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Biomedical subjects

R A Lowe

Publications and source records attributed to R A Lowe.

At least 37 records · Page 2Linked to original sources
PubMed1997

Judging who needs emergency department care: a prerequisite for policy-making.

The debate regarding risks and benefits of triaging nonurgent patients away from emergency departments (EDs) stems from widely varying estimates as to what proportion of ED visits are inappropriate. A study was undertaken based on the hypothesis that these discrepant estimates might be due to differences in how "appropriateness" is defined. This cross-sectional study included 596 ED patients. Seven different indicators of "Inappropriate" ED visits were used. Two could be determined by the patient; two were based on the triage nurse's assessment; three were determined retrospectively, by chart review. All 21 possible pairs of indicators were compared for agreement using the kappa statistic. The proportion of ED visits classified as inappropriate by the different indicators ranged from 10% to 90%. Kappa values for agreement between indicators ranged from -0.04 to 0.31, indicating poor agreement beyond that expected due to chance alone. Decisions as to which ED visits are appropriate depend heavily on the criteria used. Limiting patients' access to EDs without the aid of a valid and reliable standard for what constitutes an appropriate ED visit could create harmful barriers to care.

Cross-Sectional Studies↗
PubMed1997

Adverse outcomes of managed care gatekeeping.

OBJECTIVES: To determine whether telephone preauthorization for reimbursement of ED care (medical "gate-keeping") by managed care organizations (MCOs) is associated with adverse outcomes. METHODS: A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on-call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3) "near miss" (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above. RESULTS: Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy (n = 2), pneumothorax (n = 2), alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococal meningitis in immuno comprised host, endocarditis, incarerated inguinal hernia, meningocococemia, meninoccocal meningitis, peritonsillar abscess, pneumococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in psychiatric hospitalization, suicidal depression resulting in psychiatric hospitalization, and unstable angina. CONCLUSION: Adverse outcomes occur with MCO gatekeeping, Although the present study cannot ascertain whether this is a frequent event or a rare one, the safety of MCO gatekeeping deserves further study.

Adolescent↗
PubMed1997

Successful management of the gingival tissues for aesthetic restorative procedures.

A sage advisor once said, "Why is it that we (dentists) never seem to have the time to do all steps the first time around, but then find the time when something goes amiss?" Many of us are caught up in a prison called time that directly dictates our every move. We must be released from this mindset and rediscover the importance of patience and devotion to technique. That same wise man added, "The definition of a short cut is the longest distance between two points." The moral is time spent to gain tissue health will be returned a thousand fold. Cases will be completed with greater patient comfort and doctor satisfaction.

Crown Lengthening↗
PubMed1996

Stenting in malignant obstruction of superior vena cava.

The treatment of patients with malignant superior vena caval obstruction with minimal morbidity has been made possible by the recent introduction of expandable metal stents as the sole palliative treatment or as an adjunct to other treatment modalities. To alleviate the distressing symptoms of superior vena caval obstruction, self-expanding metal stents were used successfully in 12 (Wallstent device in 6 and Gianturco device in 6 patients) of 13 patients. The diagnoses were small cell carcinoma (n = 4), squamous cell carcinoma (n = 4), non-Hodgkin's lymphoma (n = 1), and mesothelioma (n = 1), and a diagnosis of malignancy was not confirmed (although strongly suspected) in the remaining three cases. Eleven patients had immediate relief of obstruction and there was no change in one patient. Mean follow-up was 3.7 months (range 1 to 10 months). Excellent palliation was obtained in all but one patient in whom recurrent superior vena caval obstruction developed 3 months after stenting. Mean survival was 4.8 months (range 1 to 10 months). The ease of insertion with the use of local anesthesia with radiologic control, the self-expanding nature of the stent, and the lack of major complications on follow-up of up to 10 months are particular advantages. The self-expanding superior vena caval stents are a useful addition to our armamentarium in the management of malignant superior vena caval obstruction.

Aged↗
PubMed1994

The cost-effectiveness of voluntary counseling and testing of hospital inpatients for HIV infection.

OBJECTIVE: To evaluate the cost-effectiveness of voluntary counseling and testing of US hospital inpatients for the human immunodeficiency virus (HIV). DATA SOURCES: Data for entry into the model were derived from a review of the literature, consultation with experts, and consensus of the authors. DATA EXTRACTION: We rated our confidence in these probabilities and costs by grading the data inputs using methods adapted from those of the US Preventive Services Task Force. DATA SYNTHESIS: Decision analysis models were developed to evaluate two outcomes: (1) cost per health care worker (HCW) HIV infection averted if measures are taken by the HCW to reduce his or her risk of acquiring HIV; and (2) cost per inpatient HIV infection detected. Sensitivity analyses were also conducted. Using baseline input values, testing to avert HCW infection may prevent 3.6 HIV infections per year at a total program cost of $2.7 billion, or a cost of $753 million per infection averted. At baseline assumptions (seroprevalence = 1%), testing to detect inpatient HIV infection would cost $16,104 per year per infection detected. Cost-effectiveness at baseline drops to $8353 per HIV infection detected if the seroprevalence is 10%. If testing is limited to hospitals with inpatient seroprevalences of at least 1%, approximately 5400 persons per year will be falsely labeled HIV-positive. CONCLUSIONS: This analysis provides no justification for testing inpatients to prevent HIV infection of HCWs. Screening inpatients to detect HIV infection may be justified at seroprevalences exceeding 1%, but issues of medical or social discrimination, false-positive results, informed consent, and logistics must be resolved first.

AIDS Serodiagnosis↗
PubMed1994

The cost-effectiveness of HIV testing of physicians and dentists in the United States.

OBJECTIVE: To evaluate the cost-effectiveness of alternative policies for human immunodeficiency testing (HIV) testing of physicians and dentists. METHODS: Decision analysis and cost-effectiveness analysis from a societal perspective were used. Data were derived from extensive literature review and consultation with experts. We conducted sensitivity analyses and also performed a cost-benefit analysis. ANALYSES: We analyzed policies for mandatory or voluntary testing of all physicians, surgeons, and dentists; for those testing positive, we analyzed mandatory or voluntary exclusion from practice, restriction from performance of invasive procedures, or requirements to inform patients of serostatus. MAIN OUTCOME MEASURE: Cost per patient infection averted. RESULTS: Although one-time mandatory testing of surgeons and dentists with mandatory restriction of those found to be HIV-positive is more cost-effective than other policies, the cost-effectiveness varies tremendously under different scenarios. Results were highly sensitive to several data inputs, especially HIV seroprevalence of surgeons and dentists and transmission risk. For example, under a medium seroprevalence and transmission risk scenario, mandatory testing of all surgeons might avert 25 infections at a total cost of $27.9 million or $1,115,000 per infection averted and an incremental cost of $291,000 compared with current testing; however, the incremental cost-effectiveness per patient infection averted ranges from $29,807,000 under a low-risk scenario to a savings of $81,000 under a high-risk scenario. CONCLUSION: Our analysis neither justifies nor precludes a mandatory testing policy. Further research on the key data inputs is needed. Given the ethical, social, and public health implications, mandatory testing policies should not be implemented without greater certainty as to their cost-effectiveness.

AIDS Serodiagnosis↗
PubMed1994

Refusing care to emergency department of patients: evaluation of published triage guidelines.

STUDY OBJECTIVE: To determine whether a set of published triage guidelines identifies patients who can safely be refused emergency department care. DESIGN: Historical cohort study. SETTING: A public hospital ED. TYPE OF PARTICIPANTS: All patients triaged during a one-week period who were not in the most acute triage category. MEASUREMENTS: Two ED nurses, blinded to the study hypothesis, reviewed each triage sheet to determine whether the case met the published guidelines for refusing care. In addition, each ED record was reviewed for appropriateness; a visit was considered appropriate only if predetermined, explicit criteria were met and an emergency physician agreed that a 24-hour delay in care might have worsened the patient's outcome. MAIN RESULTS: Of the 106 patients who would have been refused care according to the triage guidelines, 35 (33%) had appropriate visits. Four were hospitalized. CONCLUSION: When tested in our patient population, the triage guidelines were not sufficiently sensitive to identify patients who needed ED care. Broad application of these guidelines may jeopardize the health of some patients.

Adult↗
PubMed1993

Proposals for health care reform: how do we evaluate them?

The Society for Academic Emergency Medicine suggests a systematic approach to evaluating proposals for reform of the medical care system. Described are the three components of the problem--access, cost, and quality. Then, goals are proposed for health care reform. With this background, we describe the major questions that reform proposals must address and the potential impact of reform on emergency medicine. Emergency physicians must actively support health reform legislation that is in the over-all best interest or our patients and our specialty, and work with the new federal administration to evaluate proposed changes.

Cost Control↗
PubMed1992

Case report: metastatic transitional cell carcinoma presenting in a urinoma.

We describe a case of transitional cell carcinoma (TCC) metastasising into a urinoma cavity in a patient where the primary tumour arose at the ipsilateral ureterovesical junction. Seeding of transitional cell carcinoma into contiguous structures following surgical intervention has been reported, but to our knowledge, this is the first report of spread into a distant urinoma.

Carcinoma, Transitional Cell↗
PubMed1991

Wilderness emergency medical services: the experiences at Sequoia and Kings Canyon National Parks.

This article describes the National Park Service wilderness emergency medical services (EMS) system, as implemented at Sequoia-Kings Canyon National Park. EMS records on all 434 patients in the period from August 1, 1986, to July 31, 1987, were reviewed. Most patients had minor problems. Overall, 77% of patients contacting the EMS system were released at the scene, and base hospital contact was made in only 28% of cases. However, there were three deaths, 44 (10%) patients who received advanced life support, and 292 (67%) patients who received basic life support. Seven patients who received advanced life support were released without transport. Decisions regarding scope of practice in a low-volume, wilderness EMS system are complicated by long transport times and problems with skills maintenance. Differences between the times and problems with skills maintenance. Differences between the patients treated by a wilderness system and those seen in most urban systems may make it appropriate to release a greater portion of patients without ambulance transport. In a system with long response and transport times, use of personnel with different training than in the urban setting becomes necessary.

Adolescent↗