Biomedical subjects

R B Davis

Publications and source records attributed to R B Davis.

At least 37 records · Page 2Linked to original sources

PubMed2000

Improving cost efficiency on a vascular surgery service.

BACKGROUND: A vascular task force (VTF) consisting of two vascular surgeons and other key personnel was established to reduce costs and improve efficiency in the management of patients on a vascular surgery service. METHODS: The VTF met monthly beginning in 1994 to study and implement changes in the management of patients with (1) abdominal vascular, (2), carotid endarterectomy (3) distal bypass, and (4) other vascular procedures, including amputations. Length of stay, and fixed and variable costs were assessed for change over time using Pearson correlation coefficients. RESULTS: Improvements in efficiency (length of stay) and decreases in costs (fixed and variable costs) from fiscal year 1993 to fiscal year 1996 were significant for the total group of vascular patients (P </=0.001), with some intergroup differences. The major improvements were in the abdominal vascular and carotid endarterectomy groups, where length of stay and fixed and variable costs were reduced significantly (P </=0.01). Management of distal bypass and other vascular surgery patients showed less striking improvement. CONCLUSION: Vascular surgeons in collaboration with other dedicated personnel involved in the care of vascular patients can improve efficiency and reduce costs. Advances were greatest in patients who required operations for carotid and abdominal vascular disorders and least for patients who required distal bypasses and other vascular procedures.

Abdomen↗

PubMed2000

Patient characteristics associated with care by a cardiologist among adults hospitalized with severe congestive heart failure. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

OBJECTIVES: The goal of this study was to determine factors associated with receiving cardiologist care among patients with an acute exacerbation of congestive heart failure. BACKGROUND: Because cardiologist care for acute cardiovascular illness may improve care, barriers to specialty care could impact patient outcomes. METHODS: We studied 1,298 patients hospitalized with acute exacerbation of congestive heart failure who were cared for by cardiologists or generalist physicians. Using multivariable logistic models we determined factors independently associated with attending cardiologist care. RESULTS: Patients were less likely to receive care from a cardiologist if they were black (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.35, 0.80), had an income of less than $11,000 (AOR 0.65, 95% CI 0.45, 0.93) or were older than 80 years of age (AOR 0.23, 95% CI 0.12, 0.46). Patients were more likely to receive cardiologist care if they had college level education (AOR 1.89, 95% CI 1.02, 3.51), a history of myocardial infarction (AOR 1.59, 95% CI 1.17, 2.16), a serum sodium less than 133 on admission (AOR 1.96, 95% CI 1.30, 2.95) or a systolic blood pressure less than 90 on admission (AOR 1.97, 95% CI 1.20, 3.24). Patients who stated a desire for life extending care were also more likely to receive care from a cardiologist (AOR 1.40, 95% CI 1.04, 1.90). CONCLUSIONS: After adjusting for severity of illness and patient preferences for care, patient sociodemographic factors were strongly associated with receiving care from a cardiologist. Future investigations are required to determine whether these associations represent unmeasured preferences for care or inequities in our health care system.

Adult↗

PubMed2000

Does a physician's ability to accurately assess the likelihood of pulmonary embolism increase with training?

PURPOSE: Pulmonary embolism (PE), an elusive diagnosis, is detected by a diagnostic work-up that is often guided by the physician's level of clinical suspicion. The ability to accurately assess PE risk on solely clinical grounds may increase with the physician's level of training. This study documented the ability of house staff practicing in an academic teaching hospital to accurately assess the clinical likelihood of PE in patients. METHOD: During a seven-month period, all 245 patients with suspected acute PE who had had lung scans ordered via a computerized order-entry system were enrolled in the study. When ordering the lung scans, all physicians (interns, residents, and attending physicians) were required to also enter their levels of clinical suspicion on a scale of 0 to 100. The physicians' levels of clinical suspicion were correlated with the final determinations of PE, and receiver operating characteristic (ROC) curves were calculated for patients' and physicians' subgroups. RESULTS: Attending physicians were most able to diagnose PE; residents were moderately able to make the diagnosis, and interns were least able to diagnose PE. The area under the ROC curve for a correct identification of patients with PE was greatest for attending physicians (0.839), intermediate for residents (0.601), and least for interns (0.594). CONCLUSION: The ability to correctly assess a patient's likelihood of PE increases with a physician's level of training, suggesting that more senior physicians should be involved in the diagnostic work-up of patients with suspected acute PE. More instruction may help medical students, interns, and residents navigate clinical scenarios in which the diagnosis is uncertain or in which sequential tests must be performed to reach the correct diagnosis.

Acute Disease↗

PubMed2000

Identification of in-hospital complications from claims data. Is it valid?

OBJECTIVES: This study examined the validity of the Complications Screening Program (CSP) by testing whether (1) ICD-9-CM codes used to identify a complication are coded completely and accurately and (2) the CSP algorithm successfully separates conditions present on admission from those occurring in the hospital. METHODS: We compared diagnosis and procedure codes contained in the Medicare claim with codes abstracted from an independent re-review of more than 1,200 medical records from Connecticut and California. RESULTS: Eighty-nine percent of the surgical cases and 84% of the medical cases had their CSP trigger codes corroborated by re-review of the medical record. For 13% of the surgical cases and 58% of the medical cases, the condition represented by the code was judged to be present on admission rather than occurring in-hospital. The positive predictive value of the claim was greater than 80% for the surgical risk pool, suggesting the value of the CSP as a screening tool. CONCLUSIONS: The CSP has validity as a screen for most surgical complications but only for 1 medical complication. The CSP does not have validity as a "stand-alone" tool to identify more than a few in-hospital surgery-related events. The addition of an indicator to the Medicare claim to capture the timing of secondary diagnoses would improve the validity of the CSP for identifying both surgical and medical in-hospital events.

Aged↗

PubMed2000

Use of administrative data to find substandard care: validation of the complications screening program.

OBJECTIVE: The use of administrative data to identify inpatient complications is technically feasible and inexpensive but unproven as a quality measure. Our objective was to validate whether a screening method that uses data from standard hospital discharge abstracts identifies complications of care and potential quality problems. DESIGN: This was a case-control study with structured implicit physician reviews. SETTING: Acute-care hospitals in California and Connecticut in 1994. PATIENTS: The study included 1,025 Medicare beneficiaries greater than 265 years of age. METHODS: Using administrative data, we stratified acute-care hospitals by observed-to-expected complication rates and randomly selected hospitals within each state. We randomly selected cases flagged with 1 of 17 surgical complications and 6 medical complications. We randomly selected controls from unflagged cases. MAIN OUTCOME MEASURE: Peer-review organization physicians' judgments about the presence of the flagged complication and potential quality-of-care problems. RESULTS: Physicians confirmed flagged complications in 68.4% of surgical and 27.2% of medical cases. They identified potential quality problems in 29.5% of flagged surgical and 15.7% of medical cases but in only 2.1% of surgical and medical controls. The rate of physician-identified potential quality problems among flagged cases exceeded 25% in 9 surgical screens and 1 medical screen. Reviewers noted several potentially mitigating circumstances that affected their judgments about quality, including factors related to the patients' illness, the complexity of the case, and technical difficulties that clinicians encountered. CONCLUSIONS: For some types of complications, screening administrative data may offer an efficient approach for identifying potentially problematic cases for physician review. Understanding the basis for physicians' judgments about quality requires more investigation.

Aged↗

PubMed2000

Does clinical evidence support ICD-9-CM diagnosis coding of complications?

BACKGROUND: Hospital discharge diagnoses, coded by use of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), increasingly determine reimbursement and support quality monitoring. Prior studies of coding validity have investigated whether coding guidelines were met, not whether the clinical condition was actually present. OBJECTIVE: To determine whether clinical evidence in medical records confirms selected ICD-9-CM discharge diagnoses coded by hospitals. RESEARCH DESIGN AND SUBJECTS: Retrospective record review of 485 randomly sampled 1994 hospitalizations of elderly Medicare beneficiaries in Califomia and Connecticut. MAIN OUTCOME MEASURE: Proportion of patients with specified ICD-9-CM codes representing potential complications who had clinical evidence confirming the coded condition. RESULTS: Clinical evidence supported most postoperative acute myocardial infarction diagnoses, but fewer than 60% of other diagnoses had confirmatory clinical evidence by explicit clinical criteria; 30% of medical and 19% of surgical patients lacked objective confirmatory evidence in the medical record. Across 11 surgical and 2 medical complications, objective clinical criteria or physicians' notes supported the coded diagnosis in >90% of patients for 2 complications, 80% to 90% of patients for 4 complications, 70% to <80% of patients for 5 complications, and <70% for 2 complications. For some complications (postoperative pneumonia, aspiration pneumonia, and hemorrhage or hematoma), a large fraction of patients had only a physician's note reporting the complication. CONCLUSIONS: Our findings raise questions about whether the clinical conditions represented by ICD-9-CM codes used by the Complications Screening Program were in fact always present. These findings highlight concerns about the clinical validity of using ICD-9-CM codes for quality monitoring.

Aged↗

PubMed2000

Mobility problems and perceptions of disability by self-respondents and proxy respondents.

BACKGROUND: The Americans With Disabilities Act defines disability on the basis of physical or mental impairments or external perceptions of impairment. OBJECTIVES: The objective of this study was to examine perceptions of disability among people with lower-extremity mobility difficulties. RESEARCH DESIGN: This study used a cross-sectional, nationally representative survey, the 1994 to 1995 National Health Interview Survey-Disability (NHIS-D) supplement. Using SAS-callable SUDAAN for all analyses, we produced national population estimates. SUBJECTS: This study included 142,572 noninstitutionalized, civilian residents of the United States who were > or =18 years of age, with 80,423 self-respondents and 49,883 proxy respondents. MEASURES: We created a 4-level mobility variable using NHIS-D questions about the ability to walk, climb stairs, stand and the use of mobility aids. We examined associations between mobility and answers to 2 questions about self- and external perceptions of disability. RESULTS: The results showed that 3.1% (estimated 5.82 million persons) reported major mobility difficulties, including 3.7% of self-respondents and 2.7% of those with proxy respondents. Among persons with major mobility problems, 70.8% perceived themselves as disabled, whereas 64.8% thought other people see them as disabled. Also, 80.5% of manual wheelchair users saw themselves as disabled. Proxies were somewhat more likely to perceive disability than self-respondents, although differences were not generally statistically significant. In multivariable regressions, mobility level was the strongest predictor of self-perceived disability, followed by general health status. CONCLUSIONS: Mobility problems increase the likelihood that people will see themselves as disabled, but these perceptions are not universal. Although the schematic of wheelchair users has become an international symbol of disability, many people with serious mobility problems do not view themselves as disabled.

Adult↗

PubMed2000

Occurrence of nosocomial bloodstream infections in six neonatal intensive care units.

BACKGROUND: Nosocomial bloodstream infections (NBSIs) occur frequently in neonatal intensive care units (NICUs) and are associated with substantial morbidity and mortality. Little has been published regarding variation in NBSI among institutions. OBJECTIVE: To determine NBSI incidence among six NICUs and to explore how much variation is explained by patient characteristics and NICU practice patterns. METHODS: From October, 1994, to June, 1996, six regional NICUs prospectively abstracted clinical records of all neonates weighing <1,500 g. Occurrence of NBSI, defined as first positive culture occurring >48 h after admission, was analyzed in relation to baseline patient characteristics and several common therapeutic interventions. Variables significant in univariate analyses were analyzed by Cox proportional hazards regression. RESULTS: There were 258 NBSIs (incidence, 19.1%) among 1,354 inborn first admissions. Incidence varied significantly by site, from 8.5 to 42%. Birth weight, Broviac catheter use and parenteral nutrition were significantly associated with NBSI (P < 0.05). When controlling for these variables interinstitutional variation in NBSI occurrence decreased but remained significant. CONCLUSIONS: Neonatal NBSI incidence varies substantially among institutions despite adjustment for length of stay and some known risk factors. The uses of Broviac catheters and especially intravenous nutrition supplements were significant determinants of NBSI risk.

Analysis of Variance↗

PubMed2000

The last six months of life for patients with congestive heart failure.

OBJECTIVE: To characterize the experiences of patients with congestive heart failure (CHF) during their last 6 months of life. DESIGN: A retrospective analysis of data from a prospective cohort study. SETTING: Five geographically diverse tertiary care academic medical centers. PARTICIPANTS: A total of 1404 patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) with a diagnosis of an acute exacerbation of CHF, of whom 539 patients died within 1 year of their index hospitalization. METHODS: Data from interviews with patients or their surrogates were collected and chart abstractions performed at several time points in SUPPORT. To describe progression to death, we constructed four observational windows backward in time, beginning with patients' dates of death and ending with their date of entry into the SUPPORT project or 6 months before death, whichever came first. For each outcome, patients contributed information to all windows for which they had data collected. We describe frequency distributions for each outcome over time and report tests for trend. OUTCOME MEASURES: Outcomes examined over time included: percentage of days spent in a hospital; model-based prognostic estimates of 6-month survival; functional status; occurrence of severe physical and emotional symptoms, including pain, depression and anxiety; patients' preferences for care; and the financial impact of patients' illnesses on their families. RESULTS: As death approached, patients' prognoses became poorer and illnesses more severe. Median Acute Physiology Scores for hospitalized patients rose from 33 in the interval 6 months to 3 months before death, to 44 within 3 days of death. However, the median model-based estimate of 6-month survival was 54% even within 3 days of death. Number of functional impairments, median depression scores and percent of patients reporting severe pain or dyspnea increased as death approached, with 41% of patient surrogates reporting that the patient was in severe pain and 63% reporting that the patient was severely short of breath during the 3 days before death. Perceived quality of life did not change appreciably, with 29 to 58 % of patients reporting good to excellent quality of life in all intervals before death. As death approached, patients were more likely to prefer Do Not Resuscitate (DNR) status, with the percent of patients preferring DNR rising from 33% at 6 months to 3 months before death to 47% at 1 month to 3 days before death (P < .05). The frequency with which DNR orders were written for hospitalized patients also increased as death approached. The patients' illnesses had marked financial impact on their families, with 23 % of patients' families reporting the loss of most or all of family savings at the time of the patient's death. CONCLUSIONS: As death approaches during the last 6 months of life in CHF, illness becomes more severe, disability and the experience of certain symptoms more frequent, and patient preference not to be resuscitated more common. However, there is no significant decrement in quality of life as death approaches. Reflecting the unpredictable course of CHF during the last month of life, many patients have good median model-based 6-month prognoses and enjoy good to excellent quality of life.

APACHE↗

PubMed2000

Baby CareLink: using the internet and telemedicine to improve care for high-risk infants.

OBJECTIVE: To evaluate an Internet-based telemedicine program designed to reduce the costs of care, to provide enhanced medical, informational, and emotional support to families of very low birth weight (VLBW) infants during and after their neonatal intensive care unit (NICU) stay. BACKGROUND: Baby CareLink is a multifaceted telemedicine program that incorporates videoconferencing and World Wide Web (WWW) technologies to enhance interactions between families, staff, and community providers. The videoconferencing module allows virtual visits and distance learning from a family's home during an infant's hospitalization as well as virtual house calls and remote monitoring after discharge. Baby CareLink's WWW site contains information on issues that confront these families. In addition, its security architecture allows efficient and confidential sharing of patient-based data and communications among authorized hospital and community users. DESIGN/METHODS: A randomized trial of Baby CareLink was conducted in a cohort of VLBW infants born between November 1997 and April 1999. Eligible infants were randomized within 10 days of birth. Families of intervention group infants were given access to the Baby CareLink telemedicine application. A multimedia computer with WWW browser and videoconferencing equipment was installed in their home within 3 weeks of birth. The control group received care as usually practiced in this NICU. Quality of care was assessed using a standardized family satisfaction survey administered after discharge. In addition, the effect of Baby CareLink on hospital length of stay as well as family visitation and interactions with infant and staff were measured. RESULTS: Of the 176 VLBW infants admitted during the study period, 30 control and 26 study patients were enrolled. The groups were similar in patient and family characteristics as well as rates of inpatient morbidity. The CareLink group reported higher overall quality of care. Families in the CareLink group reported significantly fewer problems with the overall quality of care received by their family (mean problem score: 3% vs 13%). In addition, CareLink families also reported greater satisfaction with the unit's physical environment and visitation policies (mean problem score: 13% vs 50%). The frequency of family visits, telephone calls to the NICU, and holding of the infant did not differ between groups. The duration of hospitalization until ultimate discharge home was similar in the 2 groups (68.5 +/- 28.3 vs 70.6 +/- 35.6 days). Among infants born weighing <1000 g (n = 31) there was a tendency toward shorter lengths of stay (77.4 +/- 26.2 vs 93.1 +/- 35.6 days). All infants in the CareLink group were discharged directly to home whereas 6/30 (20%) of control infants were transferred to community hospitals before ultimate discharge home. CONCLUSIONS: CareLink significantly improves family satisfaction with inpatient VLBW care and definitively lowers costs associated with hospital to hospital transfer. Our data suggest the use of telemedicine and the Internet support the educational and emotional needs of families facilitating earlier discharge to home of VLBW infants. We believe that further extension of the Baby CareLink model to the postdischarge period will significantly improve the coordination and efficiency of care.

Aftercare↗

PubMed2000

Mobility impairments and use of screening and preventive services.

OBJECTIVES: Primary care for people with disabilities often concentrates on underlying debilitating disorders to the exclusion of preventive health concerns. This study examined use of screening and preventive services among adults with mobility problems (difficulty walking, climbing stairs, or standing for extended periods). METHODS: The responses of non-institutionalized adults to the 1994 National Health Interview Survey, including the disability and Healthy People 2000 supplements, were analyzed. Multivariable logistic regressions predicted service use on the basis of mobility level, demographic characteristics, and indicators of health care access. RESULTS: Ten percent of the sample reported some mobility impairment; 3% experienced major problems. People with mobility problems were as likely as others to receive pneumonia and influenza immunizations but were less likely to receive other services. Adjusted odds ratios for women with major mobility difficulties were 0.6 (95% confidence interval [CI] = 0.4, 0.9) for the Papanicolaou test and 0.7 (95% CI = 0.5, 0.9) for mammography. CONCLUSIONS: More attention should be paid to screening and preventive services for people with mobility difficulties. Shortened appointment times, physically inaccessible care sites, and inadequate equipment could further compromise preventive care for this population.

Adult↗

PubMed1999

Older age, aggressiveness of care, and survival for seriously ill, hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

BACKGROUND: Older age is associated with less aggressive treatment and higher short-term mortality due to serious illness. It is not known whether less aggressive care contributes to this survival disadvantage in elderly persons. OBJECTIVE: To determine the effect of age on short-term survival, independent of baseline patient characteristics and aggressiveness of care. DESIGN: Secondary analysis of data from a prospective cohort study. SETTING: Five academic medical centers participating in SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). PATIENTS: 9105 adults hospitalized with one of nine serious illnesses associated with an average 6-month mortality rate of 50%. MEASUREMENTS: Survival through 180 days of follow-up. In Cox proportional hazards modeling, adjustment was made for patient sex; ethnicity; income; baseline physical function; severity of illness; intensity of hospital resource use; presence of do-not-resuscitate orders on study day 1; and presence and timing of decisions to withhold transfer to the intensive care unit, major surgery, dialysis, blood transfusion, vasopressors, and tube feeding. RESULTS: The mean (+/- SD) patient age was 63 +/- 16 years, 44% of patients were female, and 16% were black. Overall survival to 6 months was 53%. In analyses that adjusted for sex, ethnicity, income, baseline functional status, severity of illness, and aggressiveness of care, each additional year of age increased the hazard of death by 1.0% (hazard ratio, 1.010 [95% CI, 1.007 to 1.013]) for patients 18 to 70 years of age and by 2.0% (hazard ratio, 1.020 [CI, 1.013 to 1.026]) for patients older than 70 years of age. Adjusted estimates of age-specific 6-month mortality rates were 44% for 55-year-old patients, 48% for 65-year-old patients, 53% for 75-year-old patients, and 60% for 85-year-old patients. Similar results were obtained in analyses that did not adjust for aggressiveness of care. Acute physiology and diagnosis had much larger relative contributions to prognosis than age. CONCLUSIONS: We found a modest independent association between patient age and short-term survival of serious illness. This age effect was not explained by the current practice of providing less aggressive care to elderly patients.

Activities of Daily Living↗

PubMed1999

Physician counseling about exercise.

CONTEXT: The increase in sedentary lifestyle may contribute to the rise in obesity nationally. Although guidelines suggest that physicians counsel all patients about exercise, physicians counsel only a minority of their patients. Whether patient factors influence physician counseling is not well established. OBJECTIVES: To examine and to identify factors associated with exercise counseling by US physicians. DESIGN AND SETTING: National population-based supplemental (Year 2000) survey to the 1995 National Health Interview Survey. PARTICIPANTS: Of the 17317 respondents to the Year 2000 supplemental survey, 9711 adults had seen a physician in the previous year, and 9299 responded when asked about physician counseling on exercise. MAIN OUTCOME MEASURE: Physician counseling to begin or to continue to exercise. RESULTS: Of 9299 respondents, 34% reported being counseled about exercise at their last visit. After adjustment for other sociodemographic and clinical factors, women were slightly more likely to be counseled, with an adjusted odds ratio (AOR) of 1.15 (95% confidence interval [CI], 1.02-1.29). Physicians counseled older patients (>30 years) more often than younger patients; those aged 40 to 49 years were counseled most often (AOR, 1.71 [95% CI, 1.34-2.20]). Patients with incomes above $50000, those with higher levels of physical activity, college graduates, and patients who were overweight to obese (body mass index: 25 to > or =30 kg/m2) were more likely to be counseled, as were patients with cardiac disease (AOR, 1.81 [95% CI, 1.52-2.14]) and diabetes (AOR, 1.87 [95% CI, 1.46-2.38]). Counseling did not vary by physician specialty or patient race. CONCLUSION: The rate of physician counseling about exercise is low nationally. Physicians appear to counsel as secondary prevention and are less likely to counsel patients at risk for obesity. The failure to counsel younger, disease-free adults and those from lower socioeconomic groups may represent important missed opportunities for primary prevention.

Adult↗

PubMed1999

Patient age and decisions to withhold life-sustaining treatments from seriously ill, hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

BACKGROUND: Patient age may influence decisions to withhold life-sustaining treatments, independent of patients' preferences for or ability to benefit from such treatments. Controversy exists about the appropriateness of using age as a criterion for making treatment decisions. OBJECTIVE: To determine the effect of age on decisions to withhold life-sustaining therapies. DESIGN: Prospective cohort study. SETTING: Five medical centers participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). PATIENTS: 9105 hospitalized adults who had one of nine illnesses associated with an average 6-month mortality rate of 50%. MEASUREMENTS: Outcomes were the presence and timing of decisions to withhold ventilator support, surgery, and dialysis. Adjustment was made for sociodemographic characteristics, prognoses, baseline function, patients' preferences for life-extending care, and physicians' understanding of patients' preferences for life-extending care. RESULTS: The median patient age was 63 years; 44% of patients were women, and 53% survived to 180 days. In adjusted analyses, older age was associated with higher rates of withholding each of the three life-sustaining treatments studied. For ventilator support, the rate of decisions to withhold therapy increased 15% with each decade of age (hazard ratio, 1.15 [95% CI, 1.12 to 1.19]); for surgery, the increase per decade was 19% (hazard ratio, 1.19 [CI, 1.12 to 1.27]); and for dialysis, the increase per decade was 12% (hazard ratio, 1.12 [CI, 1.06 to 1.19]). Physicians underestimated older patients' preferences for life-extending care; adjustment for this underestimation resulted in an attenuation of the association between age and decisions to withhold treatments. CONCLUSION: Even after adjustment for differences in patients' prognoses and preferences, older age was associated with higher rates of decisions to withhold ventilator support, surgery, and dialysis.

Activities of Daily Living↗

PubMed1999

Delays in protease inhibitor use in clinical practice.

OBJECTIVE: To determine the clinical factors associated with delayed protease inhibitor initiation. DESIGN: Chart review and telephone survey. SETTING: General medicine practice at an academic medical center in Boston, Mass. PATIENTS: One hundred ninety patients living with HIV and a viral load of more than 10,000 copies/ml. MEASUREMENTS AND MAIN RESULTS: The main outcome measurement was time to first protease inhibitor prescription after first elevated HIV viral load (>10,000 copies/ml). In this cohort, 190 patients had an elevated viral load (median age 39; 87% male; 12% history of injection drug use; 63% AIDS; 53% with depression; 17% history of pneumocystis pneumonia; 54% CD4 <200). In Cox proportional hazards modeling, significant univariate correlates for delayed protease inhibitor initiation were higher CD4 cell count (hazard ratio [HR] 2. 38 for CD4 200-500 compared with <200, 95% confidence interval [CI] 1.59, 3.57; and HR 8.33 for CD4> 500; 95% CI 2.63, 25.0), higher viral load (HR 0.43 for each 10-fold increase; 95% CI 0.31, 0.59), injection drug use (HR 2.08; 95% CI 1.05, 4.17), AIDS (HR 0.24; 95% CI 0.15, 0.36), and history of pneumocystis pneumonia (HR 0.32; 95% CI 0.21, 0.49). In multivariate models adjusted for secular trends in protease inhibitor use, factors significantly associated with delay of protease inhibitor initiation (p <.05) were higher CD4 cell count (for CD4 200-500, HR 2.63; 95% CI 1.61, 4.17; for CD4> 500, HR 11.11; 95% CI 3.57, 33.33), higher viral load (HR 0.66 for each 10-fold increase; 95% CI 0.45, 0.98), history of pneumocystis pneumonia (HR 0.57; 95% CI 0.37, 0.90), history of depression (HR 1. 49; 95% CI 1.03, 2.13), and history of injection drug use (HR 2.70; 95% CI 1.35, 5.56). CONCLUSIONS: HIV-infected patients with higher CD4 cell counts or a history of depression or history of injection drug use have significant and lengthy delays of protease inhibitor therapy. Although some delays may be clinically appropriate, enhancement of provider and patient education might prove beneficial. Further research should examine reasons for delays in protease inhibitor initiation and their appropriateness.

Adult↗

PubMed1999

Does the Complications Screening Program flag cases with process of care problems? Using explicit criteria to judge processes.

BACKGROUND: The Complications Screening Program (CSP) aims to identify 28 potentially preventable complications of hospital care using computerized discharge abstracts, including demographic information, diagnosis and procedure codes. OBJECTIVE: To validate the CSP as a quality indicator by using explicit process of care criteria to determine whether hospital discharges flagged by the CSP experienced more process problems than unflagged discharges. METHODS: The (CSP was applied to computerized hospital discharge abstracts from Mledicare beneficiaries > 65 years old admitted in 1994 to hospitals in California and Connecticut for major surgery or medical treatment. ()f 28 CSP complications, 17 occurred sufficient frequently to study. Discharges flagged (cases) and unflagged (controls) by the (CSP were sampled and photocopied medical records were obtained. Physicians specified detailed, objective, explicit criteria, itemizing 'key steps' in processes of care that could potentially have prevented or caused complications. Trained nurses abstracted medical records using these explicit criteria. Process problem rates between cases and controls were compared. RESULTS: The final sample included 740 surgical and 416 medical discharges. Rates of process problems were high, ranging from 24.4 to 82.5% across CSP screens for surgical cases. Problems were lower for medical cases, ranging from 2.0 to 69.1% across CSP screens. Problem rates were 45.7% for surgical and 5.0% for medical controls. Rates of problems did not differ significantly across flagged and unflagged discharges. CONCLUSIONS: The CSP did not flag discharges with significantly higher rates of explicit process problems than unflagged discharges. Various initiatives throughout the USA use techniques similar to the CSP to identify complications of care. Based on these CSP findings, such approaches should be evaluated cautiously.

Aged↗

PubMed1999

Screening inpatient quality using post-discharge events.

BACKGROUND: Decreasing hospital lengths of stay (LOS) hamper efforts to detect and to definitively treat complications of care. Patients leave before some complications are identified. OBJECTIVES: To develop a computerized method to screen for hospital complications using readily available administrative data from outpatient and nonacute care within 90 days of discharge. DESIGN: We developed the Complications Screening Program for Outpatient data (CSP-O) by using diagnosis and procedure codes from Medicare Part A and B claims to define 50 complication screens. Seventeen apply to specific procedural cases, and 33 apply to all adult, acute, medical, or surgical hospitalizations. The CSP-O algorithm examined outpatient, physician office, home health agency, and hospice claims within 90 days following discharge. SUBJECTS: Seven hundred thirty nine thousand, two hundred and forty eight discharges of Medicare beneficiaries (age range, > or = 65 years) were admitted to 515 hospitals nationwide in 1994. RESULTS: Complete 90-day, post-discharge windows were present for 62.8% of all and 68.5% of procedural cases. The 33 general screens flagged 13.6% of all cases; only 1.8% of procedural cases were flagged by the 17 procedural screens. When we allowed the CSP-O algorithm to scan information from acute hospital readmissions, flag rates rose to 32.8% for general and 8.7% for procedural complications. Controlling for patient and hospital characteristics, flag rates were considerably higher among the very old and at small and for-profit institutions. CONCLUSIONS: Whereas several CSP-O findings have construct validity, limitations of claims raise concerns. Regardless of the CSPO's ultimate utility, examining post-discharge experiences to identify inpatient complications remains important as LOSs fall.

Aftercare↗

PubMed1998

Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.

CONTEXT: A prior national survey documented the high prevalence and costs of alternative medicine use in the United States in 1990. OBJECTIVE: To document trends in alternative medicine use in the United States between 1990 and 1997. DESIGN: Nationally representative random household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997, respectively. PARTICIPANTS: A total of 1539 adults in 1991 and 2055 in 1997. MAIN OUTCOMES MEASURES: Prevalence, estimated costs, and disclosure of alternative therapies to physicians. RESULTS: Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997 (P < or = .001). The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3% (P = .002). In both surveys alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches. There was no significant change in disclosure rates between the 2 survey years; 39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997. The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64.0%) and 1997 (58.3%) (P=.36). Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users). Estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services. CONCLUSIONS: Alternative medicine use and expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking alternative therapies, rather than increased visits per patient.

Adult↗