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Biomedical subjects

P Glassman

Publications and source records attributed to P Glassman.

At least 19 recordsLinked to original sources
PubMed2000

How well does chart abstraction measure quality? A prospective comparison of standardized patients with the medical record.

PURPOSE: Despite widespread reliance on chart abstraction for quality measurement, concerns persist about its reliability and validity. We prospectively evaluated the validity of chart abstraction by directly comparing it with the gold standard of reports by standardized patients. SUBJECTS AND METHODS: Twenty randomly selected general internal medicine residents and attending faculty physicians at the primary care clinics of two Veterans Affairs Medical Centers blindly evaluated and treated actor-patients (standardized patients) who had one of four common diseases: diabetes, chronic obstructive pulmonary disease, coronary artery disease, or low back pain. Charts from the visits were abstracted using explicit quality criteria; standardized patients completed a checklist containing the same criteria. For each physician, quality was measured for two different cases of the four conditions (a total of 160 physician-patient encounters). We compared chart abstraction with standardized-patient reports for four aspects of the encounter: taking the history, examining the patient, making the diagnosis, and prescribing appropriate treatment. The sensitivity and specificity of chart abstraction were calculated. RESULTS: The mean (+/- SD) chart abstraction score was 54% +/- 9%, substantially less than the mean score on the standardized-patient checklist of 68% +/- 9% (P <0.001). This finding was similar for all four conditions and at both sites. "False positives"-chart-recorded necessary care actions not reported by the standardized patients-resulted in a specificity of only 81%. The overall sensitivity of chart abstraction for necessary care was only 70%. CONCLUSIONS: Chart abstraction underestimates the quality of care for common outpatient general medical conditions when compared with standardized-patient reports. The medical record is neither sensitive nor specific. Quality measurements derived from chart abstraction may have important shortcomings, particularly as the basis for drawing policy conclusions or making management decisions.

Ambulatory Care↗
PubMed2000

Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality.

CONTEXT: Better health care quality is a universal goal, yet measuring quality has proven to be difficult and problematic. A central problem has been isolating physician practices from other effects of the health care system. OBJECTIVE: To validate clinical vignettes as a method for measuring the competence of physicians and the quality of their actual practice. DESIGN: Prospective trial conducted in 1997 comparing 3 methods for measuring the quality of care for 4 common outpatient conditions: (1) structured reports by standardized patients (SPs), trained actors who presented unannounced to physicians' clinics (the gold standard); (2) abstraction of medical records for those same visits; and (3) physicians' responses to clinical vignettes that exactly corresponded to the SPs' presentations. Setting Outpatient primary care clinics at 2 Veterans Affairs medical centers. PARTICIPANTS: Ninety-eight (97%) of 101 general internal medicine staff physicians, faculty, and second- and third-year residents consented to be randomized for the study. From this group, 10 physicians at each site were randomly selected for inclusion. MAIN OUTCOME MEASURES: A total of 160 quality scores (8 cases x 20 physicians) were generated for each method using identical explicit criteria based on national guidelines and local expert panels. Scores were defined as the percentage of process criteria correctly met and were compared among the 3 methods. RESULTS: The quality of care, as measured by all 3 methods, ranged from 76.2% (SPs) to 71.0% (vignettes) to 65.6% (chart abstraction). Measuring quality using vignettes consistently produced scores closer to the gold standard of SP scores than using chart abstraction. This pattern was robust when the scores were disaggregated by the 4 conditions (P<.001 to <.05), by case complexity (P<.001), by site (P<.001), and by level of physician training (P values from <.001 to <.05). The pattern persisted, although less dominantly, when we assessed the component domains of the clinical encounter--history, physical examination, diagnosis, and treatment. Vignettes were responsive to expected directions of variation in quality between sites and levels of training. The vignette responses did not appear to be sensitive to physicians' having seen an SP presenting with the same case. CONCLUSIONS: Our data indicate that quality of health care can be measured in an outpatient setting by using clinical vignettes. Vignettes appear to be a valid and comprehensive method that directly focuses on the process of care provided in actual clinical practice. Vignettes show promise as an inexpensive case-mix adjusted method for measuring the quality of care provided by a group of physicians.

Ambulatory Care↗
PubMed2000

Management of malnutrition in the elderly and the appropriate use of commercially manufactured oral nutritional supplements.

The risk of protein calorie malnutrition among the community dwelling elderly is high. If undetected or untreated malnutrition can raise risks of morbidity and mortality. Therefore, improving screening, assessment and treatment of malnutrition, particularly in ambulatory settings that serve the elderly is imperative. The aim of this paper is to briefly detail the diagnostic criteria for protein calorie malnutrition and discuss the special considerations necessary in evaluating risk and causes of malnutrition in the elderly. We conclude with a review of current management options and discuss the cost effectiveness and potential inappropriate use of commercially manufactured oral nutritional supplements.

Aged↗
PubMed1999

Postdoctoral education in dentistry: preparing dental practitioners to meet the oral health needs of America in the 21st century.

There has been increasing interest in the organization and accreditation of Postdoctoral General Dentistry Programs (PGD). In addition, numerous national organizations have called for increases in the number of first postdoctoral year (PGY-1) positions and programs. At the same time there has been a movement to incorporate concepts of competency-based education into dental education programs in order to stress the outcomes of education rather then the process. These movements have coincided with an increased recognition that dental education will be affected by the changing demographics of our population, the emerging trends in health care delivery and financing, and the need for an increase in the number of primary care providers in dentistry, trained at an advanced level, who are capable of caring for an increasingly socially diverse and medically complex population in our country in the next century. This paper reviews the history of postdoctoral education programs in dentistry and medicine with a focus on PGD education, describes the changing health care environment in which future dental professionals will practice, and relates the dental postdoctoral experience to that in medicine. A strategy is presented for the dental profession to prepare dental practitioners with the competencies needed for the future and to create enough training opportunities to prepare these practitioners to care for the oral health needs of the nation. This proposal calls for a "National Consensus Development Conference on the Future of Postdoctoral Primary Care Education in Dentistry". This conference would define the strategies necessary to prepare dental practitioners with the competencies needed for the future and develop approaches to create enough training opportunities to prepare these practitioners to care for the oral health needs of the nation.

Clinical Competence↗
PubMed1998

Improving oral health for people with special needs through community-based dental care delivery systems.

A community-based dental care delivery system is described. This system has been used in a number of communities in California to improve oral health for people with special needs. It includes oral health assessment, coalition building, development and networking of local resources, training of dental professionals, and utilization of preventive dentistry training materials. Also discussed are challenges of the future that will need to be met to continue to make oral health a priority and reality for people with special needs in California.

Adolescent↗
PubMed1998

Developing competency systems: a never-ending story.

A competency system in its whole and its parts is described. Such a system can help dental educators rationally and efficiently organize and articulate educational programs, curricula, and courses. Repeated iterations of standard setting, design of experiences, and appraisal can reduce the need for less desirable rework or remediation and rejection of the objects of the experience such as dismissing students. Such an iterative process is one in which there is constant cyclical improvement which can move a dental education organization to develop a shared vision and become a true learning organization.

Accreditation↗
PubMed1996

Program directors' opinions on the competency of postdoctoral general dentistry program graduates.

Meeting the demand for postdoctoral general dentistry programs will require new, innovative, and flexible models. Many believe that these new models must be competency-based and focus on the outcomes of postdoctoral general dentistry training rather than on the structure and process of that training. The Section on Postdoctoral General Dentistry of the American Association of Dental Schools formed a broadly representative working group in the fall of 1994 to develop a set of competency and proficiency statements describing graduates of postdoctoral general dentistry programs. PGD program directors were then surveyed to determine the extent to which they felt these competencies matched their concepts of the PGD graduate. Between 44 and 65 competency statements that were rated highly by program directors could serve as the basis for a "core" set of statements to describe the abilities of graduates of postdoctoral general dentistry programs. These data should stimulate further discussion among educators, program directors, accrediting bodies, and government agencies about the future of postdoctoral general dentistry programs.

Accreditation↗
PubMed1995

Accreditation of postdoctoral general dentistry programs.

There is increasing demand for PGD positions. New and innovative models for accrediting these programs will be necessary if the number of positions is to grow to meet the anticipated need. The current accreditation system is the result of a historical and political evolution and now does not reflect the increasing diversity among PGD programs. Ad hoc attempts to respond to changing workforce pressures led to difficulties for program directors in meeting accreditation requirements and confusion among applicants to these programs. At the same time, there is a growing trend to describe educational endeavors using a competency-based model, emphasizing the outcome rather than the structure or process of the educational experience.

Accreditation↗
PubMed1995

Guidelines for the administration of local anesthesia in fearful dental patients.

Fear of dentistry is a major problem for patients and dentists. Fear of local anesthetic injections is one of the most common fears reported by dental patients. It is imperative that local anesthetic injections be administered to dental patients in the context of treatment of the patient's fear. To try to "get through" the injection without addressing the patient's fear is to risk perpetuating or increasing the fear and missing an opportunity to help patients overcome their fear of dentistry. This article describes principles for treatment of dental fear. An injection technique is described that can be used in conjunction with the treatment of a patient's fear and represents a part of that treatment. This "low pain and anxiety" injection technique can be used with any patient.

Anesthesia, Dental↗
PubMed1993

Treatment of high and low fear individuals.

This article presents case histories of two patients who were treated at the Dental Fears Research Program at the University of the Pacific School of Dentistry. These cases demonstrate that dental fear in various forms can be successfully treated and that there are principles which have application in patients with mild anxiety as well as with patients who experience extreme anxiety.

Anesthesia, Dental↗
PubMed1985

Psychophysiological responses to dental injections.

Dentists frequently change local anesthetic formulations on the basis of a patient's experience of adverse effects. Frequently, less effective anesthetics are selected because a lack of understanding exists regarding the nature of untoward events. This may exacerbate the problem. Allergic reactions are overreported, whereas fear responses frequently are unrecognized. This article outlines the clinical problem of adverse reactions to local anesthetics in dental practice. Clinical recommendations based on proper diagnosis are provided to prevent recurrence of the problem.

Adult↗