Biomedical subjects
R H Fletcher
Publications and source records attributed to R H Fletcher.
The effects of blinding on the quality of peer review. A randomized trial.
Peer reviewers are blinded sometimes to authors' and institutions' names, but the effects of blinding on review quality are not known. We, therefore, conducted a randomized trial of blinded peer review. Each of 127 consecutive manuscripts of original research that were submitted to the Journal of General Internal Medicine were sent to two external reviewers, one of whom was randomly selected to receive a manuscript with the authors' and institutions' names removed. Reviewers were asked, but not required, to sign their reviews. Blinding was successful for 73% of reviewers. Quality of reviews was higher for the blinded manuscripts (3.5 vs 3.1 on a 5-point scale). Forty-three percent of reviewers signed their reviews, and blinding did not affect the proportion who signed. There was no association between signing and quality. Our study shows that, in our setting, blinding improves the quality of reviews and that research on the effects of peer review is possible.
Three ways of knowing in clinical medicine.
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The costs of clinical trials.
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The treatment of patients with asthma by specialists and generalists.
The authors investigated possible differences between specialists and generalists in the intensity with which they treat patients with asthma by studying the care of 283 patients between the ages of six and 40 provided by 13 allergists and 40 randomly selected physicians in two primary care specialties: pediatrics and family practice. After excluding patients with more than one physician, allergists' patients were nearly identical to primary care physicians' patients in the frequency and duration of symptoms, and they had a similar number of asthma-related emergency room visits in the previous year and asthma-related hospitalizations in the preceding 3 years. The allergists treated their patients significantly more intensively than did the primary care physicians. Sixty-two percent of allergists' patients had received oral corticosteroids in the preceding year compared with 30% of primary care patients (P less than 0.001). More of the allergists' patients had received oral corticosteroids throughout the year (9% vs. 0%, respectively, P less than 0.01). They were also more likely to have used corticosteroid inhalers (46% vs. 19%) and a greater number of asthma medications (mean = 2.8 vs. 1.3). In a separate survey of the same physicians, using clinical vignettes, the allergists were more likely to prescribe corticosteroid tablets and inhalers. These findings suggest that specialists and generalists differ in the intensity with which they treat patients with asthma and cannot be explained by patient selection or severity differences.
Accuracy of women's self-report of their last Pap smear.
We compared interview data and physician records on when women last had a Pap smear in a sample of 98 rural Black women. We found 20 per cent of women could not accurately report on whether a Pap smear had been done within three years (sensitivity = 0.95, specificity = 0.47). Source of gynecological care and perceived barriers to obtaining a Pap smear but not education were associated with inaccurate reports. Self-report may be a misleading measure of Pap smear screening in comparable groups of women.
Patient compliance with therapeutic advice: a modern view.
Considering all the hurdles between the advice to take medication and the taking of it, that patients comply as well as they do is remarkable. It is all the more remarkable when physicians ask patients who are well to take costly and unpleasant medications or diets (for example, for hypertension or hyperlipidemia), day after day, to prevent low-probability events many years in the future. The problem of noncompliance will remain with us; it is, after all, part of the human condition. It will not be, and probably should not be, conquered altogether. Because many prescribed medications are not powerful over and above their placebo effects, noncompliance often does no harm. When patients refuse to do what physicians advise, as expressions of their own informed free will, it is also unclear that harm has been done. What we, as a health-care community, should be most concerned about is the noncompliance that arises for other, less ambiguous reasons: failure of communication or lack of opportunity. The main issue, as I see it, is to find ways to reduce unnecessary and harmful noncompliance--that is, noncompliance that occurs because of misunderstanding about what has been suggested and what is at stake, or because of poverty and other logistic problems. Therefore, I have emphasized those aspects of compliance in this review. Compliance with medical advice is far too complex, especially these days, to reduce to a simple yes-no dichotomy. A great deal of wisdom is called for, both on the patient's and on the physician's side, when medical advice is given.
Accuracy of chart diagnoses of alcoholism in patients with a history of psychosis.
At two psychiatric clinics, 76 patients with a history of psychosis were interviewed by a researcher blind to the presence or absence of a chart diagnosis of alcoholism. Another person blind to research diagnosis ascertained the chart diagnosis of alcoholism. The lifetime prevalence of alcoholism, according to a structured research interview, was 45% at a mental health center, and 29% at a teaching hospital clinic. When compared to the lifetime prevalence of alcoholism, as determined by the research interview, chart diagnoses had sensitivities of 21% and 20%, respectively; specificity was 100% at both sites. Psychiatric chart diagnoses are not sensitive indicators of psychiatric patients' alcoholism.
Debt, moonlighting, and career decisions among internal medicine residents.
In the study reported here, medical residents were surveyed to determine their patterns of educational indebtedness, the effects of debt on their decisions about training and career, the frequency with which they begin making loan payments during training, the extent to which they moonlight and the reasons for doing so, and their opinions about the effects of moonlighting on house staff training. A total of 223 residents from four residency programs were surveyed; 181 responded. Most (86 percent) had educational debt (mean = $20,500), and more than half of those with debt were making loan payments. Forty percent of the residents moonlighted, and moonlighting was related to the presence of educational debt, monthly loan payments, and number of dependents.
Predicting school failure and assessing early intervention with high-risk children.
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The impact of echocardiographic results on treatment decisions for patients suspected of mitral valve prolapse.
Although echocardiography is frequently ordered in ambulatory settings for patients suspected of mitral valve prolapse (MVP), its impact on their subsequent management is unknown. We studied the relationship between the results of echocardiography for outpatients suspected of MVP, and two frequent medical decisions: treatment with beta blockers and the recommendation of antibiotic prophylaxis to prevent bacterial endocarditis. A medical record audit was performed on 274 outpatients referred to a university medical center echocardiography laboratory to rule out MVP. Although echocardiographic evidence for MVP significantly influenced the decision to recommend antibiotic prophylaxis (P less than 0.001), symptoms were more likely to be used as indications for beta-blocker therapy in patients suspected of the condition. We conclude that echocardiographic results are used for recommending antibiotic prophylaxis to outpatients suspected of MVP, but not for beta-blocker therapy.
Seeking good care in an outpatient setting.
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Confounding and the dementia of schizophrenia.
Schizophrenia is often said to cause dementia, and previous studies have found cognitive impairment to be associated with schizophrenia. It is possible, however, that other causes of dementia and the study of patients not representative of all schizophrenics have contributed to these findings. The neuropsychological test scores of 26 schizophrenic outpatients were compared to those of 82 other patients with a history of psychosis. After other known causes of cognitive impairment were controlled for, the schizophrenics were not found to have cognitive impairment when compared to the other patients.
Families of elderly stroke patients. Effects of home care.
Elderly stroke patients and their families were studied to determine the health effects of providing home care on family caregivers, whether or not caregivers actually providing care in the home experience different effects than caregivers whose family members live in nursing homes, and factors associated with any observed deleterious effects of caregiving. One hundred forty-seven stroke patients were eligible for study. Of these, 101 were available for follow-up; 89 family caregivers were interviewed (88%). Caregivers reported both positive and negative effects of providing home care. When actual home caregivers were compared with potential caregivers (those with family members in institutions), no differences in effects were seen. The relationship between each of three health effects (general, social, and emotional) and patient and caregiver attributes was explored. No factors were found to be related to poorer perceived general health. Dependent patient functional status and additional life stress were both associated with diminished social activity and emotional ill-health. In the latter instance, insufficient social activity and help from family were additional risk factors. If policy is going to advocate home care, its consequences for family caregivers must be known.
Carcinoembryonic antigen.
The level of carcinoembryonic antigen (CEA) is often elevated in the serum of patients with cancer. This article reviews the clinical usefulness of this observation. Carcinoembryonic antigen is not useful for detecting asymptomatic cancer; its sensitivity and specificity are not high, particularly for early stages of disease, so in populations with low prevalence of disease there are many false-positive and false-negative results. Similarly, the antigen level cannot, by itself, provide enough diagnostic certainty to confirm or rule out suspected cancer. For some cancers, antigen levels at the time of diagnosis provide more precise prognosis than staging alone, but this information does not lead to more effective treatment. Serial measurement of CEA levels after surgery in patients with colorectal cancer can detect recurrences early, but few lives can be saved by this approach. Thus, CEA assays provide accurate information about some aspects of cancer but rarely lead to better outcomes for patients.
Is there a dementia of schizophrenia?
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Mitral valve prolapse. Disease or illness?
Mitral valve prolapse (MVP) is a common condition that is believed to be responsible for numerous symptoms and potentially serious complications. To determine whether symptoms and functional impairment are related to MVP itself, we studied 274 outpatients referred to an echocardiography laboratory for suspicion of MVP. The age, sex, and symptoms at the time of echocardiography were similar among patients with and without evidence of MVP. After 14 to 36 months, 158 patients were interviewed. There was a high rate of dysfunction, but echocardiographic evidence of MVP was not associated with disability, health care utilization, or reported symptoms. The results of this study suggest that symptoms and dysfunction are not related to the presence of MVP by echocardiography. The functional impairment that is seen in patients suspected of MVP may be caused by other factors.
How can we know when we are doing more good than harm for a terminally-ill cancer patient?
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