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Biomedical subjects

S D Fihn

Publications and source records attributed to S D Fihn.

82 records · Page 5Linked to original sources
PubMed1982

Clinical use of radionuclide bone imaging in a university medical center.

To assess the diagnostic utility of radionuclide bone imaging, we reviewed all examinations performed during a two-year period in a university medical center. The indication(s) for each bone image and its interpretation were compared by reviewing requisition forms and medical records. Thirty-nine percent of 988 studies demonstrated relevant abnormalities. Yields of pertinent positive findings were greatest in patients with cancers of the breast (40%) and prostate (38%) and lowest in women with uterine cancer (15%), patients with previously normal bone images, and individuals with suspected but unconfirmed malignancy. Incidental findings, unrelated to the indication for imaging, occurred frequently (up to 41% of cases). We did not find a sizable number of negative studies that could readily be labeled as unnecessary, suggesting that bone imaging to generally a useful procedure as applied by physicians in this setting.

Academic Medical Centers↗
PubMedDate not supplied

Withdrawing routine outpatient medical services: effects on access and health.

In 1983 a budget shortfall at the Seattle Veterans Administration Medical Center prompted termination of regular outpatient care for individuals of low legal priority deemed medically stable by administrative criteria. The authors examined the effects on health status and access to medical care of 157 discharged patients and 74 comparison subjects who met the discharge criteria but were retained. Seventeen months after termination, 41% of discharged patients reported their self-perceived health status was "much worse," compared with 8% of retained patients (p less than 0.001). Among discharged patients, 23% had seen no health care provider, 58% believed they lacked access to necessary care, and 47% had reduced prescribed medications. In contrast, all retained patients had seen a provider, 5% claimed to lack access, and 25% had reduced medications. Among discharged patients for whom complete follow-up data were available, the percentage whose blood pressures were out of control at their 13-month follow-up visits was 41%, compared with 5% at the time of discharge. This marked change contrasted with a rise from 9% to 17% among retained patients. A best-case/worse-case analysis indicated that the findings could not be fully explained by biased follow-up. Administrative criteria did not accurately identify medically stable patients. During the study interval 25% of discharged patients were hospitalized and at least 6% died. These findings suggest that federal health care programs are important to many indigent patients and that withdrawing services may have deleterious consequences.

Ambulatory Care↗
PubMedDate not supplied

Clinical predictors of treatment reduction in hypertensive patients.

OBJECTIVE: To demonstrate that some hypertensive patients under good blood pressure (BP) control can reduce medications, and to identify predictors of successful reduction. DESIGN: Observational study with 11-month follow-up. SETTING: Outpatient hypertension clinic at the Seattle Veterans Administration Hospital. PATIENTS: 59 males (51% of those eligible) with diastolic BP less than 95 mm Hg for greater than or equal to 6 months; 57 patients (97%) completed the study. INTERVENTION: Gradual reduction of medications unless diastolic BP rose above 95 mm Hg. MEASUREMENTS AND MAIN RESULTS: Intensity of treatment with BP medications was assessed using a scale of their comparative "vigors." 35 patients (59%) reduced medications successfully. By the end of the study, systolic BP had risen by 8.2 +/- 12.3 mm Hg (mean +/- SD) in successful patients, while diastolic BP did not change significantly. Two predictors of treatment reduction were statistically significant in both univariate and multivariate analyses: successful patients had been treated more intensively (2.7 +/- 1.7 vs. 1.3 +/- 0.5 "vigor units," p = 0.0001), and they had been enrolled in the clinic longer (5.5 +/- 3.0 vs. 3.1 +/- 2.3 years, p = 0.003). Lower systolic BP, higher urinary sodium excretion, lower compliance, and younger age were significant predictors of treatment reduction on univariate analysis only. Age less than or equal to 65 years had the highest sensitivity (86%) for treatment reduction, while treatment with two or more "vigor units" had the highest specificity (79%) and likelihood ratio (3.3). CONCLUSIONS: Treatment reduction is feasible in many well-controlled hypertensives, though systolic BP rises. Patients with high intensity and long duration of treatment are most likely to reduce medications successfully.

Antihypertensive Agents↗
PubMedDate not supplied

The association between depressive symptoms and health status in patients with chronic pulmonary disease.

This study evaluated the association between depressive symptoms and health related quality of life (HRQoL) in patients with chronic pulmonary disease using both general and disease-specific HRQoL measures. A cross-sectional analysis of HRQoL measures completed by patients enrolled in the Department of Veteran Affairs Ambulatory Care Quality Improvement Project. 1252 patients with chronic pulmonary disease screened positive for emotional distress and returned the Hopkins Symptom Checklist-20 (SCL-20). 733 of 1252 had a score of 1.75 or greater on the SCL-20 indicating significant depressive symptoms. Depressive symptoms were associated with statistically significantly worse general and pulmonary health as reflected by lower scores on all sub-scales of both the Medical Outcomes Short Form-36 and the Seattle Obstructive Lung Disease Questionnaire. In fact, 11% to 18% of the variance in physical function sub-scales was attributed to depressive symptoms alone. Patients with chronic pulmonary disease and depressive symptoms reported significantly more impaired functioning and worse health status when compared to those patients without depressive symptoms. Because there are highly effective treatments for depression, selective screening of patients with chronic pulmonary disease for depression may identify a group that could potentially benefit from treatment interventions.

Adaptation, Psychological↗
PubMedDate not supplied

Interpretation and comparison of treatment studies for uncomplicated urinary tract infections in women.

Recent treatment trials for uncomplicated urinary tract infection were reviewed to determine most commonly used methodologic approaches and to assess whether methodologic problems often compromise internal validity and comparability of these studies. The 62 studies surveyed fulfilled an average of 56% (standard deviation, 19.2%) of 12 standards necessary for accurate interpretation and comparability. Standards most often met were: reporting the incidence of adverse-effects (90%); recording presence or absence of pretreatment symptoms (81%); and describing clinical response to therapy (71%). Standards least often met were: having adequate statistical power to detect a meaningful difference between therapies (21%); double-blinded assigning of treatment regimens (37%); and clearly defining criteria for diagnosing cure and failure (35%). Two recurring characteristics that impaired both interpretation of individual studies and comparisons between studies were failure to separately randomize or stratify patients with risk factors known to adversely affect therapeutic response and inadequate description of outcome measures. Consideration of these factors and use of a proposed system for classifying therapeutic outcome in future treatment trials would improve the basis for clinical decision making.

Anti-Bacterial Agents↗
PubMedDate not supplied

Evaluation of a command-line parser-based order entry pathway for the Department of Veterans Affairs electronic patient record.

OBJECTIVE: To improve and simplify electronic order entry in an existing electronic patient record, the authors developed an alternative system for entering orders, which is based on a command- interface using robust and simple natural-language techniques. DESIGN: The authors conducted a randomized evaluation of the new entry pathway, measuring time to complete a standard set of orders, and users' satisfaction measured by questionnaire. A group of 16 physician volunteers from the staff of the Department of Veterans Affairs Puget Sound Health Care System-Seattle Division participated in the evaluation. RESULTS: Thirteen of the 16 physicians (81%) were able to enter medical orders more quickly using the natural-language-based entry system than the standard graphical user interface that uses menus and dialogs (mean time spared, 16.06 +/- 4.52 minutes; P=0.029). Compared with the graphical user interface, the command--based pathway was perceived as easier to learn (P<0.01), was considered easier to use and faster (P<0.01), and was rated better overall (P<0.05). CONCLUSION: Physicians found the command- interface easier to learn and faster to use than the usual menu-driven system. The major advantage of the system is that it combines an intuitive graphical user interface with the power and speed of a natural-language analyzer.

Consumer Behavior↗
PubMedDate not supplied

Symptom severity and patients' values in the decision to perform a transurethral resection of the prostate.

To develop and validate a method to assess patients' subjective values for outcomes of surgical and nonsurgical management of benign prostatic hypertrophy (BPH), the authors studied 20 patients who had symptoms of BPH. Eight were scheduled for prostatic surgery and 12 were not. They conducted an interview, including a time-trade-off (TTO) exercise to elicit values for single and combined outcomes and questions about symptoms used to complete a symptom severity score. Expected gain and symptom severity were independent and significant (p less than 0.001 for both comparisons) determinants of whether surgery was scheduled, while the correlation between these two factors was limited (Spearman = 0.058, p = 0.004). Based on a decision analytic model incorporating TTO values, a high expected gain in quality from surgery was strongly related to whether surgery was scheduled (p = 0.002), and had a higher positive predictive value (0.86) than symptom severity score (0.73). This small study demonstrates the feasibility and validity of using value assessment in this setting and suggests that this approach can be useful to clinicians when counseling patients.

Aged↗
PubMedDate not supplied

A model for planning optimal follow-up for outpatients on warfarin anticoagulation. Warfarin Optimal Outpatient Follow-up Study Group.

Patients taking warfarin for long-term anticoagulation require frequent clinic visits to monitor the prothrombin time ratio (PTR), a measure of blood clotting. A dynamic stochastic model using nonlinear optimization was developed to select follow-up visit intervals that minimize the overall costs of patient care. Assuming that fluctuations in a patient's PTR behave as a random diffusion process, future PTR fluctuations are unknown, except as revealed by past PTRs. To determine the incidence and costs of complications in relation to PTR, the authors reviewed the charts of 216 patients who had 719 patient-years of follow-up with 695 trivial, significant, life-threatening, or fatal complications. They modeled the relationship between costs of complications and deviation of the PTR from the therapeutic target as a fourth-order convex polynomial. The model is used to compute the interval to the next follow-up visit to minimize accumulated potential costs. Variables in the optimization are the cost of a monitoring visit and the expected costs of complications. The latter are derived from the current PTR, the variability of the patient's past PTR values, the number of past PTRs available, and the target PTR for the patient. No attempt is made to predict the level of the next PTR or suggest adjustments in the warfarin dose. Shorter follow-up is recommended for patients who have histories of large fluctuations in past PTRs and for patients with few prior PTR determinations. As visits accumulate, the patient's degree of variability can be estimated more accurately and visit intervals adjusted accordingly. The scheduling method balances costs to the health care system of monitoring each patient against the expected costs of complications. This approach has the potential to reduce the number of monitoring visits necessary for safe management of anticoagulated patients with stable PTRs and to improve control among unstable patients.

Aged↗