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Biomedical subjects

S Weingarten

Publications and source records attributed to S Weingarten.

At least 37 records · Page 2Linked to original sources
PubMed1997

Reducing length of stay for patients hospitalized with exacerbation of COPD by using a practice guideline.

UNLABELLED: Clinical practice guidelines have been promoted as an effective way of reducing costs while maintaining quality care. OBJECTIVE: To study a practice guideline to shorten length of stay for patients hospitalized with exacerbation of COPD. METHODS: We retrospectively studied a practice guideline to identify patients who were at low risk of complications from their exacerbation of COPD and hence potentially suitable for early hospital discharge. We then prospectively studied the practice guideline using an alternate month intervention and control time series over a period of 12 months. RESULTS: The practice guideline was retrospectively studied in 250 consecutive patients hospitalized with exacerbation of COPD. Of the 250 patients, 237 patients (94.8%) were classified as low risk after 72 h of hospitalization and were potentially suitable for discharge. In the prospective study, few patients (24 of 124 or 19%) were identified for implementation of the guideline. However, in those patients who were identified, length of stay was not statistically different. The data also showed that length of stay for both intervention and control groups had shortened over this time. CONCLUSION: Certain practice guidelines may appear efficacious in studies but may actually lack effectiveness when applied in clinical settings and may even increase costs. We demonstrated the importance of prospectively evaluating clinical practice guidelines before recommending them for widespread implementation.

Female↗
PubMed1997

Differences in costs of treatment for foot problems between podiatrists and orthopedic surgeons.

We examined charge data for health insurance claims paid in 1992 for persons under age 65 covered by a large California managed care plan. Charge and utilization comparisons between podiatrists and orthopedic surgeons were made for all foot care and for two specific foot problems, acquired toe deformities and bunions. Podiatrists provided over 59% of foot care services for this commercial population of 576,000 people. Podiatrists charged 12% less per individual service than orthopedists. However, podiatrists performed substantially more procedures per episode of care and treated patients for longer time periods, resulting in 43% higher total charges per episode. Hospitalization was infrequent for all providers, although podiatrists had the lowest rates. In a managed care setting in which all providers must adhere to a preestablished fee schedule, regardless of specialty, the higher utilization by podiatrists should lead to higher overall costs. In some cases, strong utilization controls could offset this effect. We do not know if the utilization difference is due to actual treatment or billing differences. Further, we were unable to determine from the claims data if one specialty had better outcomes than the other.

Blue Cross Blue Shield Insurance Plans↗
PubMed1996

Use of clinical practice guidelines in managed care physician groups.

There is increasing interest in the use of clinical guidelines as a tool to improve the quality and cost-effectiveness of health care. Yet, relatively little data are available regarding the use of guidelines by health care provider organizations. We developed a written descriptive survey investigating the development, implementation, and evaluation of clinical guidelines that was administered to medical directors or their designees from physician medical groups and independent practice associations. Eighty-seven percent of physician organizations were reported to be developing or implementing clinical guidelines. The reasons most often cited for developing clinical guidelines were quality improvement and cost containment. Local expert opinion or judgment was rated as the most important influence in the development of clinical guidelines, followed by medical and scientific literature and externally developed guidelines. Feedback of information was the most popular method of increasing compliance with clinical guidelines, although 19% of physician organizations reported imposing sanctions on physicians who did not use guidelines. Most of the physician organizations surveyed have embraced clinical guidelines. Local development or adaptation of clinical guidelines may be common. There has been disproportionately little attention paid to guideline implementation and to evaluation of guideline effects relative to their development.

California↗
PubMed1996

Clinical strategies to reduce utilization of chest physiotherapy without compromising patient care.

BACKGROUND: There is widespread interest in the evaluation of clinical strategies that safely reduce health-care costs. Elimination of inappropriate chest physiotherapy may represent one of those strategies. SETTING: An academic community hospital. METHODS: One-hundred one patients receiving chest physiotherapy were prospectively randomized to continue their chest physiotherapy or to inform their physicians that the order for the chest physiotherapy may have been inappropriate. RESULTS: Patients who were randomized to have their chest physiotherapy discontinued received 45% fewer chest physiotherapy treatments than control patients (p < 0.01). There was no increase in the mortality rate or length of hospital stay associated with the reduction in chest physiotherapy in carefully selected patients. The estimated cost savings would be $319,000, which is 50 times greater than the cost associated with the intervention. CONCLUSION: Chest physiotherapy is frequently provided to patients for inappropriate indications. Reducing chest physiotherapy for these patients may significantly reduce respiratory therapy costs without increasing length of stay or mortality rates.

Aged↗
PubMed1995

Measuring and improving physician compliance with clinical practice guidelines. A controlled interventional trial.

OBJECTIVE: To determine factors that may lead physicians not to comply with clinical practice guidelines. DESIGN: Retrospective analysis of patients whose physicians were not compliant with discharge recommendations from a prospective, controlled interventional trial of a guideline to reduce hospital length of stay for patients admitted for chest pain. SETTING: A large community teaching hospital. PARTICIPANTS: Patients admitted with chest pain who were not discharged according to a practice guideline. RESULTS: 79 (34%) of 230 patients with chest pain classified as being at low risk by concurrent or retrospective review were not discharged by day 3 (the guideline recommendation). Of these 79 patients, 33 (42%) were misclassified at concurrent review (10 were falsely classified as being at high risk and 23 were falsely classified as being at low risk). Of 46 correctly classified patients, 11 (14%) were classified as having noncompliant physicians because of health care system inefficiencies. The status of 7 (9%) patients was changed to high risk between initial classification and potential discharge. For 15 patients (19%), no obvious reason for delayed discharge was found, but they had a higher severity of illness than did low-risk patients discharged according to the guideline as measured by mean time-insensitive predictive instrument scores (41.3% +/- [SD] 14.1% compared with 31.5% +/- 14.3%; P = 0.017). In 13 patients (16%), physicians refused to follow the guideline recommendations. CONCLUSIONS: In measuring and attempting to improve physician compliance with a length-of-stay guideline, physician refusal accounts for a small percentage (16%) of noncompliance. Implementation issues, health care system inefficiency, and severity of illness were the predominant reasons why physicians did not comply with guidelines. Our study further supports the principle that clinical practice guidelines should complement rather than be a substitute for physician judgment.

Chest Pain↗
PubMed1995

The adoption of preventive care practice guidelines by primary care physicians: do actions match intentions?

OBJECTIVE: To measure primary care physicians' familiarity with, attitudes toward, and confidence in preventive care practice guidelines for the elderly and to determine whether their attitudes are associated with implementation of guidelines into clinical practice. DESIGN: A self-administered survey of physicians employed by a health maintenance organization (HMO) and of patients cared for by those physicians. Medical records were also reviewed to assess compliance with practice guidelines. SETTING: An HMO in Southern California. PARTICIPANTS: Forty-eight primary care physicians completed the survey (100% response rate). The medical records of 3,249 randomly selected elderly patients (65 to 75 years old) were studied. Of these patients, 2,799 completed a preventive care survey (response rate 86.1%). MEASUREMENT AND RESULTS: Most HMO primary care physicians agreed or strongly agreed that guidelines will improve quality of medical care (88%) and that guidelines have caused them to change their care of patients (73%). Although the physicians' general attitudes about guidelines did not often correlate with their use of preventive care guidelines, the physicians who stated that practice guidelines had changed their practices were more likely to offer their patients clinical breast examinations (75.9% vs 67.2%, p = 0.04) and to counsel their patients to exercise (70% vs 58%, p = 0.01) than were the physicians who did not. There was a significant association between physicians' support for and adoption of specific practice guidelines regarding mammography (r = 0.34, p = 0.02) and immunizations against influenza (r = 0.42, p < 0.005), pneumococcal pneumonia (r = 0.47, p < 0.001), and tetanus (r = 0.31, p = 0.03). CONCLUSIONS: Physicians employed by an HMO were familiar with and hopeful about the role of guidelines for improving patient care. Physicians' attitudes toward specific preventive care guidelines and admission that guidelines had caused them to change their practice did at times, but not always, correlate with their implementation of guidelines into clinical practice.

Adult↗
PubMed1995

Limited importance of a learned aversion in the hypophagic effect of interleukin-1 beta.

This study addressed the possible role of a learned aversion in the hypophagic effect of interleukin-1 beta (IL-1 beta) in the rat. Two repetitive intraperitoneal injections of IL-1 beta (2 micrograms/kg body weight = b.wt.) progressively reduced intake of a novel-tasting saccharin diet (SD) presented immediately after injection. When SD and the familiar diet were offered some days after an injection, SD selection was in some but not all trials reduced by IL-1 beta pretreatment. When SD was offered alone several days after an injection, SD intake was not affected by the initial pairing of SD presentation with IL-1 beta injection. In further experiments, the novelty of a flavor added to the diet fed immediately after injection proved to be crucial for the aversive effect of IL-1 beta, and enhanced its hypophagic effect. Finally, lesion of the area postrema and the adjacent nucleus of the solitary tract failed to affect the hypophagia induced by IL-1 beta (1 microgram/kg b.wt.). The results indicate that, under certain conditions, IL-1 beta can induce an aversion to the taste and flavor of the food consumed after injection. This aversive effect of IL-1 beta appears to be rather weak and is presumably not involved in the hypophagic effect of IL-1 beta under normal feeding conditions. It may however enhance IL-1 beta's hypophagic effect under certain conditions, for instance after repeated injections.

Animals↗
PubMed1995

Applied health services research: responding to the changing health care environment.

Health care in America is changing rapidly. The forces that are reforming our health care system are both numerous and compelling. Americans are requesting access to more affordable health care. At the same time, many Americans want to build upon what is considered the best and most technologically advanced health care system in the world. Especially during economically troubled times, innovative and well-formulated solutions to respond to these fundamental challenges are needed to improve the quality and accessibility of health care. It is essential that policy markers base their health care decisions on sound medical research that specifically examines which aspects of medical care improve patient outcomes.

Cardiology Service, Hospital↗
PubMed1994

Hip replacement and hip hemiarthroplasty surgery: potential opportunities to shorten lengths of hospital stay.

The potential safety and effectiveness of a practice guideline recommending a 5-day postoperative stay in the acute care hospital for hip surgery patients without clinical findings predictive of a complicated hospital course was studied retrospectively in 230 patients hospitalized for total hip replacement, total hip replacement with osteotomy, or hip hemiarthroplasty. Seventy percent of total hip replacement and hip hemiarthroplasty patients were classified as being at "low risk" for complications by the guideline (161 patients, or 73% of patients who remained hospitalized). Use of the guideline could have reduced the hospital length of stay from 8.4 days (standard deviation 3.3) to 5.9 days for these selected low-risk patients. Moreover, physicians' implicit review determined that 0% of patients (95% confidence interval, 0% to 2.3%) had a complication that would have benefited from continued stay in an acute care hospital after the fifth postoperative day. Our practice guideline may have the potential to safely reduce acute care hospital length of stay for patients recovering after total hip replacement and hip hemiarthroplasty. The guideline will require further study in a prospective clinical trial before it can be recommended for widespread use.

Aged↗
PubMed1994

Reducing lengths of stay in the coronary care unit with a practice guideline for patients with congestive heart failure. Insights from a controlled clinical trial.

Although more than 1,000 medical practice guidelines have been developed, there have been few evaluations of their use in clinical practice or information to judge whether practice guidelines can be used to reduce health care costs. For this reason, the authors conducted a prospective controlled clinical trial with an alternating-month design at a large teaching community hospital to study the use of a practice guideline to promote early transfer of patients admitted to a hospital with congestive heart failure (CHF) from the coronary care unit (CCU) and intermediate care unit to unmonitored beds. The practice guideline was supported by locally derived risk information and recommended consideration of early "step-down" transfer of low-risk patients with CHF 24 hours after hospital admission. Physicians caring for patients identified as "low risk" received concurrent personalized written and verbal reminders concerning the guideline recommendation. Study subjects were patients admitted to a hospital CCU and intermediate care unit between November 1, 1991 and April 30, 1993 with a diagnosis of CHF or pulmonary edema. Ninety patients with CHF were identified as low risk according to the guideline during the study period. Feedback of the practice guideline recommendation was not associated with a significant increase in physician adoption of the guideline or shorter lengths of stay in the CCU or intermediate care unit. Physicians may have compensated for statistically insignificant reductions in monitored lengths of stay by increasing the length of stay in unmonitored beds (1.80 +/- 2.32 to 4.02 +/- 4.09 days, P = .002) and the total length of stay (4.73 +/- 2.43 to 6.71 +/- 5.44 days, P = .03). Quality of patient care, patient outcomes, and patient satisfaction were not affected by the guideline. Our study results suggest that implementation of a locally derived practice guideline for patients with CHF did not result in adoption of the guideline by physicians. The complexity of implementing the guideline, changes in physician practice before the study, and the failure of the guideline to address the continuum of patient care across monitored and unmonitored beds may have accounted for rejection of the guideline. Our experience demonstrates that practice guidelines, whenever possible, should be evaluated in prospective trials before they should be disseminated for widespread use.

Adult↗
PubMed1993

Reducing lengths of stay for patients hospitalized with chest pain using medical practice guidelines and opinion leaders.

There are few available data on the effectiveness and safety of medical practice guidelines when used for patient care in the coronary and intermediate care units. The aim of this study was to examine the effect of educating physicians about practice guidelines to promote shorter lengths of stay for "low-risk" patients hospitalized with chest pain. Such guidelines were disseminated to physicians working in a health maintenance organization (HMO) by educational conferences, written memoranda, endorsement by opinion leaders, concurrent written feedback, and nursing-to-physician cues. A total of 208 patients were enrolled in the study. Following implementation of the practice guidelines, hospital lengths of stay were reduced from 2.51 +/- 2.1 to 1.96 +/- 1.3 days (22% reduction, p = 0.03) and intermediate care unit lengths of stay from 33.9 +/- 19 to 28.2 +/- 14 hours (17% reduction, p = 0.02) for patients with low-risk chest pain. The reduction in length of stay for patients with low-risk chest pain exceeded reductions in stay for patients hospitalized with cardiac conditions for which no guidelines were introduced. None of the patients treated according to guideline recommendations had unexpected "life-threatening" adverse events in the 2-week period after hospital discharge (95%, confidence interval 0%, 3%). This study supports the effectiveness and possible safety of practice guidelines to reduce lengths of stay for patients with low-risk chest pain.

Aged↗
PubMed1993

Is cardiac test availability a significant factor in weekend delays in discharge for chest pain patients?

The authors assessed whether the lack of weekend cardiac test availability significantly contributed to weekend delays in hospital discharge for "low-risk" chest pain patients. Mean lengths of stay were compared for late-week versus early-week admissions. Patients with late-week admissions had a 19% greater length of stay than did patients admitted earlier in the week (2.36 +/- 1.87 vs 1.91 +/- 1.21 days, p = 0.10, with p = 0.015 after adjusting for severity of illness). Cardiac diagnostic tests were ordered for only 4% of study patients. Therefore, the "weekend effect" existed in an environment where cardiac diagnostic tests were infrequently ordered.

Adult↗
PubMed1993

Comparison of the feeding responses to bacterial lipopolysaccharide and interleukin-1 beta.

To further investigate the idea that endogenous interleukin-1 plays a major role in the anorectic effect of bacterial lipopolysaccharide (LPS), feeding responses to recombinant human interleukin-1 beta (rhIL-1 beta) and LPS, as well as crosstolerance or -sensitization between both compounds, were investigated in rats. Intraperitoneally (IP) injected paracetamol (50 mg/kg body weight = b.wt.) markedly attenuated the anorectic effect of rhIL-1 beta (50,000 LAF units/kg b.wt., IP), but was clearly less effective in attenuating the anorectic effect of LPS (100 micrograms/kg b.wt., IP). As in previous experiments of ours, repeated IP injections of rhIL-1 beta (three injections of 50,000 LAF units/kg b.wt. on experimental days 1, 4, and 10) resulted in sensitization to the anorectic effect rhIL-1 beta, whereas repeated IP injections of LPS (three injections of 100 micrograms/kg b.wt. every second day) resulted in LPS-tolerance. Sensitization to the anorectic effect of rhIL-1 beta did not affect the anorectic response to LPS. Likewise, LPS-tolerance did not alter the anorectic response to rhIL-1 beta. RhIL-1 beta suppressed feeding by reducing meal frequency and meal size. In contrast, the anorectic effect of LPS was due entirely to a reduction of meal frequency. The results indicate that rhIL-1 beta and LPS do not affect feeding through exactly the same mechanism.

Acetaminophen↗
PubMed1993

Does a learned taste aversion contribute to the anorectic effect of bacterial lipopolysaccharide?

The present study addressed the possible role of a conditioned taste aversion in the anorectic effect of bacterial lipopolysaccharide (LPS) in the rat. Pairing an intraperitoneal (IP) injection of LPS (100 micrograms/kg b.wt.) with the subsequent presentation of a familiar diet (FD) or of a novel-tasting saccharin diet (SD) for several hours did not affect FD or SD intake when the same diet was offered several days later after 12 h of food deprivation. However, food intake during the second presentation of SD was reduced when food was not withheld prior to the test. In a similarly designed experiment, the antipyretic and antiinflammatory drug indomethacin (5 mg/kg b.wt., IP) attenuated the anorectic effect of LPS during the initial pairing, but did not affect the inhibition of SD intake in LPS-pretreated rats during the second feeding test. The antiemetic trimethobenzamide (5 mg/kg b.wt., IP) failed to influence the anorectic effect of LPS. Lesion of the area postrema (AP) and the adjacent nucleus of the solitary tract (NST) was found to enhance the anorectic effect of LPS, but the development of tolerance to this effect remained unchanged in AP/NST-lesioned animals. In spite of the ability of LPS to induce a taste aversion that inhibits feeding under certain conditions (novel-tasting diet, no food deprivation prior to the feeding test), the findings indicate that a learned taste aversion is not the only contributor to the anorectic effect of LPS.

Animals↗
PubMed1993

A computerized expert system for outcome-validated medical practice guidelines.

Our ongoing efforts in health services research have resulted in outcome-validated medical practice guidelines for common medical conditions. These practice guidelines have been shown to substantially reduce health care costs while maintaining quality of care. We have developed a computerized expert system from our practice guidelines which enhances the ease in which they can be implemented by Utilization Management (UM) Coordinators, physicians, nurses and other health care providers.

Cost Control↗