Biomedical subjects
Publications and source records attributed to S O'Malley.
A Kaiser Permanente medical director cites four benefits to be derived from using clinical guidelines: better outcomes, faster patient recovery, reduced costs, and increased physician accountability. And, he notes, physicians are free to deviate from the guidelines--so long as they can justify their actions.
The healthcare industry in recent years has been aggressively developing guidelines for physicians to follow in providing patient care--and physicians have just as aggressively resisted using them, arguing they stifle creativity in addressing patients' specific needs. But with studies showing that following best practices results in better outcomes and lower costs, systems are looking for ways to bring physicians on board. And they've learned a number of things to do and do not do--among them, do involve physicians in developing the guidelines, don't lock physicians into outdated protocols.
"Any human activity that absorbs resources but creates no value," says Maureen Bisognano of the Institute for Healthcare Improvement, "is waste." At war with waste--in healthcare as well as in the automobile industry--is General Motors Corp. The battle plan is an accelerated change process known as PICOS. In a four-step, three-and-one-half-day workshop, GM facilitators work with teams from the healthcare organization to identify waste and plan ways to get rid of it. See if you can identify, within your organization, the seven types of waste they attack--then read about systems that have used PICOS successfully in battle.
To keep up with today's constantly changing healthcare needs, organizations are looking for ways to expedite improvements to their systems. Some have adopted one of the nationally recognized methods--blitz improvement teams, the Breakthrough Series, PICOS or interactive accelerated replication. Other organizations are designing their own improvement programs, borrowing concepts from TQM and picking up the pace. Whatever the method used, they agree on 10 components that are essential for a successful effort.
OBJECTIVE: To assess the safety and to analyse the cost-effectiveness of home treatment, including cytotoxic chemotherapy, for cancer patients. DESIGN: A restrospective overview of a home oncology nursing service over its first five years (1989-1994), and a detailed cost analysis over 12 months, firstly, by comparing direct costs of chemotherapy administration at home or in the hospital's day treatment ward and, secondly, by assessing the marginal cost of treating home care program patients in the hospital versus the total cost of the home care program. PATIENTS AND SETTING: Patients of the Haematology/Oncology Unit of a metropolitan teaching hospital treated either at home by an experienced oncology nurse, or in the hospital day care ward. INTERVENTION: Patients were offered treatments, including chemotherapy, at home rather than in hospital. MAIN OUTCOME MEASURES: Safety, assessed by the rate of major complications (i.e., requiring any patient to be admitted to hospital), and cost-effectiveness, assessed by comparing expenditure in the home and hospital settings. RESULTS: Over five years, there were 5444 home visits to 424 patients, including 1688 chemotherapy administrations to 179 patients. Only two of the 424 patients decided against continuing in the home program once it had begun. There were no major complications. The average cost of home chemotherapy administration (excluding drugs) was $49.91, compared with $116.00 in hospital. The cost of treating patients at home was $5.09 per patient more than the "marginal cost" of treating these patients in the hospital. CONCLUSIONS: Home anticancer chemotherapy is a safe and economically realistic alternative to traditional in-hospital treatment. Efforts should be made to overcome budgetary and administrative barriers to more widespread adoption of this model of care.
STUDY OBJECTIVE: We evaluated the efficacy of safety devices (seat belts and air bags) on hospital resource use and injury severity while controlling for variables known to affect outcome of motor vehicle crashes. METHODS: We conducted a prospective observational study of motor vehicle crash victims who were transported to the hospital in a suburban-rural county with a population of 1.4 million. Out-of-hospital providers recorded patient demographic characteristics, mechanism of injury (based on American College of Surgeons criteria), and use of seat belts or air bags. Hospital charts were reviewed for hospital admission, length of hospital stay, ICU stay, surgery, major nonorthopedic surgery or death, and severe injury (Injury Severity Score > 15). RESULTS: The study group comprised 1,446 motor vehicle crash victims. Median age was 30 years, 47% were male, and 69% used safety devices. The use of safety devices reduced the likelihood of hospital admission (adjusted odds ratio [OR], .67; 95% confidence interval [CI], .46 to .98) surgery (adjusted OR, .52; 95% CI, .27 to 1.01), major surgery or death (adjusted OR, .14; 95% CI, .04 to .52), and severe injuries (adjusted OR of injury Severity Score > 15, .39; 95% CI, .19 to .83). CONCLUSION: The use of safety devices is associated with decreased hospital resource use and less severe injuries for victims of motor vehicle crashes who are transported to the hospital by emergency medical services providers, even after adjustment for many other variables known to affect the outcome of motor vehicle crashes. Continued efforts to promote safety device use are warranted.
Obstruction of the internal carotid artery by a pituitary tumor is a rare occurrence, particularly in the absence of pituitary apoplexy. A cas of occlusion of the right internal carotid artery caused by a nonhemorrhagic pituitary adenoma is reported. The patient presented with a 3-month history of headaches and a progressive loss of vision in his right eye, leading to sudden complete right-sided blindness on the day of admission. Except for the visual system, the patient's clinical examination revealed nothing remarkable. There was complete restoration of blood flow in the internal carotid artery after emergency transsphenoidal resection of the tumor was performed. The patient's vision also substantially improved shortly after the surgery. Neurodiagnostic correlation, using various imaging studies, is presented. This cas also demonstrates the importance of using magnetic resonance imaging with and without contrast to demonstrate complete occlusion or thrombosis in the affected vessel.
Two hundred one non-treatment seeking women with alcoholism, anxiety disorders, alcoholism and anxiety disorders, or neither alcoholism nor anxiety disorders were interviewed to assess core psychopathology associated with eating disorders using the Eating Disorders Examination and DSM-IIIR psychiatric diagnoses using the Schedule of Affective Disorders and Schizophrenia-Lifetime version. Alcoholic women had significantly higher mean scores on each of the Eating Disorders Examination subscales of Restraint, Overeating, Eating Concern, Shape Concern, and Weight Concern compared with nonalcoholic women. Women with anxiety disorders had significantly elevated scores on subscales of Overeating, Eating Concern, and Weight Concern compared with women without anxiety disorders. Women with both alcoholism and anxiety disorders had higher rates of bulimia nervosa and/or eating disorder NOS compared with women with either disorder alone. Implications of these findings are discussed in the context of the co-morbid association between alcoholism, eating disorders, and anxiety disorders.
OBJECTIVE: To determine the incremental benefit of individual American College of Surgeons (ACS) trauma triage criteria for prediction of severe injuries after consideration of concurrent physiologic, anatomic, mechanism, or "other" criteria. METHODS: A prospective cross-sectional study of motor vehicle crash victims transported to any of the 12 hospitals in a suburban/rural county by local ambulance services was performed. Demographic and individual ACS criteria were collected using structured data instruments. EDs provided patient disposition within 24 hours of patient arrival. Medical records were reviewed. Major outcomes were admission, operative interventions (OR), major nonorthopedic operative interventions or death (Maj-OR), and injury severity score (ISS). To optimize sensitivity and specificity of out-of-hospital triage decision rules, receiver operating characteristic (ROC) curves were derived. RESULTS: Of 1,545 patients, 13% were admitted; 6% had OR; 1% had Maj-OR; and 3% had ISSs > or = 16. For all outcomes, the most useful criteria were physiologic and anatomic. Some additional criteria (crash speed > 20 mph, > or = 30-inch vehicle deformity, axle displacement) substantially worsened specificity, with minimal or no improvement in sensitivity. For example, the optimal ROC curve for Maj-OR was determined by a systolic blood pressure < 90 mm Hg, Glasgow Coma Scale (GCS) score < 13, respiratory rate (RR) < 10 or > 29, death of a same-car occupant, penetrating injury, and/or > or = 24-inch opposite-side compartment intrusion (sensitivity, 85%; specificity, 87%). An ISS > or = 16 was predicted by GCS score < 13, RR < 10 or > 29, penetrating injury, 2 proximal long bone fractures, flail chest, > or = 24-inch opposite-side compartment intrusion, patient ejection, rollover, and/or age < 5 or > 55 years (sensitivity, 86%; specificity, 70%). CONCLUSION: Physiologic and anatomic trauma triage criteria predicted increased hospital resource utilization and severe injury. On the other hand, when used concurrently with physiologic, anatomic, and "other" criteria, some mechanism criteria worsen specificity with negligible improvement in sensitivity. In particular, crash speed > 20 mph and > or = 30-inch vehicle deformity had little predictive value for all outcomes.
Explore the source record for details and available documents.
Families struggling with decisions about care of loved ones who are dying will forever remember the help and advice provided by healthcare providers. But often providers disagree about the care patients should have to control pain and preserve life, which creates confusion and frustration among caregivers. Here, three people--a researcher who works with dying patients and their families, a supportive care expert and a family member--speak out on the kinds of help they believe that professional healthcare providers should provide to caregivers.
The same healthcare system that excels at defining best practices and coordinating care for cardiac surgery and other acute illness has paid little attention to defining and implementing care models for the terminally ill. This issue of THE QUALITY LETTER looks at the care of the dying as a quality improvement priority. Experts say that many patients' dying days are spent in pain, isolated from loved ones and subject to extraordinary lifesaving measures unwanted by the patients--often because their caregivers lack adequate training in meeting their needs. The objective, say the experts, is a compassionate and patient/family-centered model of care. Use the self-assessment tool provided to determine whether your system shows the danger signs that care of the dying is inadequate and review six ways that your community can start improving service to the dying.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Three monoclonal antibodies with either specificity to taxol or baccatin III, or cross-reactivity with several common taxanes have been prepared and used to develop sensitive competitive-inhibition enzyme immunoassays. The hybridomas producing these monoclonal antibodies were obtained by fusing P3X63Ag8.653 plasmacytoma cells and splenocytes from mice hyperimmunized with keyhole limpet hemocyanin-7-succinyltaxol or -7-succinylbaccatin III conjugates. Direct and indirect competitive inhibition enzyme immunoassays were developed with these monoclonal antibodies and microtiter plates coated with bovine serum albumin conjugates of the complementary hapten. Detection limits for the direct competitive inhibition enzyme immunoassays, conducted in buffer containing 10% MeOH, were 0.6 nM taxol for 3C6 (anti-taxol); 1.1 nM baccatin III for 3H5 (anti-baccatin III); and 0.6 nM taxol or baccatin III for 8A10 (anti-taxane). The immunoassays accurately detected taxol, baccatin III, and "total taxanes" in crude MeOH extracts of Taxus brevifolia bark and in hplc fractions of these extracts.
OBJECTIVE: To examine the dopamine D2 receptor (DRD2) gene coding sequences for abnormalities associated with schizophrenia or alcoholism and thereby help to resolve the controversy surrounding the reported association of alcoholism with a restriction fragment length polymorphism located close to the DRD2 gene. DESIGN: Mutational analysis of complete DRD2 gene coding sequences by denaturing gradient gel electrophoresis followed by direct nucleotide sequencing of detected variants. SETTING: Patients and controls from clinical and epidemiologic collections in the United States and Europe. PATIENTS: A total of 253 unrelated individuals, including 106 patients with schizophrenia, 113 with alcoholism, and 34 controls. For alcoholism we included patients from previously published series in which an association of illness with allele A1 was reported (Taql site 3' to the DRD2 gene) and from other published series in which nonconfirmations of this association were reported. Nearly all persons examined were white. MAIN OUTCOME MEASURES: Frequency of nonsilent variations in DRD2 gene DNA sequences in the different diagnostic groups. RESULTS: We found three infrequent DNA variants that predict altered amino acid sequence of the receptor. None of these is associated with either alcoholism or schizophrenia. CONCLUSION: No structural coding abnormalities in the DRD2 gene are present in alcoholism or schizophrenia.