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Biomedical subjects

S Cretin

Publications and source records attributed to S Cretin.

36 records · Page 2Linked to original sources
PubMed1986

Risk selection of families electing HMO membership.

This study analyzes the health plan selection history of approximately 30,000 employees of a large aerospace corporation. The data show that families selecting HMOs were younger, had lower income, and had less time on the job. HMOs attracted families with lower annual claimed expenditures, and these families' claimed expenses were lower still in the year immediately prior to switching into the HMO. Lower costs among families switching into the HMOs are partly explained by the composition of these families compared with families who stayed in the FFS plan. However, the selection pattern persisted even after adjusting for the size of the family, the age and sex of family members, and other family characteristics, such as race and income. Families switching out of HMOs had higher total annual claims during their first year back in the FFS sector compared with families about to switch into HMOs. However, recent HMO exiters did not always differ from families who never left the FFS plan.

Age Factors↗
PubMed1986

Estimating treatment and treatment times for special and nonspecial patients in hospital ambulatory dental clinics.

Increased time to treat the special patient is often cited as a barrier to dental care. The purpose of this study was to analyze the separate and combined effects of differences in dental services planned, services actually performed, and differences in treatment time requirements between special and nonspecial patients in a hospital ambulatory clinical setting. Data for this study were obtained from the UCLA evaluators of the RWJ-funded Hospital-Sponsored Ambulatory Dental Services Program (HSADSP). The results show that special patients require more dental treatment than nonspecial patients for advanced dental disease (i.e., periodontics, surgery, and removable prosthetics) and that they receive more of such services. The study also found that special patients should not be viewed as a homogeneous group when evaluating dental needs and required time resources for treatment. Three subgroups of special patients were identified: developmentally disabled, severely compromised, and moderately compromised. The developmentally disabled as compared to the nonspecial patients required significantly more (20 percent) provider time in completing a "representative" treatment plan.

Adult↗
PubMed1985

The immediate and subsequent outcomes of nursing home care.

To determine the relationship between admission status and subsequent outcomes, 563 patients discharged during 1980 from 24 nursing homes were followed through 1982. Only 28 per cent of patients were discharged to their homes. Reconstructed life histories of 529 discharges for the two-year follow-up revealed only 38 persons (7.2 per cent) were alive and at home; of these, 36 had been initially discharged to their homes. Four hundred and one persons (75.8 per cent) were dead. Mental orientation, urinary continence, functional status, hip fracture, and diagnoses associated with dementia were found to be significant predictors of outcome status after discharge and at follow-up. Social support had only a modest effect on the former outcomes.

Activities of Daily Living↗
PubMed1982

The use of an ROC curve to express quality of care results.

When a quality of care method which results in a continuous score is viewed as a screening device, it is possible to evaluate the efficiency and effectiveness of the score using assessment techniques usually applied to screening tests for disease. Using an independent standard (such as patient outcome) for determining which records truly represent inadequate medical care, for any quality score cutoff we can calculate the sensitivity and the specificity of the screening device for identifying inadequate care. An ROC curve allows the user of a screening test to select a threshold that takes into account both the estimated prevalence of inadequate care at the site and the relative importance placed on false positive and false negative errors. We used an ROC curve to examine the performance of criteria mapping, a chart review system. The criteria map method was employed to evaluate the disposition decision for 421 patients who came to 2 emergency departments with complaints of chest pain. The shape of the ROC curve generated from these data allows the user to evaluate the effect of choosing various cutpoints, acknowledging explicitly the tradeoffs between failure to review cases of inappropriate disposition and needless review of appropriate disposition.

Emergency Service, Hospital↗
PubMed1981

Comparison of a criteria map to a criteria list in quality-of-care assessment for patients with chest pain: the relation of each to outcome.

In a prospective study we compared the ability of two quality assessment methods--the standard criteria list and the criteria map--to predict the appropriateness of the disposition decision for 421 patients with chest pain who presented to two emergency departments. To evaluate the quality of this decision, each patient was followed at home or in the hospital to determine whether an acute condition requiring hospital admission was present. Among the 169 discharged patients, the map scores of the eight with admissible disease were significantly higher than the score for those without admissible disease (p = 0.02). For the 252 admitted patients, a similar relationship between map score and the admissible disease outcome was observed (p = 0.0001). There was no significant relationship between list score and outcome among either the admitted or the discharged patients. Multivariate logistic analyses confirmed the importance of the map score as a predictor of admissible disease. The map score was superior to the list score and to demographic variables in its ability to correctly classify patients with and without admissible disease. The demonstrated relationship between map score and patient outcome enables the map to be used in a quality assurance system. An institution can ensure that physicians review an enriched sample of the inappropriate discharges and the unjustified admissions by selecting admitted patients with low map scores and discharged patients with high map scores.

Adult↗
PubMed1981

Cholesterol, children, and heart disease: an analysis of alternatives.

Cost-effectiveness analysis is used to compare proposed cholesterol control programs. The analysis employs estimates of such biologic variables as effect of diet on cholesterol level, stability of level, and change in morbidity with level. Sensitivity analysis identifies the biologic and behavioral uncertainties that most critically affect policy choices. At a discount rate of 5%, a cholesterol-screening program for all 10-year-old children would cost about 10,000 per year of life saved. Rescreening would not improve efficiency. Targeted screening a high-risk children could improve efficiency by 25%, but would benefit only one sixth as many people. Community-wide interventions without screening may be more efficient by a factor of 3. The cost per year of life saved is most affected by the rate of discount and the dollar cost of changing behavior, but is insensitive to stability of cholesterol rank order and to the cost of screening.

Adult↗
PubMed1980

The changing face of congenital heart disease. A method for predicting the influence of cardiac surgery upon the prevalence and spectrum of congenital heart disease.

The influence of surgery upon the natural history of congenital heart disease is great. Children with many types of congenital heart lesions are now living to adult life. Most of these children will, however, require continuing medical care, care which traditionally has been given by the pediatrician. We have developed a method by which incidence figures and a knowledge of the natural history may be used to obtain prevalence estimates of congenital heart disease. We estimate that in the United States in 1995 there will be nearly 300,000 children under 21 years old with congenital heart disease; 38 per cent of these will have had one or more surgical procedures. In the last two decades the majority of care for children with congenital heart disease was aimed at the correction of the original lesion; however, we predict that in the next two decades an increasing fraction of medical resources will be directed toward the residua and sequelae of cardiac surgical procedures. This alteration in character of congenital heart disease will affect the patient mix seen by the cardiologist with adult patients as well as that of the pediatrician. For ventricular septal defect, pulmonary stenosis, atrial septal defect, persistent ductus arteriosus, coarctation of the aorta and tetralogy of Fallot, we have estimated the nationwide prevalence and the surgical requirements for 1995. Used with more specific local data on population and birth rate, this model can provide important input into planning the delivery of cardiovascular services.

Adolescent↗
PubMed1979

Arthritic hand response to pressure gradient gloves.

Five women with osteoarthritis and 10 with rheumatoid arthritis and finger joint involvement wore a pressure gradient glove, a control glove, or no glove in a randomly assigned sequence. All were outpatients. Each patient wore the assigned glove nightly for 1 week, after which a battery of subjective and objective data, including number of tender joints, ring size, grip strength, palmar temperature, and hand function were obtained. In all, 105 separate examinaion sessions were completed over 7 visits, with each hand serving as its own control in the experimental design. The palmar skin temperature was elevated in both patient groups when either a pressure gradient or control glove was worn. In patients with rheumatoid arthritis, the only significant difference was that the pressure gradient glove reduced ring size when compared to the control glove or no glove. No differences were detected in the patients with osteoarthritis.

Arthritis, Rheumatoid↗
PubMed1979

A model of prehospital death from ventricular fibrillation following myocardial infarction.

Current efforts to reduce prehospital cardiac mortality focus more on deployment of specially equipped ambulances than on reduction of patient or ambulance delays. To evaluate this strategy, we needed to find a method that would isolate the separate effects of patient delay, ambulance delay, and the resuscitative capability of the ambulance. Using published data, we have generated a mathematical model of death from ventricular fibrillation following myocardial infarction that shows the relationship among these three factors. Analyses based on the model indicate that the potential life saving impact of a defibrillation-equipped ambulance is severely limited due to typical patient response patterns. If the ambulance arrives ten minutes after the onset of infarction, defibrillation capabilities will reduce prehospital mortality from 6 percent to 2 percent. After a more typical delay of 60 minutes, the mortality rises sharply to 13 percent for an unequipped ambulance. With a delay of this length, defibrillation capabilities reduce mortality only to about 12 percent.

Ambulances↗
PubMed1977

Cost/benefit analysis of treatment and prevention of myocardial infarction.

The benefits resulting from introduction of coronary care units, mobile coronary care units, and a screening and intervention program to decrease the incidence of myocardial infarction (MI) are reduced to a common basis by modeling the effects of the three strategies as applied to a cohort of 10-years-olds. Published data on MI are used with a semi-Markov model of death from MI and other causes to estimate program effects on long-term survival, and cost/benefit ratios are compared for the three programs with both costs and benefits discounted over the lifetime of the cohort. Some problems of selecting a discount rate for comparing programs that incur costs and accrue benefits at widely separated times are discussed.

Child↗
PubMedDate not supplied

The prediction of streptococcal pharyngitis in adults.

The usefulness of clinical and laboratory findings for prediction of the presence of Group A streptococci on throat culture and of an increase in antistreptococcal antibodies was investigated in 693 adult patients. Several findings were shown to increase the likelihood of streptococcal isolation, alone and in combination: tonsillar exudate, tonsillar enlargement, tender anterior cervical adenopathy, myalgias, and a positive throat culture in the preceding year. Compared with a frequency of 9.7% in all patients, the probabilities of a positive culture were quite different (ranging from 2 to 53%) in subgroups of patients with different combinations of these clinical findings. The results of a leukocyte count and measurement of C-reactive protein added little additional predictive information. While clinical findings can never predict perfectly the results of a throat culture, they nevertheless can provide useful information--particularly in tending to "rule out" streptococcal infection--in adult patients with pharyngitis.

Adolescent↗
PubMedDate not supplied

Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age.

OBJECTIVE: The authors have shown that clinical guidelines embedded in an electronic medical record improved the quality, while lowering the cost, of care for health care workers who incurred occupational exposures to body fluid. They seek to determine whether this system has similar effects on the emergency department care of young children with febrile illness. DESIGN: Off-on-off, interrupted time series with intent-to-treat analysis. SETTING: University hospital emergency department. SUBJECTS: 830 febrile children less than 3 years of age and the physicians who treated them. INTERVENTIONS: Implementation of an electronic medical record that provides real-time advice regarding the content of the history and physical examination and recommendations regarding laboratory testing, treatment, diagnosis, and disposition. MEASUREMENTS: Documentation of essential items in the medical record and after-care instructions; compliance with guidelines regarding testing, treatment, and diagnosis; charges. RESULTS: The computer was used in 64 percent of eligible cases. Mean percentage documentation of 21 essential history and physical examination items increased from 80 percent during the baseline period to 92 percent in the intervention phase (13 percent increase; 95 percent CI, 10-15 percent). Mean percentage documentation of ten items in the after-care instructions increased from 48 percent at baseline to 81 percent during the intervention phase (33 percent increase; 95 percent confidence interval, 28-38 percent). All documentation decreased to baseline when the computer system was removed. There were no demonstrable improvements in appropriateness of care, nor was there evidence that appropriateness worsened. Mean charges were not changed by the intervention. CONCLUSION: The intervention markedly improved documentation, had little effect on the appropriateness of the process of care, and had no effect on charges. Results for the febrile child module differ from those for the module for occupational blood and body fluid exposure (a more focused and straightforward medical condition), underscoring the need for implementation methods to be tailored to specific clinical complaints.

Child, Preschool↗