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Biomedical subjects

S J Bernstein

Publications and source records attributed to S J Bernstein.

47 records · Page 3Linked to original sources
PubMed1993

The appropriateness of hysterectomy. A comparison of care in seven health plans. Health Maintenance Organization Quality of Care Consortium.

OBJECTIVE: To develop and test a method for comparing the appropriateness of hysterectomy use in different health plans. DESIGN: Retrospective cohort study. SETTING: Seven managed care organizations. PATIENTS: Random sample of all nonemergency, non-oncological hysterectomies performed in the seven managed care organizations over a 1-year period. Patients who were not continuously enrolled in a plan for 2 years prior to their hysterectomy were excluded. MAIN OUTCOME MEASURES: Proportion of women undergoing hysterectomy in each plan for inappropriate clinical reasons according to ratings derived from a panel of managed care physicians. RESULTS: Overall, about 16% of women underwent hysterectomy for reasons judged to be clinically inappropriate. Only one plan had significantly more hysterectomies rated inappropriate compared with the group mean (27%, unadjusted). Adjusting for age and race did not affect the rankings of the plans and had little effect on the numeric results. CONCLUSION: The rates of inappropriate use of hysterectomies are similar to those for other procedures and vary to a small degree among health plans. This information may be useful to purchasers when they consider which health plans to offer their employees.

Adult↗
PubMed1993

The appropriateness of use of coronary artery bypass graft surgery in New York State.

OBJECTIVE: To determine the appropriateness of use of coronary artery bypass graft surgery in New York State. DESIGN: Retrospective randomized medical record review. SETTING: Fifteen randomly selected hospitals in New York State that provide coronary artery bypass graft surgery. PATIENTS: Random sample of 1338 patients undergoing isolated coronary artery bypass graft surgery in New York State in 1990. MAIN OUTCOME MEASURES: Percentage of patients who had bypass surgery for appropriate, inappropriate, or uncertain indications; operative (30-day) mortality; and complications. RESULTS: Nearly 91% of the bypass operations were rated appropriate; 7%, uncertain; and 2.4%, inappropriate. This low inappropriate rate differs substantially from the 14% rate found in a previous study of patients operated on in 1979, 1980, and 1982. The difference in rates was not due to more lenient criteria but to changes in practice, the most important being that the fraction of patients receiving coronary artery bypass grafts for one- and two-vessel disease fell from 51% to 24%. Individual hospital rates of inappropriateness (0% to 5%) did not vary significantly. Rates of appropriateness also did not vary by hospital location, volume, or teaching status. Operative mortality was 2.0%; 17% of patients suffered a complication. Complication rates varied significantly among hospitals (P < .01) and were higher in downstate hospitals. CONCLUSIONS: The rates of inappropriate and uncertain use of coronary artery bypass graft surgery in New York State were very low. Rates of inappropriate use did not vary significantly among hospitals, or according to region, volume of bypass operations performed, or teaching status.

Coronary Artery Bypass↗
PubMed1993

The appropriateness of use of percutaneous transluminal coronary angioplasty in New York State.

OBJECTIVE: To determine the appropriateness of use of percutaneous transluminal coronary angioplasty (PTCA) in New York State. DESIGN: Retrospective randomized medical record. SETTING: Fifteen randomly selected hospitals in New York State that provide PTCA. PATIENTS: Random sample of 1306 patients undergoing PTCA in New York State in 1990. MAIN OUTCOME MEASURES: Percentage of patients who underwent PTCA for indications rated appropriate, uncertain, and inappropriate. RESULTS: The majority of patients received PTCA for chronic stable angina, unstable angina, and in the post-myocardial infarction period (up to 3 weeks). Fifty-eight percent of PTCAs were rated appropriate; 38%, uncertain; and 4%, inappropriate. The inappropriate rate varied by hospital from 1% to 9% (P = .12); the uncertain rate, from 26% to 50% (P = .02); and the combined inappropriate and uncertain rate, from 29% to 57% (P < .001). There was no difference in appropriateness when the institutions were grouped by volume (fewer than 300 procedures annually or at least 300 procedures annually), location (upstate vs downstate), or by teaching status. CONCLUSIONS: Few PTCAs were performed for inappropriate indications in New York State. However, the large number of procedures performed for indications that were rated uncertain as to their net benefit requires further study and justification at both clinical and policy levels.

Adult↗
PubMed1993

The appropriateness of use of coronary angiography in New York State.

OBJECTIVE: To determine the appropriateness of use of coronary angiography in New York State. DESIGN: Retrospective randomized medical record review. SETTING: Fifteen randomly selected hospitals in New York State that provide coronary angiography. PATIENTS: Random sample of 1335 patients undergoing coronary angiography in New York State in 1990. MAIN OUTCOME MEASURES: Percentage of patients who underwent coronary angiography for appropriate, uncertain, or inappropriate indications. RESULTS: Approximately 76% of coronary angiographies were rated appropriate; 20%, uncertain; and 4%, inappropriate. Inappropriate use did not vary significantly between the elderly (ie, patients aged 65 years and older) and nonelderly, 4.7% and 3.9%, respectively. Although the rate of inappropriate use varied from 0% to 9% among hospitals, the difference was not significant. Rates of appropriateness did not vary by hospital location (upstate vs downstate), volume (fewer than 750 procedures annually or at least 750 procedures annually), teaching status, or whether revascularization was available at the hospital where angiography was performed. CONCLUSIONS: Although coronary angiography was used for few inappropriate indications in New York State, many procedures were performed for uncertain indications in which the benefit and risk were approximately equal or unknown.

Adult↗
PubMed1993

The appropriateness of the use of cardiovascular procedures. British versus U.S. perspectives.

To determine whether patients are less likely to receive an inappropriate procedure in countries that devote fewer resources to health care than does the United States, we studied how appropriately coronary angiography and coronary artery bypass surgery were performed in the Trent region of the United Kingdom. The medical records of 320 patients who underwent coronary angiography and 319 who underwent coronary artery bypass surgery in 1987 and 1988 were randomly selected for review. Despite the United Kingdom's more limited use of coronary angiography and coronary artery bypass surgery, a substantial proportion were still performed for less than appropriate reasons, by both U.S. and U.K. criteria. Merely reducing the rate of use of these procedures will not be sufficient to eliminate such inappropriate use.

Aged↗
PubMed1990

Audit of coronary angiography and bypass surgery.

The appropriateness of coronary angiography and coronary artery bypass surgery in the Trent regional health authority was assessed by comparison with predetermined consensus criteria. 49% of coronary angiographies were considered to be entirely appropriate in relation to the patient's clinical condition, but 21% were deemed inappropriate. Coronary artery bypass surgery was considered appropriate in 55% of patients, but inappropriate in 16%. Audit by "appropriateness" scores may help to determine which patients should first be investigated and treated when resources are limited and waiting lists are long.

Adult↗
PubMedDate not supplied

The appropriateness of use of cardiovascular procedures in women and men.

OBJECTIVE: To determine whether there are differences between women and men in the appropriateness of use of cardiovascular procedures. DESIGN: Retrospective chart review. SETTING: Thirty hospitals located in New York State. PATIENTS: Random sample of 3979 patients undergoing coronary angiography, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery in 1990. MEASURES: We evaluated two measures: (1) the percent of women and men who underwent cardiovascular procedures for appropriate, uncertain, and inappropriate indications and (2) for coronary angiography patients, the prognostic exercise stress treadmill score that predicts before the coronary angiogram the 5-year probability of death from a cardiovascular event. RESULTS: The inappropriate rate of use of cardiovascular procedures was low and not significantly different for men and women (4% vs 5% for coronary angiography; 4% vs 3% for percutaneous transluminal coronary angioplasty; and 2% vs 3% for coronary artery bypass graft surgery, respectively), and the use of these procedures for uncertain reasons also did not vary significantly by gender. There was also no significant gender difference in the predicted risk of death from a cardiovascular event for coronary angiography patients: 24% of men and 22% of women were at high risk (ie, < 75% 5-year survival rate) and 20% and 16%, respectively, were at low risk (ie, > or = 95% 5-year survival rate). CONCLUSION: Based on two indicators, the RAND appropriateness score and the Duke prognostic exercise treadmill score, we were unable to find any evidence of a difference in the clinical appropriateness of use of these three cardiovascular procedures between women and men.

Adult↗
PubMedDate not supplied

Coronary angiography and revascularization: defining procedural indications through formal group processes. The Canadian Revascularization Panel, the Canadian Coronary Angiography Panel.

OBJECTIVES: To summarize the process and extent of interphysician agreement within two panels convened to derive indications for the appropriate use of coronary angiography and for coronary revascularization procedures. PARTICIPANTS: Two panels, each with nine practitioners. METHODS: Panelists rated the appropriateness of intervention for a comprehensive set of indications for each procedure. Indications were brief profiles created by combining and permuting clinical characteristics pertinent to case selection for intervention. Ratings were first made at home, with a second round at the panel meeting following open discussion. Final rankings of indications as 'appropriate', 'uncertain' or 'inappropriate' were based on the pattern of panelists' responses on a nine-point scale, including the median rating and extent of agreement among panelists. Agreement was defined as at least seven panelists' ratings within the three-point region containing the median rating. Panelists were later mailed a much-reduced list of indications for which there was agreement on appropriateness. These were re-rated on a necessity scale. A procedure was rated 'necessary' only if a physician was ethically obligated to recommend it as the preferred treatment option. RESULTS: For appropriateness of angiography, agreement occurred in 38.2% of indications in round 1 and 64.4% in round 2 (P < 0.0001). For coronary artery bypass graft (CABG) versus medical therapy, the corresponding increase was from 43.5 to 54.0% (P < 0.0001). Agreement on necessity of angiography occurred for 44.3% of scenarios. For indications where CABG alone was appropriate, agreement on necessity was 56%. However, for indications where percutaneous transluminal coronary angioplasty (PTCA) could be regarded as the first-line intervention, agreement on necessity was only 5%. CONCLUSIONS: A two-step panel process permitted considerable convergence of panelists' ratings, highlighting the importance of formal panel methods in setting utilization management criteria. However, the extent of continuing disagreement on ratings underscores the need to avoid a forced consensus; instead, divergent opinions should be taken as indicative of uncertainty about the appropriateness of intervention. Interpanelist agreement on necessity ratings was modest, but may help in setting benchmarks to assess possible underprovision of invasive cardiac services in Canada.

Angioplasty, Balloon, Coronary↗