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Morris Weinberger

Publications and source records attributed to Morris Weinberger.

At least 37 records · Page 2Linked to original sources
PubMed2004

Assessing symptoms and peak expiratory flow rate as predictors of asthma exacerbations.

OBJECTIVE: To investigate peak expiratory flow rate (PEFR) and quality of life scores for their ability to predict exacerbations of asthma. PARTICIPANTS AND METHODS: We identified adults who received oral or inhaled asthma medications from 36 community drugstores. We administered the McMaster Asthma Quality of Life Questionnaire (AQLQ) and measured PEFR, defining "red zone" (highest risk) as a PEFR < 50% of each patient's expected value based on gender, age, and height. We identified asthma exacerbations (breathing-related emergency department visits and hospitalizations) within 4 and 12 months after enrollment and used proportional hazards regression to assess the ability of PEFR and AQLQ scores to predict exacerbations, controlling for clinical and demographic factors. RESULTS: A red zone PEFR was a significant univariable predictor of exacerbations within 12 months (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.1 to 3.0; P =.027). However, neither a red zone PEFR, the raw PEFR, or percent of predicted maximal PEFR were significantly predictive when controlling for AQLQ scores, clinical characteristics, or demographic data (P >.2). However, the 4 subscales of the AQLQ were each significant univariable and multivariable predictors of asthma exacerbations. For example, the overall AQLQ scale had a multivariable HR of 0.63 (95% CI, 0.46 to 0.87; P =.005) for exacerbations occurring within 4 months and 0.66 (95% CI, 0.54 to 0.82; P <.001) within 12 months. CONCLUSIONS: PEFR added no predictive information to that contained in AQLQ scores and clinical and demographic data. These results support the National Institutes of Health asthma guidelines' recommendation for routinely assessing symptoms but not PEFR.

Acute Disease↗
PubMed2004

The effect of cost construction based on either DRG or ICD-9 codes or risk group stratification on the resulting cost-effectiveness ratios.

BACKGROUND: As cost-effectiveness analyses (CEAs) are increasingly used to inform policy decisions, there is a need for more information on how different cost determination methods affect cost estimates and the degree to which the resulting cost-effectiveness ratios (CERs) may be affected. The lack of specificity of diagnosis-related groups (DRGs) could mean that they are ill-suited for costing applications in CEAs. Yet, the implications of using International Classification of Diseases-9th edition (ICD-9) codes or a form of disease-specific risk group stratification instead of DRGs has yet to be clearly documented. OBJECTIVE: To demonstrate the implications of different disease coding mechanisms on costs and the magnitude of error that could be introduced in head-to-head comparisons of resulting CERs. METHODS: We based our analyses on a previously published Markov model for HIV/AIDS therapies. We used the Healthcare Cost and Utilisation Project Nationwide Inpatient Sample (HCUP-NIS) data release 6, which contains all-payer data on hospital inpatient stays from selected states. We added costs for the mean number of hospitalisations, derived from analyses based on either DRG or ICD-9 codes or risk group stratification cost weights, to the standard outpatient and prescription drug costs to yield an estimate of total charges for each AIDS-defining illness (ADI). Finally, we estimated the Markov model three times with the appropriate ADI cost weights to obtain CERs specific to the use of either DRG or ICD-9 codes or risk group. RESULTS: Contrary to expectations, we found that the choice of coding/grouping assumptions that are disease-specific by either DRG codes, ICD-9 codes or risk group resulted in very similar CER estimates for highly active antiretroviral therapy. The large variations in the specific ADI cost weights across the three different coding approaches was especially interesting. However, because no one approach produced consistently higher estimates than the others, the Markov model's weighted cost per event and resulting CERs were remarkably close in value to one another. CONCLUSION: Although DRG codes are based on broader categories and contain less information than ICD-9 codes, in practice the choice of whether to use DRGs or ICD-9 codes may have little effect on the CEA results in heterogeneous conditions such as HIV/AIDS.

AIDS-Related Opportunistic Infections↗
PubMed2003

The long-term effects of a self-management program for inner-city primary care patients with acute low back pain.

BACKGROUND: We evaluated the effect of a self-management program for low-income primary care patients with acute low back pain (ALBP) from inner-city neighborhood health centers. METHODS: We conducted a randomized controlled trial of a self-management program compared with usual care at university-affiliated neighborhood health centers and an emergency department of an inner-city public teaching hospital. We enrolled 211 patients who visited a physician for ALBP (<90 days' duration). The self-management program consisted of 3 group sessions and telephone follow-up that focused on understanding back pain, increasing physical activity, and dealing with fears and frustrations. RESULTS: At baseline, 4 months, and 12 months, blinded interviewers assessed back pain physical function (Roland Disability Questionnaire), health status (Arthritis Impact Measurement Scales), self-efficacy, and time spent in physical activity. Compared with patients receiving usual care, intervention patients reported significantly better scores on the Roland Disability Questionnaire (P =.009), mental functioning (P =.009), self-efficacy to manage ALBP (P =.03), time spent in physical activity (P =.047), and reduced fears of movement/reinjury (P =.005) after 12 months. CONCLUSION: A self-management program can improve and maintain functional status, mental functioning, and self-efficacy to manage future symptoms for 1 year among primary care patients with ALBP living in the urban, inner city.

Adult↗
PubMed2003

Rheumatology patients' use of complementary therapies: results from a one-year longitudinal study.

OBJECTIVE: To examine the natural history of complementary and alternative medicine (CAM) use and its impact on outcomes within a cohort of rheumatology patients. METHODS: Consecutive patients were recruited from 3 university and 3 private rheumatology practices. Baseline chart reviews provided demographic information and rheumatic diagnoses. Patients answered questions on CAM use and health status during 1 year. We identified correlates of 4 CAM usage patterns (started, maintained, stopped, nonuse) and compared outcomes among these groups. RESULTS: Of 232 baseline participants, 203 (87%) and 177 (76%) responded to the 6- and 12-month surveys. In each survey, approximately 34% reported currently using CAM. During the year, 44% of patients remained nonusers whereas 12% started, 22% maintained, and 22% stopped use. The most frequent reasons for stopping CAM were lack of effectiveness and expense. CAM users and nonusers had no difference in outcomes. CONCLUSIONS: Arthritis patients' usage behavior varied substantially, but CAM use was not associated with a difference in outcomes.

Complementary Therapies↗
PubMed2003

Randomized trial of a self-management program for primary care patients with acute low back pain: short-term effects.

OBJECTIVE: We evaluated the effect of a self-management program (SMP) on primary care patients with acute low back pain (ALBP) from low income, inner city neighborhood health centers and an emergency department of a public teaching hospital. METHODS: We randomized 211 primary care patients who visited a physician for ALBP (<90 days duration) to usual care or an SMP. The SMP consisted of 3 group sessions and telephone followup that focused on understanding back pain, increasing physical activity, and dealing with fears and frustrations. RESULTS: Of the eligible patients, 52% expressed interest in participation and 39% of all eligible patients were randomized into the study. Among patients in the treatment group, 28.3% attended at least 1 group class, 62.3% received the intervention by mail, telephone, and audiotapes, and 9.4% received no intervention. Interviewers, blinded to the treatment given, collected data at baseline and at 4 months following randomization. Compared with the control group, the intervention group reported significantly better emotional functioning (P < 0.01), increased self efficacy to manage ALBP (P = 0.03), and less fear of movement (P = 0.05) after 4 months. CONCLUSION: This SMP produced short-term improvements in emotional functioning and self efficacy to manage symptoms among patients with ALBP living in the inner city. However, methods of program delivery other than group classes are needed to reach a greater portion of the inner city patients.

Activities of Daily Living↗
PubMed2003

Integrating clinical nurse specialists into the treatment of primary care patients with depression.

OBJECTIVE: To examine the effectiveness of integrating generalist and specialist care for veterans with depression. METHOD: We conducted a randomized trial of patients screening positive for depression at two Veterans Affairs Medical Center general medicine clinic firms. Control firm physicians were notified prior to the encounter when eligible patients had PRIME-MD depression diagnoses. In the intervention firm, a mental health clinical nurse specialist (CNS) was to: design a treatment plan; implement that plan with the primary care physician; and monitor patients via telephone or visits at two weeks, one month and two months. Primary outcomes (depressive symptoms, patient satisfaction with health care) were collected at 3 and 12 months. RESULTS: Of 268 randomized patients, 246 (92%) and 222 (83%) completed 3- and 12-month follow-up interviews. There were no between-group differences in depressive symptoms or satisfaction at 3 or 12 months. The intervention group had greater chart documentation of depression at baseline (63% versus 33%, p = 0.003) and a higher referral rate to mental health services at 3 months (27% versus 9%, p = 0.019). There was no difference in the rate of new prescriptions for, or adequate dosing of, anti-depressant medications. In 40% of patients, CNSs disagreed with the PRIME-MD depression diagnosis, and their rates of watchful waiting were correspondingly high. CONCLUSIONS: Implementing an integrated care model did not occur as intended. Experienced CNSs often did not see the need for treatment in many primary care patients identified by the PRIME-MD. Integrating integrated care models in actual practice may prove challenging.

Depressive Disorder↗
PubMed2002

Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial.

CONTEXT: It is not known whether patient outcomes are enhanced by effective pharmacist-patient interactions. OBJECTIVE: To assess the effectiveness of a pharmaceutical care program for patients with asthma or chronic obstructive pulmonary disease (COPD). DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted at 36 community drugstores in Indianapolis, Ind. We enrolled 1113 participants with active COPD or asthma from July 1998 to December 1999. Outcomes were assessed in 947 (85.1%) participants at 6 months and 898 (80.7%) at 12 months. INTERVENTIONS: The pharmaceutical care program (n = 447) provided pharmacists with recent patient-specific clinical data (peak expiratory flow rates [PEFRs], emergency department [ED] visits, hospitalizations, and medication compliance), training, customized patient educational materials, and resources to facilitate program implementation. The PEFR monitoring control group (n = 363) received a peak flow meter, instructions about its use, and monthly calls to elicit PEFRs. However, PEFR data were not provided to the pharmacist. Patients in the usual care group (n = 303) received neither peak flow meters nor instructions in their use; during monthly telephone interviews, PEFR rates were not elicited. Pharmacists in both control groups had a training session but received no components of the pharmaceutical care intervention. MAIN OUTCOME MEASURES: Peak expiratory flow rates, breathing-related ED or hospital visits, health-related quality of life (HRQOL), medication compliance, and patient satisfaction. RESULTS: At 12 months, patients receiving pharmaceutical care had significantly higher peak flow rates than the usual care group (P =.02) but not than PEFR monitoring controls (P =.28). There were no significant between-group differences in medication compliance or HRQOL. Asthma patients receiving pharmaceutical care had significantly more breathing-related ED or hospital visits than the usual care group (odds ratio, 2.16; 95% confidence interval, 1.76-2.63; P<.001). Patients receiving pharmaceutical care were more satisfied with their pharmacist than the usual care group (P =.03) and the PEFR monitoring group (P =.001) and were more satisfied with their health care than the usual care group at 6 months only (P =.01). Despite ample opportunities to implement the program, pharmacists accessed patient-specific data only about half of the time and documented actions about half of the time that records were accessed. CONCLUSIONS: This pharmaceutical care program increased patients' PEFRs compared with usual care but provided little benefit compared with peak flow monitoring alone. Pharmaceutical care increased patient satisfaction but also increased the amount of breathing-related medical care sought.

Adult↗
PubMed2002

A controlled trial of inpatient and outpatient geriatric evaluation and management.

BACKGROUND: Over the past 20 years, both inpatient units and outpatient clinics have developed programs for geriatric evaluation and management. However, the effects of these interventions on survival and functional status remain uncertain. METHODS: We conducted a randomized trial involving frail patients 65 years of age or older who were hospitalized at 11 Veterans Affairs medical centers. After their condition had been stabilized, patients were randomly assigned, according to a two-by-two factorial design, to receive either care in an inpatient geriatric unit or usual inpatient care, followed by either care at an outpatient geriatric clinic or usual outpatient care. The interventions involved teams that provided geriatric assessment and management according to Veterans Affairs standards and published guidelines. The primary outcomes were survival and health-related quality of life, measured with the use of the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36), one year after randomization. Secondary outcomes were the ability to perform activities of daily living, physical performance, utilization of health services, and costs. RESULTS: A total of 1388 patients were enrolled and followed. Neither the inpatient nor the outpatient intervention had a significant effect on mortality (21 percent at one year overall), nor were there any synergistic effects between the two interventions. At discharge, patients assigned to the inpatient geriatric units had significantly greater improvements in the scores for four of the eight SF-36 subscales, activities of daily living, and physical performance than did those assigned to usual inpatient care. At one year, patients assigned to the outpatient geriatric clinics had better scores on the SF-36 mental health subscale, even after adjustment for the score at discharge, than those assigned to usual outpatient care. Total costs at one year were similar for the intervention and usual-care groups. CONCLUSIONS: In this controlled trial, care provided in inpatient geriatric units and outpatient geriatric clinics had no significant effects on survival. There were significant reductions in functional decline with inpatient geriatric evaluation and management and improvements in mental health with outpatient geriatric evaluation and management, with no increase in costs.

Activities of Daily Living↗
PubMed2002

Acute low back pain self-management intervention for urban primary care patients: rationale, design, and predictors of participation.

OBJECTIVES: To describe the rationale and design of a self-management program for low-income, urban, primary care patients with acute low back pain. Issues related to recruitment and protocol delivery, and attendance patterns and predictors of program attendance are described. METHODS: Two hundred eleven adult patients (73% female; 60% African American) were recruited from primary care neighborhood health centers. Focus groups were conducted for program development, and participants then completed a baseline interview and were randomized into groups receiving either usual care or a self-management intervention. RESULTS: Twenty-nine percent of the intervention group attended the self-management class. Significant predictors of attendance included being older, reporting less income, and not working for pay. Attendees did not differ from nonattendees on back pain severity, symptoms, health-related quality of life, self-management processes, or satisfaction with care. CONCLUSION: Effective minimal-contact behavioral interventions are needed to reach larger portions of the patient population.

Acute Disease↗
PubMed2002

Long-term follow-up of participants in clinical studies.

We evaluated a multistep protocol to locate and ascertain data from 708 subjects who participated in clinical studies at our medical center up to 27 years ago. The protocol involved computerized and manual chart audits, introductory letters, internet searches, death registries, and a commercial person locator. We were able to ascertain vital status on 596 (84%) of study participants. Moreover, of the 475 persons known to be alive, 426 (90%) returned questionnaires and 275 (58%) completed physical examination and laboratory studies in our Clinical Research Center. The relatively modest cost of the protocol ($53,426) suggests that it is a reasonable strategy to test hypotheses involving long-term outcomes among well-characterized cohorts. The fact that the protocol can be easily implemented in most sites should encourage investigators to use these strategies to conduct similar studies.

Adult↗
PubMed2002

Issues in conducting randomized controlled trials of health services research interventions in nonacademic practice settings: the case of retail pharmacies.

OBJECTIVE: To describe unexpected challenges and strategies to overcome them when conducting randomized controlled trials (RCT) of health services research interventions in retail pharmacies. STUDY SETTING: Thirty-six retail drug stores in Indianapolis. STUDY DESIGN: We conducted an RCT to evaluate the effectiveness of an intervention to increase pharmacists' involvement in caring for customers. We describe: (1) our RCT as originally designed, (2) unexpected challenges we faced; and (3) how we resolved those challenges. DATA COLLECTION/EXTRACTION METHODS: Randomized controlled trial. PRINCIPAL FINDINGS: Major modifications in research design were necessitated by factors such as corporate restructuring, heightened sensitivity to patient confidentiality, and difficulties altering employees' behavior. We overcame these barriers by conducting research that is consistent with corporate goals, involving appropriate corporate administrators and technical personnel early in the process, and being flexible. CONCLUSIONS: Health services researchers should conduct RCTs in a variety of non-academic practice settings to increase generalizability and better reflect the true impact of interventions. Pragmatic problems, although significant, can be successfully overcome.

Adolescent↗
PubMed2002

Geographic variation in health care utilization and outcomes in veterans with acute myocardial infarction.

OBJECTIVES: To examine regional variation in health care utilization and outcomes during acute and chronic care of veterans following acute myocardial infarction (AMI), identifying potentially modifiable variables and processes of care that influence patient outcomes. METHODS: Using national VA databases, we identified all veterans hospitalized at any VA Medical Center (VAMC) for AMI between October 1990 and September 1997. Demographic, inpatient, outpatient, mortality, and readmission data were extracted for 4 regions: Northeast, South, Midwest and West. Multivariable Cox proportional hazards regression models, controlled for comorbidity, were used to assess predictors of time to death and readmission. RESULTS: We identified 67,889 patients with AMI. Patient demographic characteristics by region were similar. Patients in the Northeast had more comorbid conditions and longer lengths of stay during the index AMI hospitalization. Region of the country independently predicted time to death, with lower risk of death in the Northeast (hazard ratio [HR] = 0.875; 95% confidence interval [95% CI], 0.834 to 0.918; P < .0001) and West (HR = 0.856; 95%CI, 0.818 to 0.895; P = .0001) than in the South. Patients in the Northeast and West also had more cardiology or primary care follow-up within 60 days and at 1 year post-discharge than patients in the South and Midwest. Outpatient follow-up accounted for a significant portion of the variation in all-cause mortality. CONCLUSION: Substantial geographic variation exists in subsequent clinical care and outcomes among veterans hospitalized in VAMCs for AMIs. Outpatient follow-up was highly variable and associated with decreased mortality. Further studies are needed to explore the causes of regional variation in processes of care and to determine the most effective strategies for improving outcomes after AMI.

Aged↗
PubMed2002

Can guidelines impact the ordering of magnetic resonance imaging studies by primary care providers for low back pain?

OBJECTIVE: To compare primary care providers' (PCPs') use of lumbar spine magnetic resonance imaging (MRI) studies and surgical referrals for patients with low back pain (LBP) before and after dissemination of the 1994 Agency for Healthcare Policy and Research (AHCPR) LBP guidelines. DESIGN: Retrospective cohort study. PATIENTS AND METHODS: Computerized audits identified patients with LBP evaluated by PCPs in 1994 or 1996 at a university-affiliated Veterans Affairs medical center who had an MRI order and/or a surgical referral. Research assistants recorded patients' demographic characteristics, LBP-related symptoms, and whether the PCP ordered an MRI and/or a surgery consult. For patients referred to surgery without an MRI, subsequent MRI orders by surgeons were recorded. We compared patient characteristics and utilization patterns for 1994 and 1996 and identified independent predictors of MRI orders. RESULTS: PCPs saw 279 and 261 patients with LBP in 1994 and 1996, respectively. An almost identical number of MRIs were ordered in 1994 (99 by PCPs and 42 by surgeons) and 1996 (105 by PCPs and 32 by surgeons). Nearly 50% of patients meeting AHCPR guidelines underwent an MRI in 1994 or 1996. PCPs more frequently ordered a surgery consult in 1994 than in 1996. Providers were less likely to order an MRI for patients with a previous MRI and more likely to order an MRI for those seen in an urgent visit clinic. Neither year nor meeting AHCPR guidelines predicted MRI ordering. CONCLUSIONS: Orders for MRI did not decrease after education on the guidelines. Limiting MRI orders to only "appropriate" patients would not have changed the observed results.

Aged↗
PubMedDate not supplied

The Spoken Knowledge in Low Literacy in Diabetes scale: a diabetes knowledge scale for vulnerable patients.

PURPOSE: The purpose of this study was to develop and validate a new knowledge scale for patients with type 2 diabetes and poor literacy: the Spoken Knowledge in Low Literacy patients with Diabetes (SKILLD). METHODS: The authors evaluated the 10-item SKILLD among 217 patients with type 2 diabetes and poor glycemic control at an academic general medicine clinic. Internal reliability was measured using the Kuder-Richardson coefficient. Performance on the SKILLD was compared to patient socioeconomic status, literacy level, duration of diabetes, and glycated hemoglobin (A1C). RESULTS: Respondents' mean age was 55 years, and they had diabetes for an average of 8.4 years; 38% had less than a sixth-grade literacy level. The average score on the SKILLD was 49%. Less than one third of patients knew the signs of hypoglycemia or the normal fasting blood glucose range. The internal reliability of the SKILLD was good (0.72). Higher performance on the SKILLD was significantly correlated with higher income (r = 0.22), education level (r = 0.36), literacy status (r = 0.33), duration of diabetes (r = 0.30), and lower A1C (r = -0.16). When dichotomized, patients with low SKILLD scores (< or = 50%) had significantly higher A1C (11.2% vs 10.3%, P < .01). This difference remained significant when adjusted for covariates. CONCLUSION: The SKILLD demonstrated good internal consistency and validity. It revealed significant knowledge deficits and was associated with glycemic control. The SKILLD represents a practical scale for patients with diabetes and low literacy.

Adult↗
PubMedDate not supplied

Walking speed predicts health status and hospital costs for frail elderly male veterans.

This study evaluated the use of walking speed as an indicator of function and health status in acutely ill, hospitalized, older male veterans. Hospital inpatients in a Department of Veterans Affairs (VA) study of Geriatric Evaluation and Management (GEM) (n = 1,388, age 74.2 +/- 5.7, 98% male) were followed for 1 year. The results indicate that each 0.10 m/s reduction in baseline walking speed was associated with poorer health status (36-item short form [SF-36] beta = 4.5 [95% confidence interval (CI) 2.8 to 6.1]), poorer physical functioning (beta = 2.1 [6.9 to 14.8]), more disabilities (beta = 0.63 [0.53 to 0.73]), additional rehabilitation visits (2.0 [1.4 to 2.5]), increased medical-surgical visits (2.8 [1.9 to 3.7]), longer hospital stays (2.2 [1.4 to 2.9]), and higher costs ($1,334 [$869 to $1,798]). In addition, each 0.10 m/ s/yr increase in walking speed resulted in improved health status (SF-36 beta = 8.4 [6.0 to 10.7]), improved physical function (beta = 2.9 [2.5 to 3.3]), fewer basic disabilities (0.30 [0.2 to 0.4]), fewer instrumental disabilities (0.7 [0.6 to 0.8]), fewer hospitalization days (2.3 [1.3 to 3.3]), and 1-year cost reductions of $1,188 [-$65 to $2,442]. Walking speed is useful for the functional assessment of acutely ill, hospitalized older adults. Measurement of walking speed over time may help predict those who will need and use more health-related services.

Aged↗