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Biomedical subjects

R S Dittus

Publications and source records attributed to R S Dittus.

49 records · Page 3Linked to original sources
PubMed1988

The care of elderly patients with hip fracture. Changes since implementation of the prospective payment system.

We hypothesized that the care provided to elderly patients with hip fracture in community hospitals has changed since the implementation of prospective payment systems (PPS) in 1983. We reviewed records of elderly patients admitted with hip fracture to a large community hospital from 1981 to 1986. During that period, the mean length of hospitalization decreased (from 21.9 to 12.6 days; P less than 0.0001), inpatient physical therapy decreased (from 7.6 to 6.3 sessions; P less than 0.04), and the maximal distance walked before discharge fell (from 27 to 11 m [93 to 38 ft]; P less than 0.0001). Concomitantly, the proportion of patients discharged to nursing homes rose (from 38 to 60 percent; P less than 0.0001), as did the proportion remaining in nursing homes one year after hospitalization (from 9 to 33 percent; P less than 0.0001). Neither in-hospital mortality nor one-year mortality changed significantly. As compared with beneficiaries of conventional Medicare after the implementation of PPS, HMO enrollees had shorter hospitalizations (7.3 vs. 14.0 days; P less than 0.0001), received less physical therapy (3.5 vs. 7.1 sessions; P less than 0.0001), walked shorter distances at discharge (3 vs. 13 m [11 vs. 44 ft]; P less than 0.01), and were more frequently transferred to nursing homes (83 vs. 55 percent; P less than 0.01). One year later, however, fewer HMO patients remained in nursing homes (16 vs. 35 percent; P less than 0.07). We conclude that since the implementation of PPS, hospitals have reduced the amount of care given to patients with hip fracture and have shifted much of the rehabilitation burden to nursing homes. The increase in the number of such patients remaining in nursing homes one year after the fracture suggests that the overall quality of care for these patients may have deteriorated.

Aged↗
PubMed1988

Cost-effective management of patients following myocardial infarction: the impact of ischemia on alternative approaches.

Following uncomplicated myocardial infarction patients are at varying risk for cardiovascular morbidity and mortality. In order to identify and treat high risk patients, various management approaches can be employed. We performed a decision analysis to examine the cost-effectiveness of seven alternative strategies under the assumption that prognosis is affected by both the location of anatomic obstruction and the degree of myocardial ischemia. Strategies included combinations of angiography and two theoretical diagnostic tests capable of detecting ischemia with different degrees of accuracy. The strategy associated with the lowest overall six month mortality initiated testing with the diagnostic test most sensitive for ischemia, slightly better than proceeding initially to angiography. Initial use of a test sensitive for ischemia was also considerably more cost-effective than proceeding directly to angiography. Future analyses evaluating the role of diagnostic tests in coronary artery disease should incorporate the dimension of ischemia.

Coronary Disease↗
PubMed1987

Changing patterns of hip fracture care before and after implementation of the prospective payment system.

We tested the hypothesis that since the implementation of the prospective payment system (PPS), elderly patients hospitalized for hip fractures receive shorter, less care-intensive hospitalizations and are more frequently institutionalized. In blinded fashion, we reviewed the charts of elderly patients with hip fractures admitted to a municipal hospital from 1981 through 1985. Demographic and clinical characteristics of patients treated before implementation of the PPS were similar to patients treated thereafter. After implementation of the PPS, the mean length of hospitalization fell from 16.6 to 10.3 days, and the mean number of physical therapy sessions received decreased from 9.7 to 4.9. Concomitantly, the proportion of patients discharged to a nursing home increased (21% to 48%), as did the proportion receiving nursing home care at six months after discharge (13% to 39%). This increase in long-term nursing home placement suggests that the quality of care for elderly patients with hip fractures may have deteriorated.

Aged↗
PubMed1987

Cost-effectiveness analysis of patient management alternatives after uncomplicated myocardial infarction: a model.

Quantitative decision analyses provide a means whereby the effectiveness, in terms of patient outcome, and costs of diverse clinical approaches to the care of patients with cardiovascular disease can be made explicit and understandable. Increasingly, the profession is being required to justify the costs of clinical care to society, government and third party payers. Such justifications can be effectively presented when structured in decision analytic format. To demonstrate the utility of decision analysis and its extension--cost-effectiveness analysis--as a technique for presenting the rationale for clinical practices and technology utilization, the Cardiovascular Norms Committee of the American College of Cardiology sponsored a model cost-effectiveness analysis. Alternative management options, 6 month mortality and costs for the post-myocardial infarction patient were compared. The options included exercise electrocardiography, exercise thallium scintigraphy and coronary angiography, followed by coronary artery bypass surgery for patients with left main coronary disease only or patients with left main disease, three vessel disease or single or double vessel disease and a significant amount of myocardium in jeopardy. Within the constraints of the model, proceeding directly to angiography for risk stratification was the most effective approach, lowering expected mortality from 8% to approximately 3%. The marginal costs for this strategy, however, were high. The most cost-effective approach was to screen patients initially with exercise electrocardiography.

Angiography↗
PubMed1987

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.

Career Choice↗
PubMed1986

Cost-effectiveness of culturing for Chlamydia trachomatis. A study in a clinic for sexually transmitted diseases.

We have evaluated the cost-effectiveness of using cell culture to test for chlamydial infections in 9979 patients at a clinic for sexually transmitted diseases. From results of cultures, we have established prevalence data and, using decision-theory analysis, have calculated costs and probabilities of various outcomes. According to their histories and presenting signs and symptoms, patients were classified as at high or low risk for chlamydial infections. Empiric treatment of all patients attending the clinic was the most cost-effective strategy, followed by empiric treatment of high-risk women and culture-based treatment of low-risk women. Obtaining cultures for men at high and low risk was not cost-effective. If universal treatment is not provided, the most cost-effective strategy appears to be empiric therapy in patients at high risk for chlamydial infections and therapy based on diagnostic test results in women at low risk.

Adolescent↗
PubMedDate not supplied

Management of osteoarthritis of the knee by primary care physicians.

BACKGROUND: Most patients with osteoarthritis (OA) are treated by primary care physicians (in this article, primary care physicians are family physicians and general internists). OBJECTIVE: To describe and compare the self-reported practice patterns of family physicians and general internists for the evaluation and management of severe OA of the knee, including factors that might influence referral for total knee replacement. DESIGN, SETTING, AND PARTICIPANTS: A survey was developed and mailed to randomly selected community family physicians and general internists practicing in Indiana. MAIN OUTCOME MEASURE: Self-reported physician practice patterns regarding OA of the knee. RESULTS: Physical examination was the most common method of evaluating OA of the knee. Family physicians were more likely to examine for crepitation, joint stability, and quadriceps muscle strength than were general internists (P<.05). Patients with OA of the knee treated by family physicians were more likely to receive nonsteroidal anti-inflammatory drugs or oral corticosteroids and were less likely to receive aspirin, acetaminophen, or narcotics compared with patients treated by general internists. Six patient characteristics were rated as positive factors favoring a referral for possible total knee replacement, 8 characteristics were rated as negative, and 5 were rated as not a factor in the decision about referral. CONCLUSIONS: Results from this study suggest that additional research is needed to determine the evaluative techniques for OA of the knee that provide the most useful information for management decisions, the management techniques that maximize patient outcomes, and the criteria that should be used to select patients who would benefit most from referral for possible total knee replacement.

Aged↗
PubMedDate not supplied

General internal medicine and technologically less developed countries.

OBJECTIVE: To assess the international health activities of departments of medicine, divisions of general medicine, and general medicine faculty and the interest among departments of medicine in joint international health ventures. DESIGN: 15-item, mailed questionnaire. PARTICIPANTS: 100 chiefs of divisions of general medicine associated with training programs in internal medicine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Completed questionnaires were returned by 87 division chiefs representing 1,355 general medicine faculty. 49% of division had faculty with six weeks' experience in less developed countries. 8.5% of general medicine faculty had six weeks' experience in less developed countries. 7.6% of general medicine faculty were interested in spending extended time in less developed countries. 19% of departments had formal collaborations with schools in less developed countries. 45% of departments were interested in affiliations with U.S. institutions for the purpose of joint international health ventures. CONCLUSIONS: The international health interests of current general medicine faculty may not be satisfied. Departmental and divisional encouragement of international interests would increase the number of U.S. general internists participating in less developed countries. The authors discuss the potential for greater involvement of general medicine faculty in international health.

Attitude of Health Personnel↗
PubMedDate not supplied

Institutionalized patients with hip fractures: characteristics associated with returning to community dwelling.

The authors sought to identify patient- and nursing home-specific characteristics associated with a return to community living among patients with hip fractures discharged initially to nursing homes. One hundred eighty-nine free-living elderly patients were admitted for hip fractures to a 1,120-bed community hospital during 1984-1986. At hospital discharge, 114 (60%) of these patients were institutionalized. One year later, 49/114 (43%) had returned to the community. Three factors independently correlated with patients' return to community living: being discharged to a nursing home with a large ratio of annual admissions to number of beds (RR = 2.51, 95% CI 1.65, 3.94), achieving any in-hospital ambulation (RR = 4.24, 95% CI 1.77, 8.14), and receiving conventional Medicare insurance (RR = 0.37, 95% CI 0.05, 0.53). These data suggest the existence of patient and nursing home features that identify those institutionalized patients with hip fractures who are more likely to return to community dwelling.

Age Factors↗