professional self-interest: physician responses to DRGs.

Prospective hospital reimbursement based on Diagnosis Related Groups (DRGs) began in 1983 for Medicare patients, and many states are adopting similar systems for Medicaid recipients in an attempt to curb rising health care costs. Because of their unprecedented intrusiveness compared to previous cost-containment measures and because they explicitly introduce financial incentives to reduce services, DRGs have great potential to affect health care delivery. To determine the effects of DRGs on hospitals and physicians, six months of ethnographic fieldwork was carried out on the medicine and pediatrics services of a university-affiliated hospital during the first year of DRG-based reimbursement. Observations and interviews were used to discern institutional responses to DRGs and physician knowledge of, experience with, and reactions to this cost-containment effort. Our findings indicate that the hospital instituted many changes to protect its interests. Data gathered from patients' abstracts suggest providers are successfully dealing with the new system; the average length of stay for Medicare patients was reduced by 38% in the first year of prospective reimbursement, compared with a 15% reduction for other patients (P less than 0.05). As a group, the physicians made no organized effort to educate themselves about the new cost-containment regulations. Their knowledge of DRGs was vague and included many misconceptions. Their response was not a coherent one taking broad social concerns into account. Cost-containment was viewed negatively, as a threat to the financial integrity of the hospital, patient care, and professional autonomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗
PubMed1986

Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model.

Decisions regarding estrogen replacement therapy were obtained from 50 physicians for 12 cases representing menopausal women with systematically varying levels of cancer risk, fracture risk, and symptom severity. Their decisions were compared with a decision analytic model for which each physician provided needed quantities--subjective probabilities, utilities of various outcomes, and weightings of the importance of the outcome categories. The majority of observed decisions were not to treat. By contrast, the decision analysis based on physician-provided estimates indicated that the optimal strategy was either to treat or a toss-up. Sensitivity analysis showed that these conclusions would hold over all possible utilities, over all plausible probabilities of cancer, and so long as symptom relief and fracture prevention were also considered as treatment objectives. The increased probability of early detection of cancer by regular follow-up was systematically incorporated into the decision analysis but apparently neglected in unaided clinical judgment, which follows the principle of minimizing the most important risk, regardless of its probability.

Decision Theory↗
PubMed1985

Rationale for physicians' decisions to refer obese patients.

Health care costs are an increasing burden upon American society. Referral of patients to a specialist generates additional cost. We studied the reasons behind decisions to refer patients with uncomplicated obesity to endocrinologists. Obesity may be viewed as a paradigm of diseases with relatively well-known etiology, low morbidity and mortality, chronicity, and poor outcome from standard therapy. In addition, it is a disease that is rarely curable by medical intervention, requiring behavioral change. Physicians have little direct experience in the differential diagnosis of endocrine disease, because of its low prevalence. We studied the referral decisions of 45 physicians in three medical specialties. Clinical decision making was studied using a standard set of 24 carefully structured case reports of obese women, all without obvious endocrine disease cues on history or physical. In these cases the patients' desire to be seen by endocrinologists was the major factor in the decision to refer. Referrals were not made primarily to rule out suspected endocrine disorder or because of concern for increased risk of morbidity.

Body Weight↗
PubMed1984

Differences in medical referral decisions for obesity among family practitioners, general internists, and gynecologists.

This study explored variation in the decisions of primary care physicians to refer or not to refer obese patients to an endocrinologist and the principles underlying their decisions. Forty-five physicians--family practitioners, obstetricians, and general internists--made referral judgments on 24 cases and completed a questionnaire. Data indicated a difference among specialties in the number of cases referred (P less than or equal to 0.01) that was not accounted for by physician characteristics. The number of cases referred ranged from 0 to 19, with a mean of 8. The patient's desire for treatment by an endocrinologist was overwhelmingly the major factor in decisions to refer. Gynecologists differed from other physicians by referring for management and not expecting the patient to return to their care. Referrals were not made primarily to rule out suspected endocrine disease or out of concern for morbidity due to obesity. These referrals are thus not perceived as medically beneficial, but are responses to patient pressure or physicians' desire to transfer management.

Body Weight↗
PubMed1983

A chart audit study of the referral of obese patients to endocrinologists.

The aim of this study was to identify factors in primary care physicians' decisions to refer obese patients to an endocrine clinic. Charts of 83 referred obese patients were compared with randomly selected charts of 300 obese adults in the general ambulatory clinic files. The referral rate is estimated at 1% of obese patients in the clinical center and 0.25% of obese persons in the Lansing area. Referral of obese patients appears to depend primarily on degree of obesity and secondarily on suspicion of endocrine disease. Considerations limiting the usefulness of patient charts for studies of physicians' decision making are discussed.

Adolescent↗
PubMed1977

Sensitive thin-layer chromatographic method for urine screening of barbiturates.

A simple and sensitive thin-layer chromatographic (TLC) method is described for the detection of barbiturates and other sedatives at therapeutic levels in the urine. The method consists of an extraction followed by TLC on a single plate in a solvent system which separates the barbiturates from most of the other drugs. The upper portion of the plate is sprayed with a new visualization reagent, N,2,6-trichloro-p-benzoquinone imine, followed by heating. The barbiturates appear as blue spots. This procedure is capable of detecting barbiturates at levels of 0.1 mg/dl in urine.

Barbiturates↗
PubMed1977

A rapid mini-thin-layer chromatographic procedure for the detection of barbiturates and common sedatives at overdose levels.

A simple, rapid thin-layer chromatographic method is presented for the detection of barbiturates in blood, serum, or urine in overdose situations. Extraction with ether is followed by evaporation and reconstitution with methanol. Part of the extract is spotted on a 2.5 multiplied by 7.5 cm thin-layer chromatographic plate which is then developed in a mixed solvent system. After drying, the plate is sprayed with n, 2, 6-trichloro-p-benzoquinone imine and heated. The presence of a barbiturate is indicated by a blue spot. Chromatography in another solvent system assists in the identification of the particular barbiturate ingested.

Barbiturates↗
PubMedDate not supplied

Women's and physicians' utilities for health outcomes in estrogen replacement therapy.

Estrogen replacement therapy (ERT) prevents fractures and relieves vasomotor symptoms, but it increases the risk of endometrial cancer. Previous studies and national prescribing patterns show that physicians are conservative in their approach to this therapy. The authors interviewed physicians and perimenopausal women to assess their utilities for the various health outcomes of estrogen replacement therapy. On all outcomes, physicians rated illness episodes followed by recovery as being closer to perfect health than did perimenopausal women. Physicians, in judging which outcomes were most important to women, estimated relief of symptoms above fracture prevention, whereas women rated fracture prevention above symptom relief. These results emphasize the need to assess patients' utilities directly, particularly when utilities for the outcome of a particular therapy may influence the choice of a therapeutic regimen.

Adult↗