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Biomedical subjects

S Greenfield

Publications and source records attributed to S Greenfield.

At least 109 records · Page 6Linked to original sources
PubMed1989

Changing physician test ordering in a university hospital. An intervention of physician participation, explicit criteria, and feedback.

To decrease inappropriate test ordering by medical house staff in a university hospital, we examined the feasibility of an intervention that involved physicians in developing explicit criteria for ordering four specific tests and incorporated feedback of tests ordered. We implemented a time series design with measures at 12 and six months before, during, and three weeks after the intervention. During the intervention, orders for initial or admission chest roentgenograms decreased by 22% and repeated orders for routine urinalyses, chest roentgenograms, and leukocyte differential counts decreased by 23%, 30%, and 46%, respectively, compared with the six-month preintervention period. Orders for prothrombin time and/or partial thromboplastin time did not fall. After the intervention, most test ordering remained at the intervention level. These preliminary results suggest that this intervention may be effective and not overly costly.

Blood Coagulation Tests↗
PubMed1988

Flaws in mortality data. The hazards of ignoring comorbid disease.

Recent public releases of hospital mortality data have sparked debate over methods to identify poor-quality care. We examined variations among hospitals in patient characteristics known independently to affect the risk of adverse outcomes and focused on patient comorbidity, defined as the state of health at admission apart from the primary diagnosis. Data from a study of 2935 incident cancer patients treated in seven Southern California hospitals revealed substantial variations among hospitals in age, cancer stage, and the burden of comorbid conditions. In the highest-ranked hospital, 17.9% of patients had high levels of comorbidity, compared with 9.3% in the lowest-ranked hospital. The three hospitals with the highest comorbidity were also identified as high-mortality outliers in a recent California report on hospital mortality rates. We conclude that comorbidity must be considered in any hospital quality assessment method based on patient outcome. If it is not considered, variations in referral and admission patterns may be misinterpreted as differences in hospital quality.

Age Factors↗
PubMed1988

Synthesis and receptor binding of polynuclear organometallic estradiol derivatives.

Twelve novel organometallic derivatives of estradiol were synthesized with the aim of utilizing organometallic cold bioprobes as radioisotopic labels substitutes for steroid hormone receptor assays. For this purpose, we envisaged the attachment of several stable cobalt, molybdenum, osmium carbonyl clusters (tetra- and pentanuclear species) at estradiol 17 alpha-, 16 alpha-, 2- or 4-positions. The binding affinity of these new complexes for uterine estradiol receptor has been measured by the competitive binding method. The results show that the 17 alpha-position can tolerate substitution by bulky organometallic groups (especially in the case of cobalt and molybdenum carbonyl clusters). Estradiol derivatives which are functionalized at C-4 and C-16 alpha bind estradiol receptor with reasonable affinity and the RBA values are the same for the complexed and uncomplexed hormones. The 2- position is more sensitive to organometallic substitution and the complexation at the 2- alkyne results in a dramatic decrease of the RBA values. These results show that the attachment of polynuclear moieties in estradiol 17 alpha-, 4- and 16 alpha-, positions gives rise to compounds which are of potential utility in a new non-radioisotopic receptor assay since the metal-carbonyl markers are readily detected by high-sensitivity Fourier-transform infra-red spectroscopy.

Animals↗
PubMed1988

Agreement among physician assessment methods. Searching for the truth among fallible methods.

To determine the convergent validity of four methods of physician assessment--physician interview, patient interview, chart audit, and videotaped observation--these methods were compared for their ability to detect medication regimens prescribed for patients with chronic obstructive pulmonary disease (COPD). Comparisons of data from the four methods revealed substantial discrepancies among them. In fact, the methods were in full accord only 36% of the time in detecting theophylline prescription, and even less often for the other COPD medications. According to physician interview, 78% of patients were on theophylline; chart audit revealed 62% of patients were on the medication; videotaped observation, 69%; and only 59% of patients reported themselves to be on theophylline. An iterative analysis, applied to determine which method most accurately captures data, revealed that reports from physician interviews were the most precise source of data. Although the order of merit was much the same for each of the drugs studied, there were some differences in levels of sensitivity across drugs. Specificities were consistently high for all drugs and all methods.

Adrenal Cortex Hormones↗
PubMed1988

A nurse practitioner in general practice: patient perceptions and expectations.

A study exploring the acceptability of a nurse practitioner to a random sample of 126 patients is reported. Sixty per cent of patients either approved of the concept and expressed willingness to consult the nurse or held no strong views. Fifty three per cent of the 61 patients who had seen her already were prepared to see her again. Fifty four per cent of patients had difficulty in differentiating between the role of the nurse practitioner and the doctor and the perceived differences included qualifications, ability to prescribe drugs and the severity of the condition dealt with. Women were nearly three times more likely than men to consult a nurse practitioner. Good communication skills were reported to be among the most sought after qualities of those whom patients consult about their health problems.

Consumer Behavior↗
PubMed1987

The complete blood count and leukocyte differential count. An approach to their rational application.

The complete blood count and leukocyte differential count have no value in screening asymptomatic members of the general population. The complete blood count may be useful for screening infants in the first year of life, institutionalized elderly persons, pregnant women, and recent immigrants from Third World countries, if poor nutrition or inadequate iron intake is suspected. These tests are not useful for hospitalized patients, unless an abnormality is suspected or surgery with major blood loss is anticipated. It is appropriate to obtain the tests when a hematologic or infectious disorder is suspected, but they may not affect decision making if the diagnosis is clinically evident. The leukocyte differential count is unnecessary to confirm an infection in most cases in which leukocytosis is present. Repeat tests should be limited to situations where the clinical course is unclear, and at intervals long enough such that the results might affect clinical decision making.

Ambulatory Care↗
PubMed1987

Practice nurses: social and occupational characteristics.

Three hundred practice nurses in the West Midlands responded to a questionnaire survey about their social and occupational characteristics. The nurses were mainly married women with children and had had considerable hospital experience. They were largely satisfied with their job and felt that their own general practitioner colleagues were supportive, though doctors in general might not be so. Large variations in patterns of work were revealed and in some cases there was a considerable extension of the traditional nursing role. Almost two-thirds of practice nurses were undertaking breast and vaginal examinations, 70% were carrying out cervical smears and a number of nurses were diagnosing, investigating and managing common ailments. Nurses expressed a desire for further extension of their role to allow them to undertake broader aspects of patient care and to be less task-centred, but felt that they would require further training to do so. There was evidence of a need for better definition of the practice nurse's role and for more support from health authorities and the nurses' own professional body.

Adult↗
PubMed1987

A nurse practitioner in general practice: working style and pattern of consultations.

The work of a specially trained nurse practitioner, to whom patients had open access, was studied in an inner city general practice over a period of six months in 1983. A total of 858 patients of all ages and ethnic origins sought consultations for 979 problems. Morbidity from every diagnostic group was presented but the majority of the problems (60.4%) fell into the 'Supplementary' group: preventive medicine; health instruction and education; social, marital and family problems; administrative procedures. The consultation room setting and the long appointment times available (20 minutes) may partly account for this. Additional problems, mostly concerning health education, were raised in 46.0% of consultations. Most patients chose a consultation with the nurse practitioner appropriately and in more than one-third of all consultations the nurse managed the presenting problem without further referral for investigation, prescription or other medical advice. It is concluded that nurses have a much larger and more autonomous part to play in the care of patients than hitherto.

England↗
PubMed1986

Proteolysis in quaking mouse brain and spinal cord.

Six proteolytic enzymes were assayed for activity in quaking CNS in examining the hypothesis that increased proteolytic activity contributes to the hypomyelination characteristics of this mutant. Cathepsin B-like enzyme, cathepsin D, neutral proteinase, calcium-activated neutral proteinase, prolyl endopeptidase, and diaminopeptidase II were assayed in whole homogenate of brain or spinal cord and each was found to have activity similar to that in normal mice. These results do not support a relationship between proteolysis and the genetic defect and suggest that other factors should be investigated to delineate the pathogenesis of this mutant.

Animals↗
PubMed1986

The efficacy of endoscopy in the evaluation of dyspepsia. A review of the literature and development of a sound strategy.

Diagnostic approaches to the patient with dyspepsia include immediate evaluation with an upper gastrointestinal series, immediate study with esophagogastroduodenoscopy (EGD), or empiric medical treatment, reserving diagnostic evaluation for patients with complications and persistent symptoms after therapy. A literature review of dyspepsia as a symptom, and of duodenal ulcer, gastric ulcer, gastroduodenitis, and gastric cancer summarizes how the diagnostic approaches to the dyspeptic patient affect the precision of diagnostic information, efficacy, patient outcome, and cost. For patients without clinically obvious disease, an approach is developed which reduces cost and retains optimal patient management. The strategy proposes the use of empiric medical therapy while reserving EGD for those few dyspeptic patients who have no or minimal response to therapy after 7 to 10 days, and for the approximately 30% of patients whose symptoms persist, improved, but not resolved after a 6 to 8 week period.

Costs and Cost Analysis↗
PubMed1985

The impact of routine admission chest x-ray films on patient care.

We evaluated the impact of routine chest x-ray films, obtained on admission, on the treatment of patients on internal medicine wards of the Veterans Administration Medical Center, Long Beach, California--a population known to have a high prevalence of cardiopulmonary disease. The reasons for ordering chest films were determined prospectively, and three Department of Medicine faculty members reviewed the charts of admitted patients to determine the impact of chest-film results on patient care. Routine chest x-ray films were ordered for 294 (60 per cent) of the 491 patients studied. Abnormalities were noted in 106 (36 per cent) of these 294 patients. The findings were previously known, chronic, and stable in 86 patients; they were new in only 20. Treatment was changed because of chest-film results in only 12 (4 per cent) of the patients. In only one of these patients would appropriate treatment probably have been omitted if a chest film had not been obtained, and the patient's outcome was not improved by the treatment instituted. We conclude that the impact of routine admission chest x-ray films on patient care is very small, even in a population with a high prevalence of cardiopulmonary disease. We recommend that such films not be ordered solely because of admission.

Adult↗
PubMed1985

A growth regulatory factor that can both inhibit and stimulate growth.

A growth inhibitor that is produced by BSC-1 cells (African green monkey kidney epithelial cells) has been isolated from conditioned medium. It has been purified by gel chromatography and high performance liquid chromatography. It appears to be a protein with a relative molecular mass (Mr) of 24 000. It is extremely active as a growth inhibitor with some cells, but not with others. Approximately 50% inhibition of thymidine incorporation is observed with CCL64 cells at 0.05 ng/ml and with BSC-1 cells at 1 ng/ml. The growth inhibitor induces BSC-1 cells to synthesize and secrete a glycoprotein of approximately 48 000 Mr. It inhibits Na+ accumulation in BSC-1 cells. Recently, in collaboration with R. F. Tucker, G.D. Shipley and H. L. Moses (Mayo Foundation & Medical School), we have found that the growth inhibitor is very similar to and may be identical with transforming growth factor beta (TGF-beta). Our growth inhibitor stimulates colony formation in soft agar by AKR-2B cells, and it competes with TGF-beta in binding to cell surface receptors. TGF-beta, from human platelets, is extremely active as an inhibitor of thymidine incorporation by BSC-1 cells and CCL64 cells. The growth inhibitor/TGF-beta can, therefore, stimulate or inhibit growth, depending on the cells and the growth conditions.

Animals↗
PubMed1985

Expanding patient involvement in care. Effects on patient outcomes.

An intervention was developed to increase patient involvement in care. Using a treatment algorithm as a guide, patients were helped to read their medical record and coached to ask questions and negotiate medical decisions with their physicians during a 20-minute session before their regularly scheduled visit. In a randomized controlled trial we compared this intervention with a standard educational session of equal length in a clinic for patients with ulcer disease. Six to eight weeks after the trial, patients in the experimental group reported fewer limitations in physical and role-related activities (p less than 0.05), preferred a more active role in medical decision-making, and were as satisfied with their care as the control group. Analysis of audiotapes of physician-patient interactions showed that patients in the experimental group were twice as effective as control patients in obtaining information from physicians (p less than 0.05). Results of the intervention included increased involvement in the interaction with the physician, fewer limitations imposed by the disease on patients' functional ability, and increased preference for active involvement in medical decision-making.

Adult↗
PubMed1984

Cost containment and labor-intensive tests. The case of the leukocyte differential count.

We conducted an analysis of the use of the leukocyte differential count to determine (1) the services ordering the largest numbers of tests, (2) the proportion of differentials that were clinically justifiable and useful, and (3) the potential for real cost savings as opposed to reduction in charges if unjustified differentials could be eliminated. The sources of all laboratory requisitions during three nonconsecutive weeks were determined; criteria for test justifiability were established; an audit of a random sample of medical records was conducted on two services obtaining the most tests; and a time-motion study was undertaken in the hospital hematology laboratory. Forty-seven percent of differentials were obtained on medical and surgical inpatients and only 10% in the medical clinics. Forty-eight percent and 62% of differentials on the medical and surgical services, respectively, were unjustifiable , making up 26% of all differentials done in the hospital laboratory. Test results appear to have affected patient management in less than 3% of patients; no unjustified test altered a patient's diagnosis or therapy. Elimination of only "unjustified" medical and surgical differentials would permit a reduction of 1.8 full-time equivalent positions from the hospital laboratory. The leukocyte differential is over-used, only occasionally useful, and amenable to real cost reduction.

California↗