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S R Majumdar

Publications and source records attributed to S R Majumdar.

18 recordsLinked to original sources
PubMed2007

Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment?

AIM: To investigate whether radiographic deformities suggesting inadequate reduction would be associated with adverse clinical outcomes. MATERIALS AND METHODS: Consecutive patients over 50 years of age (n=74) with non-operatively managed distal radius fractures were enrolled in a prospective cohort study. They had radiographs at cast removal ( approximately 6 weeks) and completed DASH (Disabilities of the Arm, Shoulder and Hand), SF-12 (health-related quality of life), and satisfaction surveys 6-months post-fracture. A reference-standard musculoskeletal radiologist, blinded to outcomes status, measured palmar (dorsal) tilt, radial angle, radial height, ulnar height, and intra-articular step and gap. Radiographic indices were correlated to each other and to the various patient-reported outcomes in univariate and multivariate regression analyses. DASH score was the primary study outcome. RESULTS: Of the cohort studied (n=74, mean age 68.5 years, primarily white women), 71% had at least one "unacceptable" radiographic deformity by traditional criteria. Acceptable reduction varied from 60-99% depending on which single index was reported, and 44% of patients had more than two indices reported as unacceptable. Despite these radiographic findings, 6-months post-reduction, self-reported disability was low (DASH=24+/-17), health-related quality of life was near normal, and 72% were satisfied with their care. No radiographic index of wrist deformity (alone or in combination) was significantly correlated to any of the patient-reported outcomes. CONCLUSION: Self-reported outcomes in older adults with conservatively managed wrist fractures were not related to the "acceptability" of radiographic fracture reduction. The proportion of acceptable reductions varied by 40% depending on which index was reported. Consequently, detailed reporting of these indices in older adults with distal radius fracture may be inefficient or perhaps even unnecessary.

Aged↗
PubMed2006

Persistence, reproducibility, and cost-effectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial.

INTRODUCTION: Older patients with fragility fractures are not commonly tested or treated for osteoporosis. Compared to usual care, a previously reported intervention led to 30% absolute increases in osteoporosis treatment within 6 months of wrist fracture. Our objective was to examine longer-term outcomes, reproducibility, and cost-effectiveness of this intervention. METHODS: We conducted an extended analysis of a non-randomized controlled trial with blinded ascertainment of outcomes that compared a multifaceted intervention to usual care controls. Patients >50 years with a wrist fracture treated in two Emergency Departments in the province of Alberta, Canada were included; those already treated for osteoporosis were excluded. Overall, 102 patients participated in this study (55 intervention and 47 controls; median age: 66 years; 78% were women). The interventions consisted of faxed physician reminders that contained osteoporosis treatment guidelines endorsed by opinion leaders and patient counseling. Controls received usual care; at 6-months post-fracture, when the original trial was completed, all controls were crossed-over to intervention. The main outcomes were rates of osteoporosis testing and treatment within 6 months (original study) and 1 year (delayed intervention) of fracture, and 1-year persistence with treatments started. From the perspective of the healthcare payer, the cost-effectiveness (using a Markov decision-analytic model) of the intervention was compared with usual care over a lifetime horizon. RESULTS: Overall, 40% of the intervention patients (vs. 10% of the controls) started treatment within 6 months post-fracture, and 82% (95%CI: 67-96%) had persisted with it at 1-year post-fracture. Delaying the intervention to controls for 6 months still led to equivalent rates of bone mineral density (BMD) testing (64 vs. 60% in the original study; p = 0.72) and osteoporosis treatment (43 vs. 40%; p = 0.77) as previously reported. Compared with usual care, the intervention strategy was dominant - per patient, it led to a $13 Canadian (U.S. $9) cost savings and a gain of 0.012 quality-adjusted life years. Base-case results were most sensitive to assumptions about treatment cost; for example, a 50% increase in the price of osteoporosis medication led to an incremental cost-effectiveness ratio of $24,250 Canadian (U.S. $17,218) per quality-adjusted life year gained. CONCLUSIONS: A pragmatic intervention directed at patients and physicians led to substantial improvements in osteoporosis treatment, even when delivered 6-months post-fracture. From the healthcare payer's perspective, the intervention appears to have led to both cost-savings and gains in life expectancy.

Aged↗
PubMed2006

Lack of association between mortality and timing of surgical fixation in elderly patients with hip fracture: results of a retrospective population-based cohort study.

BACKGROUND: Conventional wisdom suggests high-quality care for most patients with hip fractures is surgical fixation within 24 hours to reduce mortality and complications, although there is little evidence to support this standard. OBJECTIVES: We sought to determine the relationship between timing of hip fracture surgery and early mortality. DESIGN AND SUBJECTS: This was a retrospective population-based cohort study of 3981 patients with hip fractures>60 years of age that were admitted to hospitals in one Canadian health region from 1994-2000. METHODS: We collected sociodemographic, prefracture comorbidity, and postoperative complication data. Timing of surgery was classified as within 24 hours ("early surgery," the referent group for all analyses), 24-48 hours, and beyond 48 hours. Main outcome was in-hospital mortality. We used multivariable logistic regression methods, including adjustments with propensity scores and a validated hip fracture-specific mortality index, to determine the independent association between early versus later surgery and mortality. RESULTS: Median age of patients was 82 years, 71% were women, and 26% had >4 prefracture comorbidities. Unadjusted in-hospital mortality was 6%; it was 5% for those who had surgery within 24 hours or from 24 to 48 hours, 10% for surgery beyond 48 hours, and 21% for patients that did not have surgery. Compared with those who had surgery within 24 hours, there was no independent association between timing of surgery and in-hospital mortality (24-48 hours, adjusted odds ratio 0.89, 95% confidence interval 0.62-1.30, P=0.55; beyond 48 hours 1.30, 95% confidence interval 0.86-2.00], P=0.21). CONCLUSIONS: The timing of surgical fixation of hip fracture was not associated with early mortality in carefully adjusted analyses, and the use of "surgery within 24 hours" as a measure of high quality care may be inappropriate.

Aged↗
PubMed2006

Self-monitoring in Type 2 diabetes: a randomized trial of reimbursement policy.

AIM: Self-monitoring of blood glucose is often considered a cornerstone of self-care for patients with diabetes. We assessed whether provision of free testing strips would improve glycaemic control in non-insulin-treated Type 2 diabetic patients. METHODS: Adults with Type 2 diabetes, excluding those with private insurance or using insulin, were recruited through community pharmacies and randomized to receive free testing strips for 6 months or not; all patients received similar baseline education and a glucose meter. Primary outcome was change in HbA(1c) over 6 months. RESULTS: We randomized 262 patients (131 intervention and 131 control subjects). Mean age was 68.4 years (sd 10.9), 48% were male, mean duration of diabetes was 8.2 years (sd 7.2), 97% used oral glucose-lowering agents and mean baseline HbA(1c) was 7.4% (sd 1.2). After 6 months, we observed no difference in HbA(1c) between intervention and control patients, after adjusting for baseline HbA(1c)[adjusted difference 0.03, 95% confidence interval (CI) -0.16, 0.22; P = 0.78]. A per protocol analysis of study completers (152/262; 60%) yielded similar results. Intervention patients reported testing 0.64 days per week more often than control subjects (95% CI 0.18, 1.10; P = 0.007), although testing was not associated with better glycaemic control (Pearson r = -0.10, P = 0.12). CONCLUSIONS: Reducing financial barriers by providing free testing strips did not improve glycaemic control in patients with Type 2 diabetes not using insulin. Our results question the value of policies that reduce financial barriers to testing supplies in this population.

Aged↗
PubMed2006

Building safer systems by ecological design: using restoration science to develop a medication safety intervention.

BACKGROUND: Experts call for stronger safety cultures and transparent reporting practices to increase medication safety in today's strained healthcare environments. The field of ecological restoration is concerned with the effective, efficient, and sustainable repair and recovery of ecosystems that have been degraded, damaged, or destroyed. A study was undertaken to determine whether the lessons of restoration science can be adapted to the study of medication safety issues. METHODS: Working with 26 practitioners, the principles of good restoration were used to design and pilot an innovative multifaceted medication safety intervention. The intervention included focus groups with practitioners, the construction and administration of a research based medication safety inventory, repeat digital photography of environmental safety issues, and targeted environmental modifications. RESULTS: Participants were most concerned about staff education and the physical environment for medication administration. Ward staff used the research to build a healthy reporting culture, introduce regular discussions of near misses, develop education strategies, redesign delivery and storage processes, and renovate the environment. CONCLUSIONS: Members of a busy hospital ward successfully adapted methods of restoration science to study, redesign, and strengthen medication safety practices and ward safety culture within existing resources. Further research will be conducted to test the merits of restoration science for health care.

Alberta↗
PubMed2005

Controlled trial of interventions to increase testing and treatment for Helicobacter pylori and reduce medication use in patients with chronic acid-related symptoms.

BACKGROUND: Many symptomatic patients take proton pump inhibitors or histamine-2 blockers for years and those without gastro-oesophageal reflux disease might benefit from Helicobacter pylori eradication. AIM: To increase testing and treatment of H. pylori and reduce chronic use of proton pump inhibitors and histamine-2 blockers. METHODS: We conducted a three-armed controlled trial in 14 managed care practices. We included adults who used proton pump inhibitors or histamine-2 blockers for >1 year and excluded those with gastro-oesophageal reflux disease or previous endoscopy. We compared usual care (n = 312 patients from 6 practices) to low-intensity (n = 147 from 3 practices) and high-intensity (n = 122 from 5 practices) interventions. Low-intensity intervention consisted of guidelines, patient-lists, and a "toolkit"; high-intensity intervention added academic group detailing by a gastroenterologist with reinforcement by pharmacists. RESULTS: Compared with usual care, the high-intensity intervention increased H. pylori test-ordering (29% versus 9% at 12 months, P = 0.02). About half (23 of 58) of patients tested positive and 22 received eradication treatments. The high-intensity intervention decreased proton pump inhibitor use by 9% per year (P = 0.028), but did not alter histamine-2 blocker use. The low intensity intervention was ineffective. CONCLUSIONS: Providing guidelines, patient-lists, and toolkits was no better than usual care. Adding group detailing and pharmacist reinforcements led to improvements in H. pylori management and decreases in proton pump inhibitor use.

Adolescent↗
PubMed2005

Reduced cardiovascular morbidity and mortality associated with metformin use in subjects with Type 2 diabetes.

AIM: Metformin therapy reduces microvascular complications in Type 2 diabetes; questions remain, however, regarding its impact on macrovascular events. This study examined metformin use in relation to risk of cardiovascular-related hospitalization and mortality. METHODS: We conducted a retrospective cohort analysis, using Saskatchewan Health administrative databases to identify new users of oral antidiabetic drugs. Subject groups were defined by medication use during 1991-1999: sulphonylurea monotherapy, metformin monotherapy, or combination therapy. Deaths and non-fatal hospitalizations recorded during the study period were identified as cardiovascular-related from ICD-9 codes. The main outcome was a composite of first non-fatal hospitalization or death. Standard multivariate techniques, including propensity scores, were used to adjust for potential confounding. Multivariate Cox proportional hazard models were used to examine the relationship between metformin use and the composite endpoint. RESULTS: Metformin monotherapy was associated with a lower risk of the composite endpoint (adjusted hazard ratio 0.81; 95% confidence interval 0.68, 0.97) compared with sulphonylurea monotherapy. Combination therapy with meformin and a sulphonylurea was associated with lower mortality, but had similar hospitalization rates, to sulphonylurea monotherapy. CONCLUSIONS: Metformin monotherapy was associated with a lower risk of cardiovascular-related morbidity and mortality, and combination metformin and sulphonylurea therapy was associated with a reduced risk of fatal cardiovascular events, when compared with sulphonylurea monotherapy.

Aged↗
PubMed2004

Statin use in Type 2 diabetes mellitus is associated with a delay in starting insulin.

AIMS: It has been suggested that HMG Co-A reductase inhibitors ('statins') may reduce the risk of developing Type 2 diabetes mellitus. This study was designed to evaluate whether use of statins would also delay progression to insulin therapy. METHODS: This was a retrospective cohort study using Saskatchewan Health databases to identify subjects newly started on oral antidiabetic agents from 1991 to 1996. SUBJECTS: < 30 years of age or with previous lipid-lowering drug use were excluded. Medications known to influence glycaemic control, co-morbidity, and demographic data were collected. Statin exposure was defined as at least 1 year of use. Primary outcome was starting insulin treatment. Multivariate Cox proportional hazards models were used to examine the association between statin use and starting insulin. RESULTS: The final cohort included 10,996 new users of oral antidiabetic agents, of which 484 (4.4%) used statins. Mean age was 64 years and 55% were male. Mean duration of follow-up was 5.1 years; 11.1% (n = 1221) eventually started insulin treatment. Statin users were no less likely than non-users to start insulin treatment eventually (11.6% vs. 11.1%, P = 0.74). After multivariate adjustment, however, statin use was associated with a 10-month delay before newly treated diabetic subjects needed to start insulin treatment (adjusted hazard ratio 0.74; 95% confidence interval 0.56, 0.97, P = 0.028). CONCLUSION: The use of statins is associated with a delay in starting insulin treatment in patients with Type 2 diabetes initially treated with oral antidiabetic agents. Whether this relationship exists for patients at high risk of developing diabetes should be examined in a randomized trial.

Administration, Oral↗
PubMed2004

Underreporting of vertebral fractures on routine chest radiography.

OBJECTIVE: Osteoporosis is underdiagnosed and therefore undertreated. We determined the potential usefulness of chest radiography for detecting clinically important vertebral fractures by performing semiquantitative reviews and quantitative digital morphometry on 100 routine chest radiographs taken in the emergency department and comparing the yield of these independent reviews with official radiology reports. MATERIALS AND METHODS: One hundred randomly selected chest radiographs of patients 60 years or older who presented to the emergency department of a tertiary care hospital were evaluated. Radiographs were selected without knowledge of the presenting complaint and were independently reviewed by two board-certified radiologists and a radiology resident. A validated semiquantitative method was used to assess lateral chest radiographs for vertebral fracture. In addition, quantitative digital morphometry was undertaken. A clinically important vertebral fracture was defined as one that was at least moderate to severe (loss of height >or=> 25%). RESULTS: Mean age of the population was 75 years, 47% were women, and 46% were admitted to the hospital. According to the reference radiologist, prevalence of moderate to severe vertebral fractures was 22%. Simple agreement was 87-88% among reviewers; kappa values were moderate (0.56-0.58). The greatest agreement was between the reference standard radiologist and quantitative digital morphometry (89% agreement; kappa = 0.67). Only 55% (12/22) of vertebral fractures we identified were mentioned in the official radiology reports. CONCLUSION: Chest radiography has potential as a screening tool for revealing previously undiagnosed vertebral fractures, although in this study only half of moderate to severe fractures that we identified were mentioned in official reports.

Aged↗
PubMed2001

Designing an intervention to improve the management of Helicobacter pylori infection.

BACKGROUND: An intervention to improve the testing and treatment of Helicobacter pylori (HP) in patients receiving chronic acid suppression (AS) therapy was developed at Harvard Pilgrim Health Care (HPHC), a mixed-model not-for-profit health maintenance organization. METHODS: Ten full-time primary care physicians (4 staff model and 6 group practice) were interviewed in 1999 about their knowledge, attitudes, and practice regarding dyspepsia, the use of chronic AS drugs, and approaches to HP infection, as well as about the feasibility and acceptability of various potential interventions that might be used in a quality improvement program. RESULTS: Self-reported practice regarding dyspepsia and HP infection were relatively uniform, and physicians were generally aware of current recommendations. Three common misperceptions acted as barriers to optimal HP management: Untreated HP was not considered an important problem; patients who used drugs for chronic AS rarely had HP infection; and chronic use of AS drugs was considered effective and without adverse consequence. All physicians wanted brief educational materials with explicit guidelines, preferably locally adapted and endorsed by local experts. All informants agreed that the main barrier to successful QI interventions was the requirement for any extra time or effort, particularly when directed at populations of patients who do not have symptomatic complaints. DISCUSSION: The interviews revealed the many barriers to improving the management of HP infection and to targeting educational messages and tailoring different methods for facilitating practice change across different managed care settings. Evidence-based components of the intervention program include physician education, a notification/reminder system, and practice-based tools to facilitate change and minimize workload.

Boston↗
PubMed2001

Influence of physician specialty on adoption and relinquishment of calcium channel blockers and other treatments for myocardial infarction.

OBJECTIVE: Recent reports have linked calcium channel blockers (CCBs) with an increased risk of acute myocardial infarction (AMI). We sought to determine to what extent physicians relinquished CCBs following these adverse reports and if there were differences in the use of CCBs and other AMI therapies across 3 levels of specialist involvement: generalist attendings, collaborative care (generalist with cardiologist consultation), and cardiologist attendings. DESIGN: We measured use of CCBs during hospitalization for AMI before (1992--1993) and after (1995--1996) the adverse CCB reports, controlling for hospital-, physician-, and patient-level variables. We also examined use of effective medications (aspirin, beta-blockers, thrombolytic therapy) and ineffective AMI treatments (lidocaine). SETTING: Thirty-seven community-based hospitals in Minnesota. PATIENTS: Population-based sample of 5,347 patients admitted with AMI. MEASUREMENTS: The primary outcome was prescription of a CCB at the time of discharge from hospital. Secondary outcomes included use of other effective and ineffective AMI therapies during hospitalization and at discharge. MAIN RESULTS: Compared with cardiologists, generalist attendings were less likely to use aspirin (37% vs 68%; adjusted odds ratio [OR], 0.58; 95% confidence interval [95% CI], 0.42 to 0.80) and thrombolytics (29% vs 64%; adjusted OR, 0.18; 95% CI, 0.13 to 0.25), but not beta-blockers (20% vs 46%; adjusted OR, 0.93; 95% CI, 0.66 to 1.31). From 1992--1993 to 1995--1996, the use of CCBs in patients with AMI decreased from 24% to 10%, the net result of physicians starting CCBs less often and discontinuing them more often. In multivariate models, the odds of CCB relinquishment after the adverse reports (adjusted OR, 0.33; 95% CI, 0.27 to 0.39) were independent of, and not modified by, the involvement of a cardiologist. CONCLUSIONS: Compared with cardiologists, generalist physicians were less likely to adopt some effective AMI therapies, particularly those associated with risk such as thrombolytic therapy. However, generalists were as likely as cardiologists to relinquish CCBs after the adverse reports. This pattern of practice may be the generalist physicians' response to an expanding, but increasingly risky and uncertain, pharmacopoeia.

Adrenergic beta-Antagonists↗
PubMed1999

Beta-blockers for the treatment of hypertension in patients with diabetes: exploring the contraindication myth.

PURPOSE: To review the evidence supporting the "contraindications" (hypoglycemic unawareness, insulin resistance, and dyslipidemia) usually given as the reasons for not using beta blockers for treating hypertension in patients with diabetes mellitus. METHODS: A research synthesis based on MEDLINE (January 1966 through January 1999), hand searches of pertinent references and textbooks, and consultation with experts. RESULTS: There is little evidence to support the assertion that beta blockers should be routinely contraindicated in diabetes. Beta blockers have few clinically important effects on hypoglycemic awareness and recovery, insulin resistance and hyperglycemia, or lipid profiles. Moreover, when diabetics have been treated with beta blockers for hypertension or for the secondary prevention of myocardial infarction, they benefit as much, if not more, than nondiabetic patients. There may be circumstances (e.g., hypertensive patients with coronary disease) under which beta blockers are the drugs of first choice for diabetic patients. Recommendations to use agents other than beta blockers for the treatment of hypertension in diabetes are based on these agents' effectiveness against surrogate endpoints, and not their proven benefit in preventing important clinical endpoints. CONCLUSIONS: Except for patients with brittle glycemic control, manifest hypoglycemic unawareness, renal parenchymal disease, or documented intolerance, beta blockers should no longer be considered routinely contraindicated in the presence of diabetes.

Adrenergic beta-Antagonists↗
PubMed1999

Undertreatment of hyperlipidemia in the secondary prevention of coronary artery disease.

OBJECTIVES: To determine adherence to national guidelines for the secondary prevention of coronary artery disease (CAD) using lipid-lowering drugs (LLDs), by studying the rate of use of LLDs, predictors of use, and the rate of achieving lipid goals, among eligible patients recently hospitalized with acute myocardial infarction. DESIGN: Cross-sectional analysis of 2,938 medical records, collected from July 1995 to May 1996. SETTING: Thirty-seven community-based hospitals in Minnesota. PATIENTS: The 622 patients had previously established CAD and hyperlipidemia (total cholesterol> 200 mg/dL or currently using LLDs), and were eligible for LLDs according to the National Cholesterol Education Program II (NCEP II) Guidelines. MEASUREMENTS: The use of LLDs in eligible patients (primary outcome) and successful achievement of NCEP II goals (total cholesterol <160 mg/dL) among treated patients (secondary outcome). MAIN RESULTS: Only 230 (37%) of 622 eligible patients received LLDs. In multivariate logistic regression, factors independently related to LLD use included age greater than 74 years (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.35, 0.88) and severe comorbidity (AOR 0.60; 95% CI 0.38, 0.95), managed care enrollee (AOR 1.56; 95% CI 1.02, 2.39), past smoker (AOR 1.72; 95% CI 0.98, 3.01), prior revascularization (AOR 2.31; 95% CI 1.51, 3.53), and the use of aspirin (AOR 1.59; 95% CI 1.07, 2.38) or >/=4 medications (AOR 2.89; 95% CI 2.19, 3.84). Of the treated patients who had lipid levels measured (n = 149), 15% achieved the recommended goal of a total cholesterol below 160 mg/dL. Of the untreated patients (n = 392), 89% were discharged from hospital without a LLD prescription. CONCLUSIONS: Lipid-lowering drugs, although proven effective for the secondary prevention of CAD, were used by only one third of eligible patients. Among patients receiving LLDs, few achieved recommended lipid goals. Directed quality improvement interventions, such as starting LLDs during hospitalization, may have the potential to substantially reduce CAD morbidity and mortality in this vulnerable population.

Adult↗
PubMed1999

How does colorectal cancer present? Symptoms, duration, and clues to location.

OBJECTIVE: Most colorectal cancers still present with symptoms because screening, although effective, is not yet widely practiced. A careful history and physical examination are still the usual methods for suspecting colorectal cancer and ordering appropriate investigation. Therefore, we studied the symptoms, duration, and clues to location of colorectal cancer. METHODS: We reviewed both hospital and office records for 204 consecutive patients with colorectal cancer, first diagnosed after symptoms, at one regional referral center from 1983-87. We abstracted data on demographic characteristics, presence and duration of 15 symptoms, and characteristics of the tumors. RESULTS: The 194 patients included in the study were similar to those with colorectal cancer described elsewhere in terms of age, gender, and tumor location (58% distal to the splenic flexure), and stage (56% stage A or B). The most common symptoms were rectal bleeding (58%), abdominal pain (52%), and change in bowel habits (51%); the majority had anemia (57%) and occult bleeding (77%). The median duration of symptoms (from onset to diagnosis) was 14 wk (interquartile range 5-43). We found no association between overall duration of symptoms and the stage of the tumor. Patient age, gender, and proximal cancer location were also not associated with a longer duration of symptoms before diagnosis. We developed a rule for predicting a distal location of cancer using multiple logistic regression. Independent predictors were (odds ratio [95% CI]): Hb (1.34 for each g/dl [1.16-1.54]); rectal bleeding (3.45 [1.71-6.95]); constipation (3.16 [1.38-7.24]); and proximal symptoms (at least one of anorexia, nausea, vomiting, abdominal pain, or fatigue) (0.48 [0.20-1.02]). The rule had sensitivity of 93% and a specificity of 47%, with an area under the ROC curve of 0.79. CONCLUSIONS: Until prevention of colorectal cancer is more common, we must continue to rely on clinical findings for detecting this cancer. Our results will remind physicians to keep colorectal cancer on the differential diagnosis of "chronic" gastrointestinal symptoms, and our decision rule may prompt earlier investigation with colonoscopy.

Adenocarcinoma↗