Search PubMed⌕ Search

Biomedical subjects

R L Braham

Publications and source records attributed to R L Braham.

At least 37 records · Page 2Linked to original sources
PubMed1986

Resuscitation: how do we decide? A prospective study of physicians' preferences and the clinical course of hospitalized patients.

Physicians have to address the question of the measures to be employed in the event that a patient's condition deteriorates after admission to the hospital. To identify the information that physicians use in making such decisions, all 604 patients admitted to the medical service during a one-month period were studied. The patient's age and residents' estimates of the patient's long-term prognosis and ability to function were the three primary factors that correlated with intervention preferences. When illness severity, the reason for admission, comorbidity, and poor function were taken into account, mortality and morbidity rates did not differ between patients for whom full vs not-full intervention was favored. Apart from differential rates of admission to critical care units, there were no important differences in the care, course, or mortality of patients for whom less than full intervention was initially favored. Suggestions that physicians should discuss resuscitation with all or most patients who may die are unrealistic. A more prudent strategy is to discuss the issue with patients whose hospital course is marked by a steady deterioration.

Age Factors↗
PubMed1986

Closing the clinics: would it close the teaching hospital?

To improve their overall financial position, many teaching hospitals have considered decreasing the size of their clinics. To assess the effect this would have on the inpatient service, the medical ward service of The New York Hospital was studied during the 1981 to 1982 academic year. In 50 percent of hospitalizations, patients were enrolled in the clinic system before admission. In an additional 19 percent of hospitalizations, patients had either been previously seen in the emergency room or hospitalized at this institution, but never seen in a clinic. In the remaining 31 percent of hospitalizations, the patient's admission was the first contact with the institution. This group of "new" patients simply replaced the patients who died (14 percent) or were lost to the system through transfer to chronic-care facilities (11 percent) or referral to community physicians (7 percent). Twenty percent of patients discharged to a clinic were readmitted during the study year as opposed to only 3 percent of patients who were transferred to chronic-care facilities or referred to community physicians. The clinic system is the principal source of referral into the ward service and the most effective mechanism for insuring that a patient needing rehospitalization returns to the hospital. It is concluded that major reduction of clinic size will result in severe contraction of the inpatient service.

Health Facilities↗
PubMed1986

Assessing illness severity: does clinical judgment work?

Accurate classification of clinical severity is important for interpreting casemix in clinical studies and for stratifying patients for clinical trials. To evaluate whether clinical judgment might be an effective method of estimating severity, all 604 patients admitted to the medical service in a one month period were rated at the time of admission by the responsible resident as to how sick they were. Within the 13 comorbid disease groups, and within the 15 basic categories of reason for admission, the physicians' severity ratings were the most significant predictor of in-hospital mortality. Death rates rose from 0% in those rated as not ill, to 2% in the mildly ill, to 6% in the moderately ill, to 23% in the severely ill, and to 58% in those rated as moribund (p less than 0.001). Sickness ratings also predicted time to death: mildly ill patients died after prolonged hospitalizations, while the moribund died shortly after admission. The patients' age, sex, race, the number of comorbid diseases or problems did not predict mortality. Patients with serious comorbidity (metastases, AIDS, or cirrhosis) had a higher mortality rate than other patients (p less than 0.001); however, the severity ratings predicted outcomes within this group (p less than 0.001) as well as among those without such serious comorbidity (p less than 0.001). Patients who were admitted with acute neurologic (p less than 0.05) or acute cardiovascular (p less than 0.01) events did have an independently worse prognosis. In conclusion, physicians' estimates or sickness provided an accurate estimate of illness severity, with mortality rates that essentially tripled from one stratum to the next. Clinical judgment may suffice to classify the clinical severity of patients at the time of enrollment in prospective trials and can provide a useful method of controlling for casemix.

Acute Disease↗
PubMed1982

Effects of sample selection on the coincidence of hypertension and diabetes.

The occurrence of both hypertension and diabetes in patients at a general medical clinic at a university center and within a work-site community has been determined. In addition, the course of such patients for four years following presentation has been observed. The combination of hypertension and diabetes appeared more frequently, was expressed by greater severity, and coincided with a higher observed morbidity among the hospital clinic patients than among the work-site population. These findings regarding the prevalence and natural history of these coexistent diseases reaffirm that the source of a selected population can significantly affect the pattern of disease expression observed and, therefore, limit the capacity to extrapolate results from one population to another.

Blood Glucose↗
PubMed1979

Physician awareness of economic factors in clinical decision-making.

Physicians' awareness of economic factors in clinical decision-making at one large urban university medical center was studied by a 50-item questionnaire. Their dollar estimates were considered correct if within +/- 20 per cent of the true October 1976 figure. Eighty-one per cent of the house staff and all of the attendings correctly estimated the daily semi-private room rate, but only 15 per cent of each group correctly estimated the charge for a serum potassium. Roughly half of the questions concerning various third-party benefit plans were answered correctly. These results are consistent with those of the few previous studies. If the findings are generally applicable, they may suggest that a directed teaching program in simple economic facts and principles may be useful at all levels of physician training.

Attitude of Health Personnel↗
PubMed1978

Nutrition and its importance in dental health.

Balanced and good nutrition is necessary for the growth, development, and maintenance of the dental and oral structures. Nutrition counseling is, therefore, of paramount importance. The physician who is aware of the factors that cause dental and oral disease will be in a position to intercept the progress of dental caries caused by an incorrect diet. This paper considers the significance of highly cariogenic foods, particularly sucrose, and the difficulties of removing it from the diet. A method of conducting a diet survey is presented. The importance of fluoridation is discussed, with elaboration of the advisable prescribing techniques for fluoride supplementation of the diet. Cooperation between physician and dentist is important in order to insure the prevention of dental disease.

Adolescent↗
PubMed1977

Management of dental trauma in children and adolescents.

The emergency treatment of dental trauma has traditionally been handled in the emergency rooms of medical centers, or in the dental office. With increasing emphasis on comprehensive medical care, and the tendency of more recent graduates to locate in rural areas, there is a growing trend for physicians to be involved in providing emergency care for traumatic injuries to the dental and oral tissues. The authors discuss the etiology of dental trauma and the highly psychologic impact of such injuries upon the patient and parents. Techniques for prevention and a comprehensive plan are outlined for systematic history taking and examination. A classification of eight levels of dental injuries (5), techniques for the emergency, and subsequent restorative care are given. Emphasis is placed upon immediate care which can, if necessary, be provided by the physician pending referral to a dentist.

Child↗
PubMedDate not supplied

Diagnostic test restraint and the specialty consultation.

OBJECT: To assess the effect consultants had on the diagnostic process in the management of patients admitted to the medical service of a university hospital. DESIGN: Cohort study utilizing prospective evaluation by residents, retrospective chart review, and direct communication with the patient, a family member, or the patient's physician one year after admission to the hospital. SETTING: The medical inpatient service of an urban university hospital. PATIENTS: The 580 patients admitted to the medical service during one month in 1984 for whom complete data were available. MAIN RESULTS: Sixty-three percent of the patients had consultations. Seventy percent (198/284) of the patients admitted by generalists had consultations, while 57% (170/296) of the patients admitted by subspecialists had consultations. Of the 1,422 major diagnostic tests performed on these patients, 504 (35%) were first recommended by consultants, and the consultants recommended cancellation of only ten major diagnostic tests. Patients who were seen by consultants had a length of stay that was more than double that of patients not seen by consultants. Consultation was associated with prolonged stay when patients were stratified by important clinical variables and remained an important independent factor in a multivariate model. The prolongation of hospitalization was principally due to delays in scheduling and interpreting sophisticated tests recommended by the consultants. When stratified into prognostically similar clinical groupings, there was no significant difference in in-hospital mortality between patients seen and those not seen by a consultant. CONCLUSION: Efforts to foster diagnostic restraint in the management of hospitalized patients should be broadened to include attention to the specialty consultation process.

Clinical Laboratory Techniques↗
PubMedDate not supplied

Dental care for the handicapped-ambulatory and hospital considerations.

Estimates of the incidence of handicap are totally confused, and there is little coordination in provision of information as to types of disability. The author attempts to distinguish between the various handicaps from a standpoint of dental services delivery. Some of the psycho-social problems of the handicapped are discused in relation to dental care, and distinction is made between those who can be treated on an ambulatory basis and those who have to be hospitalized. Guidelines are established for each of the aforementioned techniques in order to make the experience more bearable for patient, parent and dentist.

Aged↗
PubMedDate not supplied

Audit and feedback as a cost-effective strategy.

Despite more than a decade of cost containment initiatives, medical care costs continue to rise at levels that concern both policy makers and third-party payers. Various explanations can be offered for this apparent lack of success. A crucial factor in the opinion of the authors, Robert Braham, M.D., and Hirsch Ruchlin, Ph.D., is the way in which cost containment is approached. Braham and Ruchlin describe how their organization successfully tackled this concern.

Cost Control↗