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Biomedical subjects

R B Haynes

Publications and source records attributed to R B Haynes.

At least 73 records · Page 4Linked to original sources
PubMed1994

How was your hospital stay? Patients' reports about their care in Canadian hospitals.

OBJECTIVE: To survey adult medical and surgical patients about their concerns and satisfaction with their care in Canadian hospitals. DESIGN: Cross-sectional telephone survey undertaken from June 1991 to May 1992 with a standardized questionnaire. SETTING: Stratified random sample of public acute care hospitals in six provinces; 57 (79%) of the 72 hospitals approached agreed to participate. PATIENTS: Each participating hospital provided the study team with the names of 150 adult medical and surgical patients discharged home in consecutive order. A total of 4599 patients agreed to be interviewed (69% of eligible patients and 89% of patients contacted). MAIN OUTCOME MEASURES: Satisfaction with (a) provider-patient communication (including information given), (b) provider's respect for patient's preferences, (c) attentiveness to patient's physical care needs, (d) education of patient regarding medication and tests, (e) quality of relationship between patient and physician in charge, (f) education of and communication with patient's family regarding care, (g) pain management and (h) hospital discharge planning. RESULTS: Most (61%) of the patients surveyed reported problems with 5 or fewer of the 39 specific care processes asked about in the study. Forty-one percent of the patients reported that they had not been told about the daily hospital routines. About 20% of the patients receiving medications reported that they had not been told about important side effects in a way they could understand; 20% of the patients who underwent tests reported similar problems with communication of the test results. Thirty-six percent of those having tests had not been told how much pain to expect. In discharge planning, the patients complained that they had not been told what danger signals to watch for at home (reported by 39%), when they could resume normal activities (by 32%) and what activities they could or could not do at home (by 29%). Over 90% of the patients reported that they had had a relationship of confidence and trust with their physician and that they had been involved in decision making as much as they wanted to be. Fifteen percent of the patients whose admissions had been scheduled felt that they should have been admitted sooner. CONCLUSION: The self-reported patient data from this survey suggest that hospital routines, medications, tests, pain management and discharge planning are areas of communication to target in future quality-improvement efforts in Canadian hospitals.

Adult↗
PubMed1994

Prevention of functional impairment by endarterectomy for symptomatic high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.

OBJECTIVE: To determine whether carotid endarterectomy prevents deterioration of functional status among patients with transient ischemic attacks or nondisabling strokes and ipsilateral carotid stenosis of 70% to 99%. DESIGN: Multicentered randomized controlled trial with an average 18-month follow-up. SETTING: Fifty clinical centers in North America. PATIENTS: A total of 659 patients presenting with recent transient attacks of nondisabling stroke and ipsilateral atherosclerotic carotid stenosis of 70% to 99% were included. Patients were stable neurologically at the time of entry. No patient was lost to follow-up. INTERVENTION: Vascular surgeons and neurosurgeons were prescreened for low perioperative complication rates. Patients were randomly allocated to carotid endarterectomy plus continuing medical care (n = 328) or medical care alone (n = 331), including antiplatelet therapy. MAIN OUTCOME MEASURES: All patients were assessed by neurologists for the occurrence of stroke and functional status at scheduled intervals after entry. RESULTS: In addition to a previously reported risk reduction for ipsilateral stroke for patients assigned to carotid endarterectomy, there was an absolute risk reduction (and relative risk reduction [RRR]) for functional status impairment of 5.6% (RRR, 69%) for vision, 4.6% (RRR, 87%) for comprehension of language, 8.3% (RRR, 88%) for fluency of speech, 4.3% (RRR, 84%) for swallowing, 6.0% (RRR, 53%) for lower-limb function, 9.3% (RRR, 75%) for upper-limb function, 7.4% (RRR, 60%) for shopping, and 10.5% (RRR, 50%) for visiting outside usual residence (P < .05, two-tailed, for all items). CONCLUSIONS: Carotid endarterectomy reduced the risk for impairment of function among patients with recent symptomatic cerebral ischemia and ipsilateral high-grade carotid stenosis.

Carotid Artery, Internal↗
PubMed1994

Can bruits distinguish high-grade from moderate symptomatic carotid stenosis? The North American Symptomatic Carotid Endarterectomy Trial.

OBJECTIVE: To determine whether cervical bruits, alone or combined with other clinical characteristics, can distinguish high-grade (70% to 99%) carotid artery stenoses from less severe stenoses in patients with symptoms of cerebrovascular disease. DESIGN: Cross-sectional comparison of clinical observations with contemporaneous angiography. SETTING: The North American Symptomatic Carotid Endarterectomy Trial (NASCET), a multicenter randomized controlled trial of carotid endarterectomy. PATIENTS: All patients enrolled in the NASCET from its inception in 1988 to November 1991. RESULTS: A focal ipsilateral carotid bruit had a sensitivity of 63% and a specificity of 61% for high-grade stenosis and, when absent, only lowered the probability for high-grade stenosis from a pretest value of 52% to a post-test probability of 40%. When combined with four other clinical characteristics (an infarction on computed tomography of the head, a carotid ultrasound scan suggesting more than 90% stenosis, a transient ischemic attack rather than a minor stroke as a qualifying event, and a retinal rather than a hemispheric qualifying event), the predicted probabilities of high-grade stenosis ranged from a low of 18% (when none of the features was present) to a high of 94% (when all the features were present. CONCLUSIONS: Cervical bruits alone were not sufficiently predictive of high-grade symptomatic carotid stenosis to be useful in selecting patients for angiography; they were absent in over one third of patients with high-grade stenosis. When combined with other clinical variables, patients with high or low probabilities of 70% to 99% stenoses could be identified, but this prediction model still missed many individuals with high-grade stenosis, even in this training set of selected patients.

Angiography↗
PubMed1994

Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research.

OBJECTIVE: To review the evidence from controlled trials of the effects of computer-based clinical decision support systems (CDSSs) on clinician performance and patient outcomes. DATA SOURCES: The literature in the MEDLARS, EMBASE, SCISEARCH, and INSPEC databases was searched from 1974 to the present. Conference proceedings and reference lists of relevant articles were reviewed. Evaluators of CDSSs were asked to identify additional studies. STUDY SELECTION: 793 citations were examined, and 28 controlled trials that met predefined criteria were reviewed in detail. DATA EXTRACTION: Study quality was assessed, and data on setting, clinicians and patients, method of allocation, computer system, and outcomes were abstracted and verified using a structured form. Separate summaries were prepared for physician and patient outcomes. Within each of these categories, studies were classified further according to the primary purpose of the CDSS: drug dose determination, diagnosis, or quality assurance. RESULTS: Three of 4 studies of computer-assisted dosing, 1 of 5 studies of computer-aided diagnosis, 4 of 6 studies of preventive care reminder systems, and 7 of 9 studies of computer-aided quality assurance for active medical care that assessed clinician performance showed improvements in clinician performance using a CDSS. Three of 10 studies that assessed patient outcomes reported significant improvements. CONCLUSIONS: Strong evidence suggests that some CDSSs can improve physician performance. Additional well-designed studies are needed to assess their effects and cost-effectiveness, especially on patient outcomes.

Clinical Competence↗
PubMed1994

Quantitative comparison of pre-explosions and subheadings with methodologic search terms in MEDLINE.

OBJECTIVE: To compare the retrieval characteristics of subheadings with methodologic textwords and MeSH terms in MEDLINE for identifying sound clinical studies on the etiology, prognosis, diagnosis, prevention and treatment of disorders in general adult medicine. DESIGN: Analytic survey of the information retrieval properties of methodologic textwords, single methodologic MeSH terms, pre-explosions and subheadings selected to detect studies meeting basic methodologic criteria for direct clinical use in general adult medicine. MEASURES: The sensitivity, specificity, and precision of search terms were determined by comparing the citations retrieved by the search strategies in MEDLINE with that of a manual review (the gold standard) of all articles in 10 internal and general medicine journals for 1986 and 1991. RESULTS: For treatment and diagnosis in 1991, and treatment, diagnosis, and etiology in 1986, pre-explosions yielded the highest sensitivity, with typical absolute increases exceeding 15%. For etiology and prognosis in 1991, and prognosis in 1986, textwords or MeSH terms yielded the highest sensitivity. In all cases the increase in sensitivity was coupled with a loss in specificity and precision. CONCLUSIONS: Compared with searching with single methodologic textwords and subject headings, the detection of sound clinical studies on the diagnosis and treatment of disorders in general adult medicine was consistently enhanced by searching with pre-explosions, but at a price of decreased specificity and precision.

Abstracting and Indexing↗
PubMed1993

Some problems in applying evidence in clinical practice.

There is a considerable gap between sound evidence concerning health care interventions and the services that patients actually receive as health care. Practitioners and the health care system must overcome a number of barriers to narrow the gap. Viewed simplistically, there are three steps from evidence to practice: getting the evidence straight; developing clinical practice guidelines that are faithful to both the evidence and the clinical and personal situations of patients; and applying these guidelines to the right patient at the right time in the right way. Special problems in getting the evidence straight stem from difficulties in finding sound evidence. Lack of agreement on evidence standards undermine the effectiveness of authoritative practice guidelines. Applying evidence and practice guidelines effectively and efficiently is often thwarted by mismatches between evidence and usual practice circumstances. Time pressures undermine interpretation and application of evidence at every step. Understanding these problems may permit development of more effective strategies to bridge the gap between evidence and practice.

Decision Making↗
PubMed1993

Report of the Canadian Hypertension Society Consensus Conference: 2. Diagnosis of hypertension in adults.

OBJECTIVE: To update recommendations for the diagnosis of mild hypertension in adults and to assess the role of echocardiography, self-measurement of blood pressure and ambulatory blood pressure monitoring. DATA SOURCES: Literature reviews of previous consensus conferences were updated with searches of MEDLINE for the period Jan. 1, 1988, to Nov. 15, 1991, and supplemented by reference lists and personal files. STUDY SELECTION: Panel members selected relevant articles and rated them according to methodologic criteria. DATA EXTRACTION: The data extracted concerned the measurement of blood pressure, the diagnosis of hypertension, the treatment of mild hypertension, and the reliability and validity of echocardiography, self-measurement of blood pressure and ambulatory blood pressure monitoring in the diagnosis of mild hypertension. The recommendations made were graded according to the level of evidence available, circulated to many experts and approved at a consensus conference. MAIN RESULTS: Previous recommendations for the accurate measurement of blood pressure remain mostly unchanged. Antihypertensive treatment should be prescribed for patients (including the elderly) with an average diastolic blood pressure of at least 100 mm Hg, for those with isolated systolic hypertension (systolic blood pressure of at least 160 mm Hg and diastolic blood pressure of less than 90 mm Hg) and for patients with a diastolic blood pressure of 90 to 99 mm Hg and target-organ damage. Clinical judgement is required in treating patients with a diastolic blood pressure of 90 to 99 mm Hg without target-organ damage, and individual risk for cardiovascular disease must be taken into account. There is insufficient evidence to warrant the routine use of echocardiography, self-measurement of blood pressure or ambulatory blood pressure monitoring in diagnosis. CONCLUSIONS: Recent high-quality evidence supports several new recommendations for the diagnosis of mild hypertension in adults. Additional research is needed to determine the role of echocardiography, self-measurement of blood pressure and ambulatory blood pressure monitoring.

Adult↗
PubMed1993

A program to enhance clinical use of MEDLINE. A randomized controlled trial.

OBJECTIVE: To determine if a preceptor and individualized feedback improves the performance of physicians in searching MEDLINE in clinical settings. DESIGN: Randomized controlled trial with 2 to 10 months follow-up. SETTING: A 300-bed teaching hospital. PARTICIPANTS: All 392 physicians and physicians-in-training from 6 major clinical departments were invited to participate if they made patient-care decisions during the study period; 79.4% agreed. INTERVENTIONS: All participants were given 2 hours of basic training, then randomized to a control group (no further intervention) or an intervention group in which each person chose a clinical preceptor experienced in MEDLINE searching and received individualized feedback from a study librarian on each of their 1st 10 searches. MAIN OUTCOME MEASURES: The number and proportion of relevant and irrelevant references retrieved for 1st, 4th, and 8th searches of participants were compared with independent librarian searches on the same topics. RESULTS: Intervention group members did not search more often than controls (5.9 searches per month versus 4.7, respectively; P = 0.26) and there were no significant differences in the quality of searches. Rather, search performance for both groups improved, with the average number of relevant references retrieved per search increasing from 4.5 to 7.4 (P < 0.01). The librarian retrieved more relevant citations than participants for the 1st search (P = 0.001) but not for the 4th (P = 0.60) or 8th (P = 0.76) searches. CONCLUSIONS: A program of assigning preceptors and providing feedback on individual searches did not enhance the quantity or quality of searches. Soon after a basic introduction to searching, however, clinicians in both groups improved their search performance.

Clinical Medicine↗
PubMed1993

More informative abstracts of articles describing clinical practice guidelines.

UNLABELLED: Recommendations are proposed for preparing more informative abstracts of articles describing clinical practice guidelines. Information about the development and content of guidelines should be summarized with the following structure. OBJECTIVE: a succinct statement of the objective of the guideline, including the targeted health problem, the targeted patients and providers, and the main reason for developing recommendations concerning this problem for this population. OPTIONS: principal practice options that were considered in formulating the guideline. OUTCOMES: significant health and economic outcomes identified as potential consequences of the practice options. EVIDENCE: Methods used to gather, select, and synthesize evidence, and the date of the most recent evidence obtained. VALUES: persons and methods used to assign values (relative importance) to potential outcomes of alternative practice options. BENEFITS, HARMS, AND COSTS: the type and magnitude of the main benefits, harms, and costs that are expected to result from guideline implementation. RECOMMENDATIONS: a brief and specific list of key recommendations. VALIDATION: the results of any external review, comparison with guidelines developed by other groups, or clinical testing of guideline use. SPONSORS: key persons or groups that developed, funded, or endorsed the guideline. Abstracts adhering to these recommendations could enhance readers' ability to appraise the applicability, importance, and validity of guidelines for specific providers, patients, and settings. More informative abstracts could also promote the use of more explicit methods of guideline development, more consistent reporting of guideline documents, and the more appropriate use of guidelines by clinicians.

Abstracting and Indexing↗
PubMed1993

Effect of problem-based, self-directed undergraduate education on life-long learning.

OBJECTIVE: To compare how well graduates of a self-directed, problem-based undergraduate curriculum (at McMaster University [MU], Hamilton, Ont.) and those of a traditional curriculum (at the University of Toronto [UT]) who go on to primary care careers keep up to date with current clinical practice guidelines. DESIGN: Analytic survey. Management of hypertension was chosen as an appropriate topic to assess guideline adherence. An updated version of a previously validated questionnaire was mailed to the participants for self-completion. SETTING: Private primary care practices in southern Ontario. PARTICIPANTS: A random sample of 48 MU graduates and 48 UT graduates, stratified for year of graduation (1974 to 1985) and sex, who were in family or general practice in Ontario; 87% of the eligible subjects in each group responded. MAIN OUTCOME MEASURES: Overall and component-specific scores; analysis was blind to study group. RESULTS: The overall mean scores were 56 (68%) of a possible 82 for the MU graduates and 51 (62%) for the UT graduates (difference between the means 5, 95% confidence interval 1.9 to 8.2; p < 0.01). Multivariate linear regression analysis of seven factors that might affect questionnaire scores revealed that only the medical school was statistically significant (p < 0.01). The MU graduates had significantly higher mean scores than the UT graduates for two components of the questionnaire: knowledge of recommended blood pressures for treatment (p < 0.05) and successful approaches to enhance compliance (p < 0.005). The trends were similar for the other components but but were not significant. CONCLUSIONS: The graduates of a problem-based, self-directed undergraduate curriculum are more up to date in knowledge of the management of hypertension than graduates of a traditional curriculum.

Curriculum↗
PubMed1993

Assessment of methodologic search filters in MEDLINE.

OBJECTIVE: To determine the retrieval characteristics of methodologic textwords and MeSH terms in MEDLINE for identifying methodologically sound studies on the etiology, prognosis, diagnosis, and prevention and treatment of disorders in general adult medicine. DESIGN: Comparison of methodologic search terms and phrases for the retrieval of citations in MEDLINE with a manual hand search of the literature (the gold standard) for 10 internal and general medicine journals for 1986 and 1991. MEASURES: Sensitivity (proportion of methodologically sound and correct topic studies retrieved) and specificity (proportion of unsound or wrong topic articles not retrieved) of the search strategies. RESULTS: The individual terms yielding the best sensitivity for 1991 by purpose category were: risk (tw) for etiology; exp cohort studies for prognosis; sensitivity (tw) for diagnosis; and clinical trial (pt) for treatment. The corresponding terms for 1986 were: risk (tw) for etiology; prognosis: (tw) for prognosis; sensitivity (tw) for diagnosis; and random: (tw) for treatment. CONCLUSIONS: The performance of methodologic MeSH terms and textwords varied greatly in MEDLINE and changed from 1986 to 1991. More complex search strategies may be required to optimize retrieval.

Information Storage and Retrieval↗
PubMed1992

Evidence for the effectiveness of CME. A review of 50 randomized controlled trials.

OBJECTIVE: To assess the impact of diverse continuing medical education (CME) interventions on physician performance and health care outcomes. DATA SOURCES: Using continuing medical education and related phrases, we performed regular searches of the indexed literature (MEDLINE, Social Science Index, the National Technical Information Service, and Educational Research Information Clearinghouse) from 1975 through 1991. In addition, for these years, we used manual searches, key informants, and requests to authors to locate other indexed articles and the nonindexed literature of adult and continuing professional education. STUDY SELECTION: From the resulting database we selected studies that met the following criteria: randomized controlled trials; educational programs, activities, or other interventions; studies that included 50% or more physicians; follow-up assessments of at least 75% of study subjects; and objective assessments of either physician performance or health care outcomes. DATA EXTRACTION: Studies were reviewed for data related to physician specialty and setting. Continuing medical education interventions were classified by their mode(s) of activity as being predisposing, enabling, or facilitating. Using the statistical tests supplied by the original investigators, physician performance outcomes and patient outcomes were classified as positive, negative, or inconclusive. DATA SYNTHESIS: We located 777 CME studies, of which 50 met all criteria. Thirty-two of these analyzed physician performance; seven evaluated patient outcomes; 11 examined both measures. The majority of the 43 studies of physician performance showed positive results in some important measures of resource utilization, counseling strategies, and preventive medicine. Of the 18 studies of health care outcomes, eight demonstrated positive changes in patients' health care outcomes. CONCLUSION: Broadly defined CME interventions using practice-enabling or reinforcing strategies consistently improve physician performance and, in some instances, health care outcomes.

Clinical Competence↗
PubMed1992

An overview of interventions to improve compliance with appointment keeping for medical services.

OBJECTIVE: To determine, by a quantitative meta-analysis of randomized trials, the effectiveness of strategies to improve patient compliance with screening, referral, and clinic appointments for health services that are provided at the time of the visit. DATA SOURCES: Computerized searches of MEDLINE (1966 through 1990) were done using two search strategies: (1) (Patient Compliance OR Adhere* OR Dropout*) AND (Appointment*) AND (Screen* OR Follow* OR Refer*); and (2) (Patient Compliance OR Adhere* OR Dropout*) AND (Attend* OR Screen*) OR (Appointment*). A computerized search of PSYCHLIT was done with the terms Compliance AND Appointment*. In addition, the reference list of each retrieved article was reviewed and relevant citations retrieved. STUDY SELECTION: Only randomized trials with quantitative data concerning the effect of interventions to improve attendance at appointments for supervised administration of care were considered for detailed review. Studies of appointment keeping for self-administered treatments or tests were excluded. Two independent reviewers assessed each article for inclusion (kappa, for agreement, 0.66 for MEDLINE; 0.95 for PSYCHLIT) and validity (kappa, 0.62) using a priori criteria. Twenty-three (26%) of 88 relevant articles met all criteria. DATA EXTRACTION: Data on study populations, interventions, and outcomes were extracted and analyzed using pooled odds ratios (ORs). DATA SYNTHESIS: The average rate of compliance with appointments was 58%. Mailed reminders and telephone prompts were consistently useful in reducing broken appointments (OR, 2.2; 95% confidence interval [CI], 1.7 to 2.9; and OR, 2.9, CI, 1.9 to 4.3, respectively). An "orientation statement" (OR, 2.9; CI, 1.5 to 5.6), "contracting" with patients (OR, 1.9; CI, 1.04 to 3.5), and prompts from physicians (OR, 1.6; CI, 1.4 to 2.0) showed positive effects as well. CONCLUSIONS: In clinic settings where kept appointments can be an accurate measure of patient compliance with health care interventions, broken appointments can be reduced by mail, telephone, or physician reminders; orienting patients to the clinic; or contracting with patients.

Appointments and Schedules↗