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Biomedical subjects

S D Pearson

Publications and source records attributed to S D Pearson.

At least 37 records · Page 2Linked to original sources
PubMed1998

Discontinuity of care: urgent care utilization within a health maintenance organization.

OBJECTIVE: To determine the demographic characteristics, attitudes, and perceived barriers to primary care reported by patients seen in the urgent care department of a health maintenance organization (HMO) health center. STUDY DESIGN: Cross-sectional survey. PATIENTS AND METHODS: Patients aged 18 years or older who sought care at the urgent care department of a large, urban health center of a staff-model HMO were eligible for the study. Patients were handed a survey as they registered in the urgent care department. Demographic and visit diagnoses data were obtained through review of the computerized medical record. RESULTS: Patients seeking treatment at the urgent care department were significantly younger than those seen at a primary care physician's office (mean age, 40 years versus 46 years; P < or = 0.0001) but otherwise had similar demographic characteristics. Nearly 90% of 421 patients seen in the urgent care department reported having a primary care physician. When asked to list the reasons why they came to the urgent care department instead of the primary care offices, 64% said they needed to be seen immediately, 47% came because the primary care offices were closed, 27% cited the constraints of work or childcare, and 25% said they were unable to get an appointment with their primary care physician. Almost half of patients (47%) said they would have preferred to see their primary care physician within a day or two rather than seeking care at the urgent care department. CONCLUSIONS: Patients treated in the urgent care department reported various barriers to seeing their primary care physician. Improving same-day access to primary care providers will help alleviate this problem and may increase patient satisfaction.

Acute Disease↗
PubMed1996

Importance of findings on the initial evaluation for cancer in patients with symptomatic idiopathic deep venous thrombosis.

BACKGROUND: The relation between thrombosis and cancer is well documented, but the clinical evaluation appropriate for detecting underlying cancer in patients with deep venous thrombosis remains unknown. OBJECTIVES: To 1) determine the appropriate initial evaluation for cancer in patients with idiopathic deep venous thrombosis and 2) estimate the incidence of subsequently diagnosed cancer in patients who were not found to have cancer when deep venous thrombosis was diagnosed. DESIGN: Retrospective cohort study. SETTING: Urban, tertiary care teaching hospital. PATIENTS: 986 consecutive patients (637 women and 349 men; mean age +/- SD, 53 +/- 17 years) who had no risk factors for venous disease and had venous ultrasonography because idiopathic deep venous thrombosis was suspected. MEASUREMENTS: Initial clinical evaluation was assessed by using chart review. The incidence of cancer at a median of 34 months after diagnosis of deep venous thrombosis was obtained through hospital chart review (38%), computerized record extraction (54%), mailed questionnaires (6%), telephone interviews (1%), or a death registry (1%). RESULTS: Deep venous thrombosis was diagnosed in 142 patients (14%); 136 of the 142 were hospitalized. Cancer was diagnosed in 16 of these 136 patients (12%) during the index hospitalization. All 16 of these patients had one or more abnormalities on at least one of the four components of the clinical examination: history, physical examination, basic laboratory testing, or chest radiography. The probability of detecting cancer increased as the number of findings suggestive of cancer on the four components of the clinical evaluation increased. Cancer was diagnosed in none of the 56 patients with deep venous thrombosis who did not have findings on the clinical evaluation. The probability of cancer-free survival during follow-up (median, 34 months) was similar in patients with (3 of 122 [2.5%]) and without (23 of 844 [2.7%]) deep venous thrombosis and in the age- and sex-matched U.S. population. CONCLUSIONS: A clinical evaluation that includes a comprehensive medical history, physical examination, routine laboratory testing, and chest radiography seems to be appropriate for detecting cancer in these patients. Additional testing should be guided by any abnormalities detected by this clinical evaluation.

Adult↗
PubMed1996

Gender differences in the management of acute chest pain. Support for the "Yentl syndrome".

OBJECTIVE: To determine whether evaluation and management of males and females differ after presentation to the emergency department with acute chest pain. DESIGN: Prospective cohort study with follow-up at 1 month. SETTING: Urban teaching hospital. PATIENTS: The study population included 1,411 patients who were 30 years of age or older who visited the emergency department with acute chest pain from October 1990 through May 1992. These 1,411 patients represent 69% of the 2,056 patients approached for consent. The utilization of exercise stress testing as outpatients was measured for a subset of 954 patients who were interviewed at 1 month after their presentation. MEASUREMENTS/MAIN RESULTS: After controlling for clinical and nonclinical predictors, women were less likely to be admitted to the hospital (adjusted odds ratio [OR] 0.68; 95% confidence interval [CI] 0.47, 0.99). Among the 954 patients with 1-month follow-up, women were less likely than men to undergo an exercise stress test during the first month after presentation, with borderline statistical significance after adjusting for the interaction between gender and admission to the hospital (adjusted OR 0.30; 95% CI 0.09, 1.0). Among the patients who were admitted to the hospital, women were as likely as men to undergo exercise stress testing (adjusted OR 0.81; 95% CI 0.57, 1.2) but were less likely to undergo cardiac catheterization (adjusted OR 0.44; 95% CI 0.25, 0.80). CONCLUSIONS: Gender-based differences in management may occur at several stages in the evaluation of patients with acute chest pain. Observed differences in use of invasive procedures between men and women may be due in part to lower rates of exercise test use and admission to the hospital for evaluation of acute chest pain.

Adult↗
PubMed1996

Variation in the management of deep vein thrombosis: implications for the potential impact of a critical pathway.

PURPOSE: To evaluate the potential impact of a practice guideline in the form of a critical pathway on variation and quality of care in patients with deep vein thrombosis (DVT). METHODS: Goals were identified for key steps and processes that were believed to be important for meeting a length-of-stay (LOS) goal of 5.5 days, and for improving quality of care for patients with DVT. Data collected via chart review were used to determine the percentage o patients with uncomplicated DVT admitted in the year after October 1, 1992, whose management would have met these goals. RESULTS: Only 11 (12%) of 92 eligible patients with a primary discharge diagnosis of DVT met the LOS goal. In 30%, the activated partial thromboplastin time (aPTT) was >60 seconds within a target of 12 hours after admission. The goals for the initiation of warfarin (within 12 hours after aPTT >60 seconds) and the achievement of a therapeutic international normalized ratio (INR) level (within 120 hours) were met in 51% and 58% of patients, respectively. The target duration of intravenous heparin therapy was achieved in 78% of patients. Only 18% of patients, however, were discharged within 12 hours after 96 hours of heparin therapy had been given and a therapeutic INR had been achieved. CONCLUSIONS: These data demonstrate considerable variation in management of uncomplicated DVT at a single hospital, suggesting that a critical pathway could have impact on both LOS and quality of care.

Adult↗
PubMed1996

A critical pathway to treat proximal lower-extremity deep vein thrombosis.

To address variation in treatment of deep vein thrombosis (DVT) while maximizing the efficiency and quality of care, our institution developed a critical pathway guideline. This paper presents this critical pathway and the clinical rationale underlying its recommendations. The DVT pathway synthesizes recommendations for all aspects of patient care, including laboratory evaluation at admission, dosing and management of heparin therapy, timing of warfarin initiation, elements of patient education, discharge planning, and anticipated duration of heparinization and hospitalization. Differences among interpretations of the medical literature, patient populations, physician skills, test availability, and other variables make it unlikely that all elements of this pathway would best meet the needs of another institution. Nevertheless, the critical pathway format and the specific contents of this pathway may serve as a useful benchmark for others involved in creating clinical guidelines for this patient population.

Activities of Daily Living↗
PubMed1996

Payer-hospital collaboration to improve patient satisfaction with hospital discharge.

BACKGROUND: Brigham and Women's Hospital, in Boston, and its major health maintenance organization (HMO), Harvard Community Health Plan, collected data in spring 1994 which revealed that patients were less satisfied with hospital discharge planning than with other elements of care. PROBLEM IDENTIFICATION PROCESS: An interdisciplinary team, formed in November 1994 and composed of eight members from the hospital and HMO, used data from the hospital's Patient Satisfaction Survey, flowcharting, and phone interviews with patients to identify discharge planning-related problems. For example, follow-up contact with patients after discharge was erratic and no clear signal of the successful "hand off" of care from the hospital team to the community team existed. IMPROVEMENT CYCLE 1: Eighty-three percent of the payer's patients that received the improvement strategy developed by the interdisciplinary team-a concierge service-rated discharge planning as excellent or very good, compared to 63% of control patients. IMPROVEMENT CYCLE 2: PLAN SOLUTIONS/STRATEGIES FOR IMPROVING HOSPITAL DISCHARGE PLANNING: The results of the team's Cycle 1 improvement provided information for the team to use in designing a second cycle of incremental improvement activity. For example, to address the lack of clarity about who was responsible for making decisions about discharge and follow-up care, the attending physician was designated the transition-of-care coordinator. Once all the improvements were implemented, Cycle 2 patients who received the intervention rated satisfaction with discharge higher (83% versus 73%) than the control group. CONCLUSIONS: Implications of hospitalwide implementation of discharge planning-related services attempted on one unit are being considered.

Ancillary Services, Hospital↗
PubMed1995

Critical pathways as a strategy for improving care: problems and potential.

In an era of increasing competition in medical care, critical pathway guidelines have emerged as one of the most popular new initiatives intended to reduce costs while maintaining or even improving the quality of care. Developed primarily for high-volume hospital diagnoses, critical pathways display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency. Despite the rapid dissemination of critical pathway programs in hospitals throughout the United States, many uncertainties remain about their development, implementation, and evaluation. In addition, serious concerns have been raised about their effect on patient outcomes and satisfaction with care, physician autonomy, malpractice risks, and the teaching and research missions of many hospitals. Underlying these concerns is the absence of data from controlled trials to evaluate the effects of critical pathways. Physicians should understand the potential benefits and problems associated with critical pathways because physicians are increasingly being asked to provide leadership for pathway programs. Physicians and other health service investigators should also develop methods to study pathways in evolving health care settings. Although the promise of reduced costs and improved quality is enticing, the gaps in our knowledge about critical pathways are extensive; therefore, like any new health care technology, pathway programs should be fully evaluated in order to understand the conditions under which that promise may be fulfilled.

Analysis of Variance↗
PubMed1995

A critical pathway to evaluate suspected deep vein thrombosis.

Uncertainty regarding the optimal evaluation of suspected deep vein thrombosis (DVT) results in wide variations in practice, even within the same institution. To address variation in practice while maximizing the efficiency and quality of care, our institution developed a critical pathway guideline for the emergency department evaluation of patients suspected of having DVT. We present the critical pathway and the clinical rationale underlying its recommendations. The critical pathway was developed by a multidisciplinary team using chart review of practice at our institution, benchmarking at other institutions, and review and discussion of the medical literature. Consensus was achieved for the selection of ultrasound as the primary imaging test for all patients and for recommending initial doses of heparin sodium that are higher than the current norm at our institution to reduce the length of time required to achieve therapeutic anticoagulation. A total time for patient evaluation of 5 hours or less was established as the target. Controversy arose in two key areas: (1) the treatment of patients with normal ultrasound scans when high clinical suspicion for DVT exists and (2) the evaluation and treatment of suspected isolated calf-vein DVT. In its final form, the critical pathway recommendations seek to balance the benefits of standardization with the prerogatives of physicians to make decisions tailored to individual patients.

Decision Making↗
PubMed1995

Failure of information as an intervention to modify clinical management. A time-series trial in patients with acute chest pain.

OBJECTIVE: To test whether a low-intensity, nonintrusive intervention improved the efficiency of management of patients with acute chest pain. DESIGN: Time-series trial with six 14-week cycles, each including a 5-week intervention period and a 5-week control period separated by 2-week "washout" periods. SETTING: Urban teaching hospital. PATIENTS: 1921 patients aged 30 years or older with acute chest pain unexplained by local trauma or chest radiograph. INTERVENTION: Risk estimates and triage recommendations were made available to physicians at the time of emergency department evaluation and, for hospitalized patients, on a daily basis before morning rounds. Flowsheets and stickers, but no direct human contact, were used to transmit this information. MEASUREMENTS: Rates of admission to the hospital and coronary care unit, inpatient costs, and lengths of stay. RESULTS: Rates of admission during intervention and control periods were similar in both the hospital (52% and 51%, respectively) and the coronary care unit (10% and 10%, respectively). Total lengths of stay in the hospital were similar (4.9 +/- 5.9 days and 4.9 +/- 5.7 days, respectively), as were average total costs ($7822 +/- $13,217 and $7955 +/- $13,400, respectively). No differences in management were detected for the subgroup of patients with low clinical risk for acute myocardial infarction. CONCLUSIONS: The use of information alone--without direct human contact--did not affect management of patients with acute chest pain at this hospital. Although this low-intensity intervention might be more effective for other conditions and in other settings, our data support the use of other strategies to affect physician decision making.

Acute Disease↗
PubMed1995

Triage decisions for emergency department patients with chest pain: do physicians' risk attitudes make the difference?

OBJECTIVE: To determine whether physicians' risk attitudes correlate with their triage decisions for emergency department patients with acute chest pain. DESIGN: Cohort. SETTING: The emergency department of a university teaching hospital. PATIENTS: Patients presenting to the emergency department with a chief complaint of acute chest pain. PHYSICIANS: All physicians who were primarily responsible for the emergency department triage of at least one patient with acute chest pain from July 1990 to July 1991. METHODS: The physicians' risk attitudes were assessed by two methods: 1) a new, six-question risk-taking scale adapted from the Jackson Personality Index (JPI), and 2) the Stress from Uncertainty Scale (SUS). RESULTS: The physicians who had high risk-taking scores ("risk seekers") admitted only 31% of the patients they evaluated, compared with admission rates of 44% for the medium scores and 53% for the physicians who had low risk-taking scores ("risk avoiders"), p < 0.001. After adjustment for clinical factors, the patients triaged by the risk-seeking physicians had half the odds of admission [odds ratio (OR) 0.51, 95% confidence interval (95% CI) 0.27 to 0.97], and the patients triaged by the risk-avoiding physicians had nearly twice the odds of admission (OR 1.83, 95% CI 1.10 to 3.03) of the patients triaged by the medium-risk scoring physicians. The SUS did not correlate significantly with admission rates. Of the 92 patients released home by the risk-seeking physicians, 91 (99%) were known to be alive four to six weeks afterwards and one was lost to follow-up; among the 66 patients released by the risk-avoiding physicians, 64 (97%) were known to be alive at four to six weeks, one was lost to follow-up, and one died of ischemic heart disease during a subsequent hospitalization (p = NS). CONCLUSIONS: The physicians' risk attitudes as measured by a brief risk-taking scale correlated significantly with their rates of admission for emergency department patients with acute chest pain. These data do not suggest that the risk-seeking physicians achieved lower admission rates by releasing more patients who needed to be in the hospital, but an adequate evaluation of the appropriateness of triage decisions of risk-seeking and risk-avoiding physicians will require further study.

Acute Disease↗
PubMed1995

Using PERT/CPM (Program Evaluation and Review Technique/Critical Path Method) to design and improve clinical processes.

Recent changes in health care have focused attention on new tools for planning and managing clinical processes. The use of one tool in particular, clinical pathways, has increased dramatically. Pathways employ a concept long used in other industries: the explicit design and documentation of a process. However, the most common tools used in other industries to perform process design, the Program Evaluation and Review Technique (PERT) and the Critical Path Method (CPM), have not migrated to health care. This article presents a methodology for incorporating PERT/CPM into the design and management of clinical processes.

Analysis of Variance↗
PubMed1995

Is consensus reproducible? A study of an algorithmic guidelines development process.

The authors evaluated the reproducibility of a clinical algorithm consensus development process across three different physician panels at a health maintenance organization. Physician groups were composed of primary care internists, who were provided with identical selections from the medical literature and first-draft "seed" algorithms on the management of two common clinical problems: acute sinusitis and dyspepsia. Each panel used nominal group process and a modified Delphi method to create final algorithm drafts. To compare the clinical logic in the final algorithms, the authors applied a new qualitative and quantitative comparison method, the Clinical Algorithm Patient Abstraction (CAPA). Dyspepsia algorithms from all physician groups recommended empiric anti-acid therapy for most patients, favored endoscopy over barium swallow, and had very similar indications for endoscopy. The average CAPA comparison score among final physician algorithms was 6.1 on a scale of 0 (different) to 10 (identical). Sinusitis algorithms from all groups proposed empiric antibiotic therapy for most patients. Indications for sinus radiographs were similar between two algorithms (CAPA = 4.9), but differed significantly in the third, resulting in lower CAPA scores (average CAPA = 1.9, P < 0.03). The clinical similarity of the algorithms produced by these physician panels suggests a high level of reproducibility in this consensus-driven algorithm development process. However, the difference among the sinusitis algorithms suggests that physician consensus groups using a consensus process that a health maintenance organization can do with limited resources will produce some guidelines that vary due to differences in interpretation of evidence and physician experience.

Acute Disease↗
PubMed1995

Comparison of the Medical Outcomes Study Short-Form 36-Item Health Survey in black patients and white patients with acute chest pain.

Few data are available regarding the performance of the Medical Outcomes Study (MOS) Short-Form 36-Item Health Survey (SF-36) in black patients. In this article, the reliability and validity of the MOS SF-36 is compared in a population of black patients and white patients with acute chest pain. The MOS SF-36 was administered to 1,160 patients (31% black) who presented to the emergency department of an urban teaching hospital with acute chest pain from October 1990 to May 1992. In unadjusted analyses, black patients had significantly lower scores compared with white patients for several dimensions of the SF-36. Correlations among the eight subscales were similar, and the internal consistency of each of the eight subscales was excellent for both groups (Cronbach's coefficient alpha range .64 to .93). Each subscale had similar clinical and nonclinical correlates in black patients and white patients. In multivariate models, race was not a significant independent correlate of any of the eight subscales. Thus, the MOS SF-36 had similar reliability and validity in this population of black patients and white patients with acute chest pain who presented to an urban teaching hospital. If these findings are confirmed in other populations, they suggest that results from the MOS SF-36 may be interpreted similarly in black patients and white patients, after adjusting for clinical and sociodemographic data. Whether these findings are generalizable to other conditions and less acute settings requires further investigation.

Acute Disease↗
PubMed1994

The case for case-mix adjustment in practice profiling. When good apples look bad.

OBJECTIVE: To assess the influence of patient characteristics on practice profiling. Using the example of specialty referrals by primary care physicians, we evaluated the impact of adjusting for patient characteristics (age/sex vs case mix) on the estimation of practice variation, the identification of outlier practices, and the evaluation of potential predictors of variation. DESIGN AND SETTING: We applied several measurement strategies to a retrospective cohort of patients (N = 37,830) within 52 physician practices in a large staff-model health maintenance organization during a 1-year period. OUTCOME MEASURES: We calculated unadjusted referral rates and adjusted standardized referral ratios for each physician. Using these, we determined coefficients of variation and statistical "outlier status." RESULTS: Adjustment for patient characteristics decreased the observed variation in referral profiles, with a decrease of more than 50% in the coefficient of variation. Three quarters of the physicians identified as statistical outliers with use of an age/sex-adjusted measure were no longer identified as such with use of an case-mix-adjusted measure. Several key predictors of unadjusted referral rate (including physician age, practice tenure, site of practice, and extent of laboratory test ordering) dropped out of regression models when the outcome variable was adjusted for patient characteristics. CONCLUSION: Failure to adjust for case mix in physician practice profiles may lead to overestimates of variation and misidentification of outliers. To the extent that unadjusted practice profiles are used for decisions about education, sanctions, or employment, physicians may be subject to inequitable decisions and actions. Misinformation about the causes and extent of practice variation may also lead to misdirection of scarce resources for quality improvement efforts.

Age Factors↗
PubMed1994

Storage of lorazepam in three injectable solutions in polyvinyl chloride and polyolefin bags.

The stability of lorazepam 0.1 mg/mL in three intravenous infusion solutions in polyvinyl chloride (PVC) and polyolefin bags at 37, 24, 4, and -20 degrees C was evaluated over seven days of storage. Triplicate test solutions of lorazepam 0.1 mg/mL in 50-mL PVC bags and 50-mL polyolefin bags containing 0.9% sodium chloride injection, 5% dextrose injection, and lactated Ringer's injection were prepared and stored at 37, 24, and 4 degrees C. Samples were removed initially and at various times over seven days and analyzed for lorazepam content. In addition, lorazepam 0.1 mg/mL in 5% dextrose injection in polyolefin bags was stored at -20 degrees C and samples were removed initially and after seven days and analyzed for lorazepam content. The rate of lorazepam sorptive loss to PVC bags was evaluated with lorazepam 0.1 mg/mL in 5% dextrose injection in PVC bags and stored at 24 degrees C. Samples were removed initially and after two, four, six, and eight hours. High-performance liquid chromatography was performed in duplicate on each sample for lorazepam quantitation. Rapid loss of lorazepam occurred in all samples stored in PVC bags. After seven days at 4 degrees C, 8-9% was lost from 0.9% sodium chloride injection and 5% dextrose injection. At 24 degrees C, 17% was lost in 24 hours; at 37 degrees C, 27-29% was lost in 24 hours. About 10% of the lorazepam was lost from the lactated Ringer's solution in PVC bags after three days at 4 degrees C; 25% was lost in 24 hours at 24 degrees C; and 25% was lost in eight hours at 37 degrees C.(ABSTRACT TRUNCATED AT 250 WORDS)

Child↗
PubMed1994

Physician response to a prediction rule for the triage of emergency department patients with chest pain.

OBJECTIVE: To determine the response of physicians to a noncoercive prediction rule for the triage of emergency department patients with chest pain. DESIGN: Prospective time-series intervention study. SETTING: A university hospital emergency department. PARTICIPANTS/PATIENTS: 68 physicians, all of whom were responsible for the triage of at least one of 252 patients presenting to the emergency department with a chief complaint of acute chest pain. INTERVENTION: A previously validated algorithmic prediction rule that was attached to the back of patient data forms in the emergency department. MEASUREMENTS: Patients' clinical data were recorded by the examining physician in the emergency department or by a research nurse blinded to patient outcome. The physicians recorded their own estimates of the risk of acute myocardial infarction and their reactions to the prediction rule in a self-administered questionnaire completed at the time of triage. MAIN RESULTS AND CONCLUSIONS: The physicians reported that they looked at the prediction rule during the triage of 115 (46%) of the 252 patients. The likelihood of using the prediction rule decreased significantly with increasing level of physician training. The most common reasons given for disregarding the prediction rule were confidence in unaided decision making and lack of time. The physicians reported that of the 115 cases for which the prediction rule was used, only one triage decision (1%) was changed by it. Future research should explore how prediction rules can be designed and implemented to surmount the barriers highlighted by these data.

Algorithms↗
PubMed1994

The impact of membership in a health maintenance organization on hospital admission rates for acute chest pain.

OBJECTIVE: We evaluate the impact of membership in a staff-model health maintenance organization (HMO) on hospital admission rates for patients presenting to an emergency department with acute chest pain. DATA SOURCES AND STUDY SETTING: Primary prospective data were gathered from all 3,006 patients presenting with a chief complaint of chest pain to the emergency department (ED) of a university teaching hospital from October 1987 to November 1989. STUDY DESIGN: Prospective cohort analysis used clinical data to stratify patients into groups at high (> or = 25%), medium (8-24%), and low risk (< or = 7%) of acute myocardial infarction (AMI). Insurance status was determined as either HMO, Medicare, commercial, Medicaid, or self-pay. Triage decisions were recorded, and patient outcomes of AMI and other final diagnoses were determined for all patients. DATA COLLECTION METHODS: Clinical data were recorded by the physicians in the ED as part of a detailed protocol. Insurance data were recorded separately by the ED staff as part of the hospital administrative database. Patient outcomes were recorded daily by research nurses for hospitalized patients; for patients who were discharged from the ED, telephone or physician follow-up was accomplished within seven days after discharge. PRINCIPAL FINDINGS: HMO patients were more likely to be admitted to the hospital than patients in other insurance groups in both the medium- and low-risk patient categories. Within the low-risk category, after controlling for clinical differences in a multiple logistic model, HMO membership retained an independent positive association with hospital admission compared to all other insurance groups except Medicaid. CONCLUSIONS: For patients with acute chest pain who were at medium and low risk of acute myocardial infarction, HMO membership was associated with higher rates of hospital admission. These findings suggest that organizational factors beyond financial incentives may exercise an important influence on hospitalization rates for HMO patients.

Acute Disease↗