Search PubMed⌕ Search

Biomedical subjects

R M Tamblyn

Publications and source records attributed to R M Tamblyn.

At least 19 recordsLinked to original sources
PubMed1997

Use of standardized patients to assess between-physician variations in resource utilization.

CONTEXT: As medical costs are increasingly being scrutinized, there is heightened interest in defining variations in physician behavior in clinical settings. OBJECTIVE: To evaluate if standardized patient (SP) technology is a reliable and feasible method of studying interphysician variations in test ordering, referral requests, prescribing behavior, and visit costs. DESIGN: The study was conducted with blinded SP visits to family medicine and internal medicine residents, university-affiliated family physicians, and community-based family physicians. Resource utilization and visit costs were assessed using test requisitions, consult requests, and prescriptions that were collected by the SPs. SETTING: Physicians' offices in ambulatory care, hospital-based clinics and in the community. PARTICIPANTS: Four persons (aged 57-77 years) trained to simulate having osteoarthritis of the hip. In one simulation, the patient had gastropathy due to nonsteroidal anti-inflammatory drug use, and in the other, the patient sought therapy for hip discomfort. MAIN OUTCOME MEASURES: Reliability of cost estimates of physician services, tests, consultations, prescriptions, and total visits and test-ordering behavior for nonsteroidal anti-inflammatory gastropathy. RESULTS: Overall, 112 (63%) of the physicians who were sent invitations to the study agreed to participate. Of 312 total SP visits conducted over a 1-year period, unblinding due to SP detection occurred on 36 occasions (11.5%). Reliable cost estimates of physician services, tests, and consultations, and moderately reliable estimates of total visit costs, were obtained with 4 visits per practicing physician and with 2 visits per resident. There were extreme variations in total visit costs generated by the study physicians. A small number of physicians had a major impact on this variability. CONCLUSION: Standardized patient technology provides a reliable, feasible method to assess variations in resource utilization between physicians.

Diagnosis-Related Groups↗
PubMed1997

Defining inappropriate practices in prescribing for elderly people: a national consensus panel.

OBJECTIVE: To develop a consensus-based list of inappropriate practices in prescribing for elderly people. DESIGN: Mail survey of a 32-member national panel. SETTING: Academic medical centres across Canada. PARTICIPANTS: Thirty-two specialists selected arbitrarily, including 7 clinical pharmacologists, 9 geriatricians, 8 family practitioners and 8 pharmacists. OUTCOME MEASURES: Consensus that the practice would introduce a substantial and significant increase in the risk of serious adverse effect and is common enough that its curtailment would decrease morbidity among elderly people, ranking of clinical importance of the risk, and availability of equally or more effective and less risky alternative therapy. RESULTS: The 32-member national panel developed a list of 71 practices in prescribing for elderly people and rated the clinical significance of each on a scale of 1 (not significant) to 4 (highly significant). The practices in prescribing identified fell into 3 categories: drugs generally contraindicated for elderly people, drug-disease interactions and drug-drug interactions. The mean significance rating was greater than 3 for 39 practices. For each practice, alternative therapies were recommended. There was surprising congruence among the specialists on the significance rating and the suggested alternative therapies. CONCLUSION: The authors have developed a valid, relevant list of inappropriate practices in prescribing for elderly people, to be used in a practice-based intervention study.

Aged↗
PubMed1997

Characteristics of physicians who frequently prescribe long-acting benzodiazepines for the elderly.

Long-acting benzodiazepines (LABZs) are relatively contraindicated for elderly patients because they increase the risk of impaired cognitive function, falls, and hip fractures. The purpose of this study was to identify the characteristics of physicians who frequently prescribe LABZs for elderly patients. The authors examined the prescribing profile of 4,976 physicians who saw at least 20 elderly Quebec medicare registrants in 1990. Physicians who frequently prescribed LABZs for their elderly patients were more likely to have graduated before 1979, to be general practitioners as opposed to specialists, to practice in long-term care settings, and to have graduated from a medical school in Quebec as opposed to other schools in Quebec, in other provinces, or in other countries. The authors have identified several characteristics of physicians who frequently prescribed LABZs for the elderly. Strategies to improve prescribing in this field should target this group of physicians.

Aged↗
PubMed1997

[Characteristics of physicians prescribing more psychotropic drugs to women than to men].

In industrialized countries, gender differences observed in health condition and the use of medical services appear insufficient to explain a greater consumption of psychotropic drugs in women than men. The authors have tested the hypothesis that physician prescribing patterns largely explains this observation. They demonstrate, using data from the Régie de l'assurance maladie du Québec for people aged 65 and over, that physicians' sociodemographic and practice characteristics are significantly associated with the percentage of men and women who receive a psychotropic drug prescription in their practice.

Adult↗
PubMed1996

Do too many cooks spoil the broth? Multiple physician involvement in medical management of elderly patients and potentially inappropriate drug combinations.

OBJECTIVES: To determine (a) whether the risk of a potentially inappropriate drug combination (PIDC) increases with the number of physicians involved in the medical management of an elderly patient and (b) whether the risk of a PIDC is reduced if a patient has a single primary care physician or a single dispensing pharmacy, or both. DESIGN: Cross-sectional retrospective provincial database study. PARTICIPANTS: A regionally stratified random sample of 51,587 elderly medicare registrants in Quebec who (a) visited at least one physician in 1990, (b) were not living in a health care institution for the entire year and (c) had been dispensed at least one prescription for a cardiovascular drug, a psychotropic drug or a nonsteroidal anti-inflammatory drug (NSAID). OUTCOME MEASURES: Information on all physician visits and drugs dispensed during 1990. Physician claims were used to identify the number of physicians involved in a patient's management and whether the patient had one primary care physician. Prescription claims were used to identify the number of PIDCs, prescribing physicians and dispensing pharmacies. RESULTS: The prevalence of PIDCs ranged from 4.0% (among those in the NSAID group) to 20.3% (among those in the psychotropic drug group). Of the PIDCs identified, 17.6% to 25.8% resulted from contemporaneous prescribing by different physicians. The number of prescribing physicians was the most important risk factor for a PIDC in all drug groups (odds ratio [OR] 1.44 to 1.71). The presence of a single primary care physician lowered the risk for cardiovascular and psychotropic PIDCs (OR 0.70 and 0.79 respectively) but not for NSAID PIDCs (OR 0.94). The use of a single dispensing pharmacy lowered the risk of a PIDC in all drug groups (OR 0.68 to 0.79). CONCLUSION: The greater the number of physicians prescribing medications for an elderly patient, the greater is the risk that the patient will receive a PIDC. A single primary care physician and a single dispensing pharmacy may be "protective" factors in preventing PIDCs.

Aged↗
PubMed1996

Who should rate candidates in an objective structured clinical examination?

PURPOSE: To determine who is the better rater of history taking in an objective structured clinical examination (OSCE): a physician or a standardized patient (SP). METHOD: During the 1991 pilot administration of an OSCE for the Medical Council of Canada's qualifying examination, five history-taking stations were videotaped. Candidates at these stations were scored by three raters: a physician (MD), an SP observer (SPO), and an SP rating from recall (SPR). To determine the validity of each rater's scores, these scores were compared with a "gold standard", which was the average of videotape ratings by three physicians, each scoring independently. Analysis included both correlations with the standard and a repeated-measures analysis of variance (ANOVA) comparing raters' mean scores on each station with mean scores of the gold standard. RESULTS: Ninety-one videotapes were scored by the "gold-standard" physicians. Correlations with the standard showed no clear preference for MD, SPO, or SPR raters. ANOVAs revealed significant differences from the standard on three stations for the SPR, two stations for the SPO, and one stations for the MD. CONCLUSIONS: An MD rater is less likely to differ from a standard established by a consensus of MD ratings than are SP raters rating from recall. If an MD cannot be used, an SP observer is preferable to an SP rating from recall.

Analysis of Variance↗
PubMed1996

Exposure to varying levels of contaminants and symptoms among workers in two office buildings.

OBJECTIVES: We hypothesized that exposure to contaminants would be associated with symptoms reported by office workers. METHODS: In two mechanically ventilated office buildings in. Montreal, the outdoor air supply was manipulated for 6 weeks, while symptoms were reported and environmental parameters were measured at multiple sites. RESULTS: Contaminant concentrations varied considerably, in part related to experimental changes in outdoor air supply. Eye symptoms were reported with higher dust and with higher concentrations of nitrogen dioxide. Mucosal symptoms were increased with higher TVOCs, higher nitrogen dioxide, and higher total contaminant load. Systemic symptoms were associated with higher dust levels. CONCLUSIONS: Symptoms reported by the workers were associated with increased concentrations of several contaminants and a summary measure of all contaminants.

Air Pollution↗
PubMed1994

Questionable prescribing for elderly patients in Quebec.

OBJECTIVE: To estimate the prevalence of questionable and rational high-risk prescribing among elderly people of the three drug groups most commonly implicated in drug-related illness: cardiovascular drugs, psychotropic drugs and nonsteroidal anti-inflammatory drugs (NSAIDs). DESIGN: Retrospective prevalence study; all prescription and billing records for the period Jan. 1 to Dec. 31, 1990, for the study sample were retrieved from the relevant provincial databases of the Régie de l'assurance-maladie du Québec. SETTING: Quebec. PARTICIPANTS: Regionally stratified random sample of 63,268 elderly medicare registrants who made at least one visit to physician in 1990 and were not living in a health care institution for the entire year. MAIN OUTCOME MEASURE: Prescription information was examined for three types of high-risk prescribing: rational and questionable drug combinations, excessive treatment duration and drugs relatively contraindicated for use in elderly people. RESULTS: Overall, 52.6% of the patients experienced one or more events of high-risk prescribing, and 45.6% experienced at least one that was questionable. High-risk prescribing was most prevalent for psychotropic drugs, and questionable prescribing was more frequent than rational prescribing in this drug group. An estimated 30.8% of the total elderly population in Quebec received benzodiazepines for more than 30 consecutive days, 12.9% received a long-acting benzodiazepine, and 13.0% received a questionable high-risk psychotropic drug combination. The prevalence of high-risk prescribing was higher among the women than among the men and increased with age until 75 to 84 years. There were significant unexplained differences between regions in the regional prevalence of high-risk prescribing, particularly of psychotropic drugs. CONCLUSION: The prevalence of questionable high-risk prescribing, especially of psychotropic drugs, is substantial among elderly people. This may be a potentially important and avoidable risk factor for drug-related illness in elderly people.

Age Factors↗
PubMed1993

Compliance and cognitive function: a methodological approach to measuring unintentional errors in medication compliance in the elderly. McGill-Calgary Drug Research Team.

This study describes the development of a method for assessing the relationship between cognitive function, comprehension, and compliance with medication. We assessed multiple aspects of cognitive performance, medication planning ability, and medication compliance in a convenience sample of 20 outpatients. Using a test battery that measured mental status, attention/concentration, memory function, and motor strength and dexterity, we found that: (1) standard mental status assessment was poorly correlated with memory function; (2) attention/concentration and memory were related to medication planning accuracy; (3) motor dexterity and strength were related to the ability to access medications; and (4) visual perception and memory were the skills most strongly correlated with medication compliance. Findings suggest that aspects of attention/concentration, visual and verbal memory, and motor function which are untapped by simple mental status assessment are related to medication access, planning, and compliance in elderly patients.

Aged↗
PubMed1992

The feasibility of using a double blind experimental cross-over design to study interventions for sick building syndrome.

Methodological problems have limited scientific investigation of the causes of and solutions for sick building syndrome. The feasibility of using an experimental double blind cross-over study to resolve many of these methodological problems was assessed in a pilot study. The experimental intervention was to vary the amount of outdoor air from 10 cubic feet per minute per person (cfmpp) to 20 cfmpp or 50 cfmpp by central manipulation of the building heating, ventilation and air-conditioning (HVAC) system. Over 6 consecutive study weeks, 2 trials of rates were administered in random order. Study subjects and investigators of the study were blinded to intervention sequence. Unblinding, office environment rating and symptom occurrence were measured weekly. Of 305 eligible workers, 254 participated. Problems were encountered in delivering the lowest dose of ventilation due to building leakage. The prevalence of symptoms diminished steadily over the 6 study weeks, time trends which could be controlled by recommended design modifications. Blinding to the intervention was successfully maintained. Weekly non-response did not introduce a response bias but reduced the number of subjects available for analysis by one-third for each trial. We conclude that this design, with certain modifications, is feasible to evaluate many proposed interventions for sick building syndrome.

Adult↗
PubMed1991

The accuracy of standardized patient presentation.

The accuracy of standardized patient clinical problem presentation was evaluated by videotape rating of a random sample of 839 student-patient encounters, representing 88 patients, 27 cases and two university test sites. Patient-student encounters were sampled from a collaborative inter-university final-year clinical examination of fourth-year medical students which was conducted at the University of Manitoba and Southern Illinois University in 1987 and 1988. The accuracy, replicability and portability of standardized patient cases were evaluated. The average accuracy of patient presentation was 90.2% in 1987 and 93.4% in 1988. Perfect accuracy scores were obtained by 15 patients; however, 11 patients had average scores below 80% with the accuracy of presentation in some encounters being as low as 30%. There were significant differences in the accuracy score achieved by patients trained together for the same case in 6 of 35 possible comparisons. There was also a systematic trend for patients trained at Southern Illinois to be more accurate in their presentation than patients trained at the University of Manitoba. These differences were significant in 5 of the 15 cases used in the examination.

Clinical Clerkship↗