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Biomedical subjects

S H Gehlbach

Publications and source records attributed to S H Gehlbach.

At least 19 recordsLinked to original sources
PubMed2003

Hospital care of osteoporosis-related vertebral fractures.

Resource implications of hospitalization for osteoporosis-related vertebral fracture are sparsely documented. This study utilized data abstracted from a national sample of hospitalized patients to identify characteristics of patients who are hospitalized with vertebral fracture and their patterns of resource utilization. These were compared with patterns observed for hip fracture hospitalizations. Data from the Nationwide Inpatient Sample (NIS) for 1997 were used to identify men and women age 45 years and above who had a primary diagnosis of vertebral fracture. After patients whose fractures might have been due to metastatic cancer or severe trauma were excluded, 68,901 individuals hospitalized for vertebral fracture were identified. Seventy-seven percent of these were women, most were white, 75 years and older, and had multiple comorbid diagnoses. Total charges averaged 8000-10,000 US dollars per hospitalization and were higher in men. Mean length of stay was just under 6 days and more than 50% of discharged patients required some form of continuing care. Hospitalizations for vertebral fracture occurred at only one-fourth the rate of those for hip fracture, and created only half the hospital charges per admission. Vertebral fracture accounted for over 400,000 total hospital days and generated charges in excess of 500 million US dollars. This resource impact is considerably higher than has been described in prior studies.

Age Distribution↗
PubMed2000

Recognition of vertebral fracture in a clinical setting.

Osteoporosis-related vertebral fractures have important health consequences for older individuals, including disability and increased mortality. Because these fractures can be prevented with appropriate medications, recognition and treatment of high-risk patients is warranted. A cross-sectional survey was carried out in a large, regional hospital in New England to examine the frequency with which vertebral fractures are identified and treated by clinicians in a population of hospitalized older women who have radiographic evidence of fractures. The study population consisted of 934 women aged 60 years and older who were hospitalized between October 1, 1995 and March 31, 1997, and who had a chest radiograph obtained. Vertebral fractures in the thoracic region were identified by two radiologists. Discharge diagnoses, medical record notes and radiology reports were compared with the results of the radiologists' readings to determine the frequency with which fractures were identified and appropriate, osteoporosis-preventing medications prescribed. Moderate or severe vertebral fractures were identified for 132 (14.1%) study subjects, but only 17 (1.8%) of the 934 participants had a discharge diagnosis of vertebral fracture. Of these 132, only 17% had fracture noted in the medical record or discharge summary; 50% of contemporaneous radiology reports identified a fracture as present; and 23% of the time it was found in the radiologist's summary impression. Only 18% of medical records indicated that fracture patients had been prescribed calcium, vitamin D, estrogen replacement or an antiresorptive agent. Relatively few hospitalized older women with radiographically demonstrated vertebral fractures were thus identified or treated by clinicians, suggesting a need for improved recognition.

Aged↗
PubMed1994

Mortality probability models for patients in the intensive care unit for 48 or 72 hours: a prospective, multicenter study.

OBJECTIVE: To develop models in the Mortality Probability Model (MPM II) system to estimate the probability of hospital mortality at 48 and 72 hrs in the intensive care unit (ICU), and to test whether the 24-hr Mortality Probability Model (MPM24), developed for use at 24 hrs in the ICU, can be used on a daily basis beyond 24 hrs. DESIGN: A prospective, multicenter study to develop and validate models, using a cohort of consecutive admissions. SETTING: Six adult medical and surgical ICUs in Massachusetts and New York adjusted to reflect 137 ICUs in 12 countries. PATIENTS: Consecutive admissions (n = 6,290) to the Massachusetts/New York ICUs were studied. Of these patients, 3,023 and 2,233 patients remained in the ICU and had complete data at 48 and 72 hrs, respectively. Patients < 18 yrs of age, burn patients, coronary care patients, and cardiac surgical patients were excluded. OUTCOME MEASURE: Vital status at the time of hospital discharge. RESULTS: The models consist of five variables measured at the time of ICU admission and eight variables ascertained at 24-hr intervals. The 24-hr model demonstrated poor calibration and discrimination at 48 and 72 hrs. The newly developed 48- and 72-hr models--MPM48 and MPM72--contain the same 13 variables and coefficients as the MPM24. The models differ only in their constant terms, which increase in a manner that reflects the increasing probability of mortality with increasing length of stay in the ICU. These constant terms were adjusted by a factor determined from the relationship between the data from the six Massachusetts and New York ICUs and a more extensive data set, from which the ICU admission Mortality Probability Model (MPM0) and MPM24 were developed. This latter data set was assembled from ICUs in 12 countries. The MPM48 and MPM72 calibrated and discriminated well, based on goodness-of-fit tests and area under the receiver operating characteristic curve. CONCLUSIONS: Models developed for use among ICU patients at one time period are not transferable without modification to other time periods. The MPM48 and MPM72 calibrated well to their respective time periods, and they are intended for use at specific points in time. The increasing constant terms and associated increase in the probability of hospital mortality exemplify a common clinical adage that if a patient's clinical profile stays the same, he or she is actually getting worse.

Adult↗
PubMed1994

Evaluating worksite health programs.

Worksite health enhancement programs utilize screening and early disease detection or risk reduction as health promotion activities. Objectives for these include improving the health and productivity of employees and reducing health care costs. However, critical questions about the effectiveness of programs should be answered before managers initiate these activities. Issues include accuracy of measurement and subject classification, adequate use of comparisons and follow-up in evaluation studies, and evidence of cost effectiveness.

Adult↗
PubMed1993

Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients.

OBJECTIVE: To revise and update models in the Mortality Probability Model (MPM II) system to estimate the probability of hospital mortality among 19,124 intensive care unit (ICU) patients that can be used for quality assessment within and among ICUs. DESIGN AND SETTING: Models developed and validated on consecutive admissions to adult medical and surgical ICUs in 12 countries. PATIENTS: A total of 12,610 patients for model development, 6514 patients for model validation. Patients younger than 18 years and burn, coronary care, and cardiac surgery patients were excluded. OUTCOME MEASURE: Vital status at hospital discharge. RESULTS: The admission model, MPM0, contains 15 readily obtainable variables. In developmental and validation samples it calibrated well (goodness-of-fit tests: P = .623 and P = .327, respectively, where a high P value represents good fit between observed and expected values) and discriminated well (area under the receiver operating characteristic curve = 0.837 and 0.824, respectively). The 24-hour model, MPM24 (developed on 10,357 patients still in the ICU at 24 hours), contains five of the admission variables and eight additional variables easily ascertained at 24 hours. It also calibrated well (P = .764 and P = .231 in the developmental and validation samples, respectively) and discriminated well (area under the receiver operating characteristic curve = 0.844 and 0.836 in the developmental and validation samples, respectively). CONCLUSIONS: Among severity systems for intensive care patients, the MPM0 is the only model available for use at ICU admission. Both MPM0 and MPM24 are useful research tools and provide important clinical information when used alone or together.

Adult↗
PubMed1989

Functional versus structural social support and health care utilization in a family medicine outpatient practice.

Three hundred forty-three family-practice patients were surveyed by questionnaire and medical record audit to evaluate the relationships between social support and medical care utilization. Social support was not associated with laboratory test ordering. The mean number of office visits per year was higher for patients with low versus high confidant support (4.71 vs. 3.81, P less than 0.10) and affective support (5.21 vs. 3.60, P less than 0.05). Mean total charges in 1 year were higher for patients with low versus high confidant support ($232 vs. $148, P less than 0.05) and affective support ($244 vs. $154, P less than 0.05). Poor confidant and affective support were both associated with longer visits. Structural measures of social support were not related significantly to any utilization indicator. These findings were maintained in multiple-regression models controlling for physical health and seven demographic characteristics. Second-order regression models revealed interaction by race, employment status, and sex. Blacks showed no effect of confidant support on office visits. Poor confidant support resulted in $201 more in total charges for the unemployed (P = 0.003) versus $49 more for the employed (P = 0.15). Women with low affective support had $119 more in charges (P = 0.001) versus $16 less for men (P = 0.82). The results suggest that low functional social supports are important determinants of increased medical service utilization and that they may have differential effects by race, sex, and employment status, all of which should be considered independently in future studies.

Adolescent↗
PubMed1988

Caregivers and elderly relatives. The prevalence of caregiving in a family practice.

Persons 65 years and older are the most rapidly growing age group in the United States. As age increases, functional ability deteriorates and the need for help from another person escalates. Caring for elderly persons experiencing functional deterioration is stressful, creating hidden patients among caregivers. This study surveyed randomly selected active family practice patients 40 years and older to determine the prevalence and extent of the caregiving role and functional disability among elderly relatives. One in five patients (126/602) surveyed had caregiving responsibilities for noninstitutionalized relatives (total, 153 patients). One third of caregivers lived with the relative; most of the remaining two thirds visited their relative at least twice weekly. Caregivers reported some functional impairment in 60% of their relatives, and substantial impairment in 40%. The caregiving experience is common, and the potential for stress from managing an elderly relative's disability is substantial. Further research is needed to elaborate on the burden of the caregiver.

Activities of Daily Living↗
PubMed1988

Effect of prepaid health plans on a family practice residency.

The rapid growth of prepaid health care plans imposes clinical, financial, and educational changes on residency programs. In the study reported here, the authors examined some perceived and actual effects of such plans on a family medicine center associated with a family medicine residency training program. In the study, 37 residents and 19 faculty members completed a 5-point, 16-item survey covering the effect of the prepaid plans used at the center on the program's practice profile, cost-containment efforts, and education activities over a three-year period. Overall, the respondents agreed with the need for cost containment that accompanied participation in the prepaid plan and agreed that prepaid plans increased the number of patient visits and visits by family members. The residents and faculty members agreed that prepaid patients were more demanding and were seen more often for minor or inappropriate problems. Regarding the educational impact of the prepaid plans, the respondents agreed that they improved their clinical decision-making, and no significant concern regarding limitation of laboratory or consultations was noted. Some of the respondents' perceptions were corroborated by findings in the clinic data base that showed increased numbers of patient visits, more visits by members of the same family, and no significant change in outpatient consultation rates.

Attitude of Health Personnel↗
PubMed1988

The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients.

A 14-item, self-administered, multidimensional, functional social support questionnaire was designed and evaluated on 401 patients attending a family medicine clinic. Patients were selected from randomized time-frame sampling blocks during regular office hours. The population was predominantly white, female, married, and under age 45. Eleven items remained after test-retest reliability was assessed over a 1- to 4-week follow-up period. Factor analysis and item remainder analysis reduced the remaining 11 items to a brief and easy-to-complete two-scale, eight-item functional social support instrument. Construct validity, concurrent validity, and discriminant validity are demonstrated for the two scales (confidant support--five items and affective support--three items). Factor analysis and correlations with other measures of social support suggest that the three remaining items (visits, instrumental support, and praise) are distinct entities that may need further study.

Adult↗
PubMed1988

Bacterial diseases of the colon.

Acute diarrhea of bacterial origin is discussed for seven enteric pathogens, and specific antimicrobial therapy based on positive identification is stressed. Selection of patients with self-limited disease not requiring antimicrobial therapy is emphasized in order to avoid costly laboratory tests. The role of daycare facilities in the spread of enteric pathogens in this country is discussed. This article includes a review of newer methods for treating infants and children with oral rehydration and rapid refeeding.

Adult↗
PubMed1988

Fever in children younger than three months of age. A pooled analysis.

Concern that febrile infants younger than 3 months of age are at high risk of serious infection has prompted a management policy of routine hospitalization with antibiotic administration. Ten published studies of febrile infants younger than 3 months of age were reviewed, and data were statistically combined to develop estimates of the risk of bacteremia and serious infection. Factors that predicted increased risk were similarly evaluated. Mean and median risk estimates included, respectively, 3.0 and 3.4 percent for bacteremia, 1.3 and 1.0 percent for septic meningitis, and 5.0 and 7.0 percent for pneumonia. These were no higher than comparable estimates for older infants. Clinical appearance was 92 percent sensitive in predicting bacteremia in 500 infants (23 of 25 cases). Younger age, higher fever, and elevated white blood cell count were associated with increased risk of serious infection. Data from these studies do not support the belief that febrile infants younger than 3 months are uniformly at greater risk of serious infection than older infants. Judicious evaluation of younger infants could lead to more selective, cost-efficient management.

Fever↗
PubMed1987

Family practice residents' evaluation of a competency-based psychiatry curriculum.

The authors report the formal evaluation of a competency-based curriculum in psychiatry in a family practice residency program at a community hospital five years after the program was implemented. In interviews, the 35 residents in the program in 1985 responded to a questionnaire on their understanding of and attitude toward the requirements of the competencies and the difficulties they encountered in documenting the competencies. All but two of the residents were aware of the nature of the curriculum, but only 43 percent had completed one or more of the 15 required competencies. The residents' attitude toward the requirements of demonstrating specific competencies in psychiatry during the residency were generally negative, although they were favorable toward required competencies in other disciplines. The results of the present study identify specific problems in implementing such a curriculum. Successful implementation may have been impeded by the novelty of the new educational format and a lack of reinforcement by faculty members.

Competency-Based Education↗
PubMed1985

Epidemiology for medical students: a controlled trial of three teaching methods.

Medical students taking a course in epidemiology for clinical practice were taught by either lectures, small group seminars or self-learning packages. Examination performances were no different for the three groups, but self-perceived mastery of learning objectives, and satisfaction with the course were higher for students who received self-learning packages. Sixty per cent of self instruction students found the teaching method was successful compared with 37% of the seminar students and only 19% who received lectures. A combination of self-instructional package and seminar would seem to hold most promise for a workable and effective course.

Education, Medical, Undergraduate↗
PubMed1985

Treatment of lower urinary tract infections with single-dose trimethoprim-sulfamethoxazole.

Two hundred three women from a primary care medical practice with symptoms of lower urinary tract infection and positive urine cultures were treated with trimethoprim-sulfamethoxazole. One hundred eleven women received a single dose and 92 were treated for ten days. Cure rates were 87 percent and 89 percent, respectively, one week after therapy. A narrow 95 percent confidence interval for the difference between the two cure rates (.02 +/- .09) suggests the treatments are equally effective. Patients were followed by chart audit and a self-reporting questionnaire. No difference in recurrence rates was found between the two groups six months after therapy. Single-dose trimethoprim-sulfamethoxazole is as effective as ten-day treatment in women with symptoms suggestive of lower urinary tract infection and has no greater relapse rate.

Adult↗
PubMed1985

Early termination of breast-feeding: identifying those at risk.

In a private pediatric practice, 94 infants who were breast-feeding were followed for the first 2 months of life in order to define the frequency of cessation of breast-feeding and to identify factors that would predict mothers and infants at risk for early cessation. At 8 weeks, 30% of the mothers had stopped nursing. Factors associated with cessation were: maternal lack of confidence in breast-feeding (P less than .001); anticipated duration of nursing less than 6 months (P = .002); ratings by the nursery staff of infant's excessive crying (P = .007), infant's demanding personality (P = .007), trouble with feeding (P = .001), and future trouble with feeding (P = .004). Together, these factors predicted 77% of the mothers who terminated breast-feeding. Supplementing with formula before the 2-week office visit also led to termination of breast-feeding by 8 weeks (P = .006). This decision was frequently made without medical advice. Nearly 64% (14/22) of the mothers who added formula within the first 2 weeks did so without contacting the pediatric practice.

Adult↗