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Biomedical subjects

R H Brook

Publications and source records attributed to R H Brook.

At least 91 records · Page 5Linked to original sources
PubMed1995

The appropriateness of chiropractic spinal manipulation for low back pain: a pilot study.

OBJECTIVE: Spinal manipulation is an efficacious therapy for some patients with low back pain (LBP). In this pilot study, we tested the feasibility of assessing the appropriateness of chiropractic spinal manipulation for patients with LBP. METHODS: Criteria for the appropriate and inappropriate use of spinal manipulation for low back pain were developed using the RAND/UCLA appropriateness method. Two separate expert panels, one multidisciplinary and one all chiropractic, each rated a comprehensive array of clinical scenarios for appropriateness. A random sample of practicing chiropractors was selected, and data were collected from ten randomly selected office records from each participating clinician. Assessment of the appropriateness for the use of spinal manipulation was made by comparing the care delivered with the appropriateness criteria determined by each expert panel. RESULTS: Eight of thirteen (62%) eligible chiropractors agreed to participate. For the remainder, by the multidisciplinary panel's criteria, 38% of care was appropriate and 26% of care was inappropriate. By the all-chiropractic panel's criteria, the same cases were judged 74% appropriate and 7% inappropriate. The two panel's appropriateness ratings were in agreement on 48% of all cases. CONCLUSIONS: In this geographic area, the rate of appropriate care is between 38% and 74% and the rate of inappropriate care is between 7% and 19%, depending on the criteria used to assess appropriateness. Data from other geographic areas of the U.S. will be needed before inferences to a larger population may be drawn, and we have demonstrated that such a study is feasible.

Adolescent↗
PubMed1995

Geographic variation in rates of selected surgical procedures within Los Angeles County.

OBJECTIVE: We explore the contribution of income and ethnicity to geographic variation in utilization of surgical procedures. DATA SOURCES/STUDY SETTING: We assessed the use of eight procedures from 1986 through 1988 among residents of Los Angeles County using data from the California Discharge Dataset, the 1980 census, and other secondary sources. Procedures chosen for evaluation were coronary artery bypass grafting (CABG), coronary artery angioplasty, permanent pacemaker insertion, mastectomy, simple hysterectomy, transurethral prostate resection (TURP), carotid endarterectomy, and appendectomy. STUDY DESIGN: The amount of inter-zip code variation for each procedure was first measured using various estimates including the analysis of variance coefficient of variation (CVA). Population-weighted multivariate regression analysis was used to model variation in age- and gender-adjusted rates of procedure use among 236 residential zip codes. PRINCIPAL FINDINGS: Highest-variation procedures were coronary artery angioplasty (CVA = .392) and carotid endarterectomy (CVA = .374). The procedures with the lowest degree of variation were cardiac pacemaker implantation (CVA = .194) and hysterectomy (CVA = .195). Variation was significantly related to income (carotid endarterectomy) and either African American or Latino zip code ethnicity for all procedures except pacemaker implantation. For all procedures except appendectomy, the direction of the effect was toward fewer procedures with lower income. However, the effect of African American or Latino population ethnicity varied. CONCLUSIONS: In this large urban area both population ethnicity and socioeconomic status are significantly associated with the geographic utilization of selected surgical procedures.

Age Factors↗
PubMed1994

The medical appropriateness of tympanostomy tubes proposed for children younger than 16 years in the United States.

OBJECTIVE: To describe the clinical reasons tympanostomy tubes are proposed for children and to assess their appropriateness. DESIGN: Analysis of data previously collected prospectively by a national utilization review (UR) firm during a two-step UR process to assess the medical appropriateness of tympanostomy tube placement. Nurses interviewed otolaryngologists' and primary care physicians' office staff to collect clinical data. For a randomly selected subsample of cases found inappropriate, we reviewed subsequent interviews of the otolaryngologists by physician reviewers, who looked for possible extenuating clinical circumstances or additional clinical data that might have changed the appropriateness category. SETTING: Otolaryngologists' practices from 49 states and the District of Columbia. PATIENTS: All 6611 children younger than 16 years who were insured by three clients of the UR firm and whose proposal to receive tympanostomy tubes were reviewed by this system from January 1, 1990, through July 31, 1991. The insurance companies in the study insured 5.6 million Americans at the time of the study. MAIN OUTCOME MEASURE: The medical appropriateness of tympanostomy tube surgery according to explicit criteria developed by an expert panel using the RAND/University of California-Los Angeles modified Delphi method. RESULTS: A total of 6429 (97%) of the cases were proposed for recurrent acute otitis media, otitis media with effusion, or both. Making generous clinical assumptions, 41% of the proposals for these reasons had appropriate indications, 32% had equivocal indications, and 27% had inappropriate ones. Considering the additional information available from the subsample review, the proportion appropriate was 42%, equivocal 35%, and inappropriate 23%. CONCLUSION: About one quarter of tympanostomy tube insertions for children in this study were proposed for inappropriate indications and another third for equivocal ones.

Adolescent↗
PubMed1994

Health care for black and poor hospitalized Medicare patients.

OBJECTIVE: To analyze whether elderly patients who are black or from poor neighborhoods receive worse hospital care than other patients, taking account of hospital effects and using validated measures of quality of care. DESIGN: We compare quality of care provided to insured, hospitalized Medicare patients who are black or live in poor neighborhoods as compared with others, using simple and multivariable comparisons of clinically detailed measures of sickness at admission, quality, and outcomes. SETTING: Two hundred ninety-seven acute care hospitals in 30 areas within five states. PATIENTS OR OTHER PARTICIPANTS: The sample includes a nationally representative sample of 9932 patients 65 years of age or older who lived at home prior to hospitalization for congestive heart failure, acute myocardial infarction, pneumonia, or stroke. INTERVENTIONS: This was an observational study. MAIN OUTCOME MEASURES: Processes of care, length of stay, instability at discharge, discharge destination, and mortality. RESULTS: Within rural, urban nonteaching, and urban teaching hospitals, patients who are black or from poor neighborhoods have worse processes of care and greater instability at discharge than other patients (P < .05). However, this worse quality is offset by patients who are black or from poor neighborhoods being 1.8 times more likely to receive care in urban teaching hospitals that have been shown to provide better quality of care (P < .001). Because these patients receive more of their care in better-quality hospitals, there are no overall differences in quality by race and poverty status. Death rates did not vary by race or poverty status. CONCLUSIONS: Quality of hospital care for insured Medicare patients in influenced both by the patient's race and financial characteristics and by the hospital type in which the patient receives care.

Black or African American↗
PubMed1994

Functional disability screening of ambulatory patients: a randomized controlled trial in a hospital-based group practice.

The authors conducted a randomized controlled trial of functional disability screening in a hospital-based internal medicine group practice. They assigned 60 physicians and 497 of their patients to either an experimental or a control group. Every four months the patients in both groups completed a self-administered questionnaire measuring physical, psychological, and social function. The experimental group physicians received reports summarizing their patients' responses; the control group physicians received no report. At the end of one year the authors found no significant difference between the patients of the experimental and control group physicians on any measure of functional status. Functional disability screening alone does not improve patient function.

Activities of Daily Living↗
PubMed1994

Effect of panel composition on appropriateness ratings.

Cholecystectomy is performed frequently and for relatively few indications. An all surgical panel agreed on more indications and fewer contra-indications for cholecystectomy than a mixed specialty panel but did not approve indications for patients with higher comorbidity. In mixed panels subspecialists (gastroenterologists) were more conservative than generalists and surgeons. Similar findings have been shown for carotid endarterectomy. Comparing the results of British and Israeli panels showed variations in rating appropriateness that indicate differences in approach between countries. We conclude that the composition of panels will influence the assessment of appropriateness.

Cholecystectomy↗
PubMed1994

Measuring the necessity of medical procedures.

This is a report on the extension of the concept of the appropriateness of a procedure to the necessity, or crucial importance, of that procedure. To state that a procedure is crucial means that withholding the procedure would be deleterious to the patient's health. Appropriateness and necessity ratings for six procedures were obtained using a modified Delphi panel process developed in earlier work. Panels were composed of practicing clinicians who were recognized leaders in their fields. The panels included both performers and nonperformers of the procedure under discussion. For most procedures and panelists, necessity was related to appropriateness, but was distinct from it. The proportion of indications for which the procedure was crucial varied in clinically consistent ways both among and within procedures. However, panelists did not achieve a consensus on necessity. Further research is suggested to refine the method to promote consensus and to validate further the ratings of necessity. In conclusion, necessity ratings can be used together with appropriateness ratings to address not only the overuse of procedures, but also to indicate limited access to care through underuse of procedures.

Angioplasty, Balloon, Coronary↗
PubMed1994

The effect of alternative case-mix adjustments on mortality differences between municipal and voluntary hospitals in New York City.

OBJECTIVE: This study investigated how mortality differences between groups of municipal versus voluntary hospitals are affected by case-mix adjustment methods. DATA SOURCES AND STUDY SETTING: We sampled about 10,000 random admissions from administrative data for patients hospitalized with each of six conditions in hospitals in New York City during 1984-1987. STUDY DESIGN: We developed logistic regression models adjusting for age and gender, for principal diagnosis, for "limited other diagnoses" (secondary diagnoses that were very unlikely to result from care received), for "full other diagnoses" (all secondary diagnoses irrespective of whether they might have been due to care received), for previous diagnoses, and for other variables. PRINCIPAL FINDINGS: For five of the six conditions, when the limited other diagnoses adjustment was used there was higher mortality in the municipal hospitals (p < .05), with 3.3 additional deaths/100 admissions for myocardial infarction, 1.2 for pneumonia, 8.3 for stroke, 2.8 for head trauma, and 0.8 for hip repair. However, when the full other diagnoses adjustment was used, differences remained significant only for stroke (4.3 additional deaths/100 admissions) and head trauma (1.3) (p < .05). CONCLUSIONS: Estimates of mortality differences between New York City municipal and voluntary hospitals are substantially affected by which secondary diagnoses are used in case-mix adjustment. Judgments of quality should not be based on administrative data unless models can be developed that validly capture level of sickness at admission.

Adolescent↗
PubMed1993

The appropriateness of hysterectomy. A comparison of care in seven health plans. Health Maintenance Organization Quality of Care Consortium.

OBJECTIVE: To develop and test a method for comparing the appropriateness of hysterectomy use in different health plans. DESIGN: Retrospective cohort study. SETTING: Seven managed care organizations. PATIENTS: Random sample of all nonemergency, non-oncological hysterectomies performed in the seven managed care organizations over a 1-year period. Patients who were not continuously enrolled in a plan for 2 years prior to their hysterectomy were excluded. MAIN OUTCOME MEASURES: Proportion of women undergoing hysterectomy in each plan for inappropriate clinical reasons according to ratings derived from a panel of managed care physicians. RESULTS: Overall, about 16% of women underwent hysterectomy for reasons judged to be clinically inappropriate. Only one plan had significantly more hysterectomies rated inappropriate compared with the group mean (27%, unadjusted). Adjusting for age and race did not affect the rankings of the plans and had little effect on the numeric results. CONCLUSION: The rates of inappropriate use of hysterectomies are similar to those for other procedures and vary to a small degree among health plans. This information may be useful to purchasers when they consider which health plans to offer their employees.

Adult↗
PubMed1993

Appropriateness of the use of cardiovascular procedures: a method and results of this application.

Resources available to provide adequate health care in western countries must compete with other priorities such as education and the environment. At the same time the allocation of health resources often does not correspond to the real needs of patients. We have developed a method that combines what is known in the literature with expert physician judgment to generate clinically valid appropriateness guidelines. The method involves a modified Delphi approach, including a detailed literature review, consultations with experts, and three rounds of panel ratings. Clinical scenarios, or indications, are rated appropriate, uncertain, or inappropriate. Appropriate means that the procedure is worth doing for the given indication if the health benefit exceeds the health risk. We have conducted panels relating to coronary procedures in four countries. Application of the indications to individual cases has demonstrated that the amount of inappropriate care is too large to be ignored. Dissemination of appropriateness results might take the form of public disclosure or as part of the physician/patient exchange to improve performance. Indications for which a procedure is frequently performed and which are rated uncertain should be considered to be the focus of controlled clinical trials.

Aged↗
PubMed1993

The appropriateness of use of coronary artery bypass graft surgery in New York State.

OBJECTIVE: To determine the appropriateness of use of coronary artery bypass graft surgery in New York State. DESIGN: Retrospective randomized medical record review. SETTING: Fifteen randomly selected hospitals in New York State that provide coronary artery bypass graft surgery. PATIENTS: Random sample of 1338 patients undergoing isolated coronary artery bypass graft surgery in New York State in 1990. MAIN OUTCOME MEASURES: Percentage of patients who had bypass surgery for appropriate, inappropriate, or uncertain indications; operative (30-day) mortality; and complications. RESULTS: Nearly 91% of the bypass operations were rated appropriate; 7%, uncertain; and 2.4%, inappropriate. This low inappropriate rate differs substantially from the 14% rate found in a previous study of patients operated on in 1979, 1980, and 1982. The difference in rates was not due to more lenient criteria but to changes in practice, the most important being that the fraction of patients receiving coronary artery bypass grafts for one- and two-vessel disease fell from 51% to 24%. Individual hospital rates of inappropriateness (0% to 5%) did not vary significantly. Rates of appropriateness also did not vary by hospital location, volume, or teaching status. Operative mortality was 2.0%; 17% of patients suffered a complication. Complication rates varied significantly among hospitals (P < .01) and were higher in downstate hospitals. CONCLUSIONS: The rates of inappropriate and uncertain use of coronary artery bypass graft surgery in New York State were very low. Rates of inappropriate use did not vary significantly among hospitals, or according to region, volume of bypass operations performed, or teaching status.

Coronary Artery Bypass↗
PubMed1993

The appropriateness of use of percutaneous transluminal coronary angioplasty in New York State.

OBJECTIVE: To determine the appropriateness of use of percutaneous transluminal coronary angioplasty (PTCA) in New York State. DESIGN: Retrospective randomized medical record. SETTING: Fifteen randomly selected hospitals in New York State that provide PTCA. PATIENTS: Random sample of 1306 patients undergoing PTCA in New York State in 1990. MAIN OUTCOME MEASURES: Percentage of patients who underwent PTCA for indications rated appropriate, uncertain, and inappropriate. RESULTS: The majority of patients received PTCA for chronic stable angina, unstable angina, and in the post-myocardial infarction period (up to 3 weeks). Fifty-eight percent of PTCAs were rated appropriate; 38%, uncertain; and 4%, inappropriate. The inappropriate rate varied by hospital from 1% to 9% (P = .12); the uncertain rate, from 26% to 50% (P = .02); and the combined inappropriate and uncertain rate, from 29% to 57% (P < .001). There was no difference in appropriateness when the institutions were grouped by volume (fewer than 300 procedures annually or at least 300 procedures annually), location (upstate vs downstate), or by teaching status. CONCLUSIONS: Few PTCAs were performed for inappropriate indications in New York State. However, the large number of procedures performed for indications that were rated uncertain as to their net benefit requires further study and justification at both clinical and policy levels.

Adult↗
PubMed1993

The appropriateness of use of coronary angiography in New York State.

OBJECTIVE: To determine the appropriateness of use of coronary angiography in New York State. DESIGN: Retrospective randomized medical record review. SETTING: Fifteen randomly selected hospitals in New York State that provide coronary angiography. PATIENTS: Random sample of 1335 patients undergoing coronary angiography in New York State in 1990. MAIN OUTCOME MEASURES: Percentage of patients who underwent coronary angiography for appropriate, uncertain, or inappropriate indications. RESULTS: Approximately 76% of coronary angiographies were rated appropriate; 20%, uncertain; and 4%, inappropriate. Inappropriate use did not vary significantly between the elderly (ie, patients aged 65 years and older) and nonelderly, 4.7% and 3.9%, respectively. Although the rate of inappropriate use varied from 0% to 9% among hospitals, the difference was not significant. Rates of appropriateness did not vary by hospital location (upstate vs downstate), volume (fewer than 750 procedures annually or at least 750 procedures annually), teaching status, or whether revascularization was available at the hospital where angiography was performed. CONCLUSIONS: Although coronary angiography was used for few inappropriate indications in New York State, many procedures were performed for uncertain indications in which the benefit and risk were approximately equal or unknown.

Adult↗