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Biomedical subjects

S M Retchin

Publications and source records attributed to S M Retchin.

50 records · Page 3Linked to original sources
PubMed1985

The application of official policy. Prophylaxis recommendations for patients with mitral valve prolapse.

In 1977, the American Heart Association recommended that patients with mitral valve prolapse (MVP) and mitral insufficiency receive antibiotic prophylaxis prior to procedures that place them at risk for bacterial endocarditis. To study how clinicians conformed to this recommendation, the authors selected 126 patients with MVP admitted to a University Medical Center in 1978, the year following the official policy. Overall, only 47 patients (37%) had the antibiotic prophylaxis recommended. Furthermore, information that might have increased the certainty of diagnosis of MVP or the likelihood of mitral insufficiency did not influence the physician's decision: symptoms, previous history, procedures, sex, evidence for mitral insufficiency, other serious illnesses, or the use of cardiac medications. However, patients seen in consultation by a cardiologist were much more likely to have prophylaxis recommended (P less than 0.05). It was concluded that the application of an official policy about prophylaxis for a condition such as MVP, where the risks are uncertain, is likely to be guided by other factors, such as the opinions of local experts.

Adult↗
PubMed1984

Clinical geriatric research: still in adolescence.

Clinical investigators face formidable methodologic and ethical challenges in the study of elderly people. To define problems specific to geriatric research the fundamental elements of clinical research are outlined and considerations important to a geriatric study population are identified. Because of the underestimated biologic variation of elderly people, the evaluation of new interventions in one older population may be difficult to generalize to all older people. Inasmuch as older people represent a study population with a lifetime of cumulative exposures for various diseases such as cancer, historical cohort studies are particularly suitable research designs. Despite these advantages, the retrospective study of certain interventions research designs. Despite these advantages, the retrospective study of certain interventions in older people, for example cardiopulmonary resuscitation, requires thoughtful attention to avoid strong and often subtle selection biases. Issues of informed consent and the presence of multiple, comorbid illnesses, especially relevant to clinical trials, are problematic in studying geriatric conditions. Recently, instruments measuring function and disability have been used extensively by investigators in geriatric research, but the precise way to quantify these observations remains controversial. Testing artifacts may be considerably greater in older persons than in many of the populations in which the instruments have been validated. Finally, certain statistical assumptions and inferences may be inappropriate in the study of older people.

Activities of Daily Living↗
PubMedDate not supplied

Factors associated with the frequency of house calls by primary care physicians.

OBJECTIVE: To evaluate factors associated with the frequency of house calls by primary care physicians. DESIGN: A cross-sectional design with a self-administered mailed survey. SITTING/PARTICIPANTS: 751 primary care physicians who care for Medicaid patients in Virginia. RESULTS: Among 389 physician respondents (52%), regular house callers (n = 216) were compared with occasional house callers (n = 162). Among physician characteristics, specialty and practice duration were associated with house call frequency. Regular house callers also more often cited chronic illness (67% vs. 20%, p less than 0.01) and terminal illness (67% vs. 40%, p less than 0.01) as indications for house calls, compared with occasional house callers. Use of visiting nurses to substitute for physician house calls was less often considered appropriate by frequent house callers (7% vs. 24%, p less than 0.01), and regular house callers were less likely to report being "too busy" to make house calls (71% vs. 29%, p less than 0.01). Multivariate analysis confirmed the association of these attitudes with house call frequency. CONCLUSION: These data suggest that specific attitudes among primary care physicians are associated with house call frequency.

Adult↗
PubMedDate not supplied

Health behavior changes in the United States, the United Kingdom, and France.

OBJECTIVE: To determine changes in health behaviors in the United States, the United Kingdom, and France over the previous two years. DESIGN: Cross-sectional survey of nationally representative samples. SETTING/PARTICIPANTS: Surveys conducted between June and November 1988 on persons aged 16 to 50 years in the United States (n = 1,940), the United Kingdom (n = 1,833), and France (n = 2,294) regarding health behaviors, attitudes toward health, and changes in health practices during the previous two years. MEASUREMENTS AND MAIN RESULTS: Using Bonferroni's adjustment for multiple comparisons, residents of the United States had significantly (p < 0.05) higher Quetelet indices and reported higher egg and red meat consumption, but had lower alcohol consumption, than did residents of either the United Kingdom or France. Americans were also significantly more likely to report attitudes accepting personal responsibility for their health and much more often endorsed the role of health behaviors (e.g., exercise) for decreasing the risk of cardiovascular disease. Changes in health behavior over two years were consistently more likely in the United States for weight loss, decreased alcohol consumption, decreased red meat and egg consumption, and increased exercise. Americans were also much more likely to have changed at least three health behaviors in the previous two years (United States 41.5%, United Kingdom 25.5%, France 13.8%, p < 0.002). A multivariate linear model confirmed the high likelihood of health behavior changes in the United States compared with the United Kingdom or France. CONCLUSIONS: The findings confirm that changes in health behaviors are continuing to occur in the United States, but remain comparatively modest in the United Kingdom and France. These international variations in health behaviors parallel differential declines in mortality rates in ischemic heart disease.

Adolescent↗
PubMedDate not supplied

Continuity of care after July: what happens to the resident's patients?

When internal medicine residents leave teaching programs, continuity of care for outpatients is affected. The authors had departing residents send their patients computer-generated letters identifying another physician to provide continuing care. The letters were randomly withheld from 20% of the patients (NL), and they were compared with patients who received letters (RL). A telephone survey was administered and visits and no-show rates were determined. The RL patients more often knew of the change in provider (84% vs 54%, p less than 0.01) and identified the resident as the source of the information (77% vs 43%, p less than 0.01) than NL patients. There were no significant differences between RL and NL patients in mean numbers of appointments (1.0 vs 0.8) or no-show rates (24% vs 21%) following housestaff turnover. Both groups wanted to be told by the physician about future changes and were willing to be informed by letter. A computer-generated letter appears to be an effective way of notifying patients about transfer of care during the annual housestaff turnover in teaching programs.

Appointments and Schedules↗
PubMedDate not supplied

Management of colorectal cancer in Medicare health maintenance organizations.

Because of the financial incentives of prepaid care, the quality of care for Medicare enrollees in Health Maintenance Organizations (HMOs) is a concern. Therefore, the care in 150 newly diagnosed cases of colorectal cancer in eight HMOs was compared with that in 180 similar fee-for-service (FFS) cases. As part of the diagnostic workup, HMO patients were more likely to have had fecal occult blood tests (74% vs 52%, p less than 0.01) and endoscopy or barium enemas (97% vs 90%, p less than 0.05). FFS patients were more likely to have had preoperative imaging studies (54% vs 38%, p less than 0.01). Although there were longer diagnostic delays for HMO enrollees with gastrointestinal bleeding, there were no significant differences in disease stage or clinical status, and postoperative follow-up was similar. The authors conclude that enrollees in Medicare HMOs with colorectal cancer receive medical and surgical care at least equal to that received in FFS settings.

Aged↗
PubMedDate not supplied

The costs and benefits of a screening program to detect dementia in older drivers.

A Markov model was used to assess the cost-benefit ratios of six strategies of screening older drivers for mental status, beginning at age 65. Probabilities of motor vehicle collisions (MVCs), injuries, and fatalities were obtained from national data. Dementia prevalence, test characteristics, and costs were obtained from the literature. Costs included lost wages, car ownership, alternative transportation, and injuries. Using a relative risk of MVC for those with dementia of 5 and a 5% annual discounting rate, the average cost per driver ranged from $51,600 (no testing) to $58,400 (testing every five years). The benefit was < one day of life gained, and the benefits of screening cost approximately 2.8 million dollars per life-year gained. Increasing the relative risk from 5 to 20 substantially improved the cost-benefit of mental status screening. However, mental status screening of older drivers would also be cost-beneficial if physician referral costs were lowered to $60 per evaluation. The authors conclude that a dementia screening program for older drivers would be cost-beneficial if physician evaluations were limited or their cost lowered to < or = $60.

Accidents, Traffic↗
PubMedDate not supplied

Marketplace challenges and opportunities for faculty practice plans.

Because of marketplace challenges related to the growth of managed care, faculty practice plans (FPPs) now are faced with issues similar to community group practices. Emphasis on primary care and price discounts are particularly thorny concerns. Unreimbursed care looms as a hazards for the FPPs affiliated with teaching hospitals in low socioeconomic areas. However, as the marketplace cultivates more global pricing strategies, the FPP-hospital relationship also could prove a distinct advantage. Additionally, the recent emergence of practice management corporations could represent opportunities for FPPs, who need new competencies, and even capital, to remain competitive. This article also discusses the promise of integrated delivery networks and addresses the construction of community partnerships.

Community Networks↗
PubMedDate not supplied

Establishing physician networks within evolving antitrust guidelines.

Rapid changes in health care are being driven by the growth of managed care. Health plans have become more aggressive in negotiating with physicians, and providers have increasingly chosen to establish networks in response. Because these provider networks frequently represent horizontal forms of integration between competitors, antitrust issues have become increasingly important. This article addresses current antitrust law as it relates to physician networks. In particular, it reviews the most recent statements of antitrust enforcement policy of the Department of Justice and the Federal Trade Commission concerning physician networks. Procompetitive activities by physician networks are central to the latest rulings.

Antitrust Laws↗
PubMedDate not supplied

The modification of physician practice patterns.

While physicians are directly responsible for only a small proportion of healthcare expenditures, their decisions influence the majority of medical costs. Because practice variations among physicians have been demonstrated abundantly, strategies to modify practice patterns have evolved. This article addresses the different factors that influence variations in patterns of practice, including physician characteristics, knowledge, beliefs, and attitudes. In designing programs to modify practice patterns, educational efforts, along with practice guidelines and feedback, all have been used. Although there are mixed results for each, the use of opinion leaders and the timing of interventions proximal to practice decisions are important. The costs and benefits of interventions are discussed as a method for assessing the utility of different programs to modify practice patterns.

Behavior Therapy↗
PubMedDate not supplied

Adverse selection at academic health centers.

Market influences are placing many academic health centers (AHCs) in financial distress. Competitive forces threaten the core missions of AHCs, principally because of selective contracting, which has introduced price competition to medical care. This manuscript discusses the issue of adverse selection for AHCs, the probability that patients with higher levels of illness severity seek care at, or are referred to, AHCs. AHCs are particularly vulnerable to adverse selection because of their prominence as referral centers, their specialty composition, research expertise, and the socioeconomic status of patients located proximal to their centers. The adverse selection of AHCs increases the likelihood that health plans will trim their networks to exclude them. Health plans may still contract with AHCs for tertiary care only, but this will only worsen the adverse selection at AHCs.

Academic Medical Centers↗
PubMedDate not supplied

Factors associated with changes in satisfaction with care.

OBJECTIVE: Satisfaction with care is an important outcome for evaluating the effectiveness of medical care. Many factors can influence satisfaction, including disease state, healthcare utilization, and health-status changes. However, few studies have investigated the association between these factors and changes in satisfaction. DESIGN: This study examined the influence of personal characteristics, type of health plan, disease states, and healthcare utilization on changes in satisfaction with care in a prospective cohort over a 12-month period through two surveys, baseline and follow-up. PARTICIPANTS: Enrollees in one of three different commercial health plans: point-of-service product, an unrestricted fee-for-service product, and a preferred-provider organization product. MEASUREMENTS AND MAIN RESULTS: Two multivariate logistic regression models were constructed. The first model evaluated factors that predicted increased satisfaction with care between the two surveys. Compared with respondents who reported no change in health status, both those with improved health status (odds ratio [OR], 1.29, 95% confidence interval [CI95], 1.03-1.61) and those with declines in health (OR, 1.29, CI95, 1.03-1.61) were significantly more likely to report an increase in satisfaction with care. Those with a history of hospitalization were also more likely to report an increase in satisfaction with care (OR, 1.27, CI95, 1.01-1.59). The second multivariate logit model evaluated factors that predicted decreases in satisfaction with care from the baseline survey. Those with reported declines in health status were more likely to report decreases in satisfaction with medical care (OR, 1.43, CI95, 1.13-1.79). Neither age, gender, race, type of health plan, disease state, nor doctor's office visits were related to observed changes in satisfaction with medical care. CONCLUSION: Changes in satisfaction with care appear to be related to changes in health status. However, the relation between these two attributes is not intuitively apparent.

Adult↗