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Biomedical subjects

Sanjay Saint

Publications and source records attributed to Sanjay Saint.

At least 91 records · Page 5Linked to original sources
PubMed2003

Impact factor: a valid measure of journal quality?

OBJECTIVES: Impact factor, an index based on the frequency with which a journal's articles are cited in scientific publications, is a putative marker of journal quality. However, empiric studies on impact factor's validity as an indicator of quality are lacking. The authors assessed the validity of impact factor as a measure of quality for general medical journals by testing its association with journal quality as rated by clinical practitioners and researchers. METHODS: We surveyed physicians specializing in internal medicine in the United States, randomly sampled from the American Medical Association's Physician Masterfile (practitioner group, n = 113) and from a list of graduates from a national postdoctoral training program in clinical and health services research (research group, n = 151). Respondents rated the quality of nine general medical journals, and we assessed the correlation between these ratings and the journals' impact factors. RESULTS: The correlation between impact factor and physicians' ratings of journal quality was strong (r2 = 0.82, P = 0.001). The correlation was higher for the research group (r2 = 0.83, P = 0.001) than for the practitioner group (r2 = 0.62, P = 0.01). CONCLUSIONS: Impact factor may be a reasonable indicator of quality for general medical journals.

Adult↗
PubMed2003

Use of critical pathways to improve efficiency: a cautionary tale.

BACKGROUND: Critical pathways are healthcare management plans that specify patient goals and the sequence and timing of actions necessary to achieve these goals with optimal efficiency. More than 80% of hospitals in the United States use critical pathways for at least some of their patients. Unfortunately, critical pathway effectiveness in improving clinical efficiency is unclear. OBJECTIVES: To assess whether critical pathways have been successful in reducing patient length of stay (LOS) and resource utilization in our tertiary-care academic medical center. STUDY DESIGN: A before-and-after observational study using multivariate linear regression analyses. METHODS: We identified all critical pathways initiated in our medical center between 1993 and 1996 in which at least 50 adult patients would be evaluated in the year preceding and succeeding pathway implementation; 13 pathways satisfied these inclusion criteria. Using a before-and-after design, multivariate linear regression was used to evaluate each pathway's effect on average monthly LOS and resource utilization after adjusting for case mix and secular trends. RESULTS: Three of the 13 pathways were associated with a statistically significant immediate decrease in inpatient LOS: acute myocardial infarction (20.7% decrease; P = .001), cesarean section (14.6% decrease; P = .03), and kidney transplantation (24.5% decrease; P = .003). Only 1 pathway, percutaneous transluminal coronary angioplasty (PTCA), produced a statistically significant decrease in LOS slope (a decrease of 5.2% per month; P = .001). Two pathways were accompanied by a statistically significant immediate reduction in ancillary resource utilization: kidney transplantation (26.4% decrease; P = .001) and community-acquired pneumonia (21.8% decrease; P = .002). Only the PTCA pathway produced a statistically significant decrease in resource utilization slope during the 12-month follow-up period (a decrease of 8.4% per month; P < .001). CONCLUSIONS: Although some pathways did reduce LOS or resource utilization or both, most pathways reduced neither. Because substantial resources must be expended on pathway development, implementation, and maintenance, future efforts should be placed on further evaluating the effectiveness of critical pathways and understanding the reasons behind their success or failure before additional resources are consumed for this management strategy.

Critical Pathways↗
PubMed2002

Syncope in acute aortic dissection: diagnostic, prognostic, and clinical implications.

BACKGROUND: Syncope is a well-recognized symptom of acute aortic dissection, often indicating the development of dangerous complications such as cardiac tamponade. SUBJECTS AND METHODS: We identified consecutive patients with acute aortic dissection at 18 referral centers in six countries. Data on key clinical findings and outcomes were collected via extensive questionnaires. Multiple logistic regression models were used to determine the association between syncope and in-hospital mortality, adjusting for demographic characteristics, dissection type, comorbid conditions, and complications (e.g., cardiac tamponade). RESULTS: Syncope was reported in 96 (13%) of 728 patients. Patients with syncope were more likely to die in the hospital (34% [n = 33 deaths]) than were those without syncope (23% [144/632], P = 0.01). They were also more likely to have cardiac tamponade (28% [n = 27] vs. 8% [n = 49], P <0.001), stroke (18% [n = 17] vs. 4% [n = 27], P <0.001), and other neurologic deficits (25% [n = 24] vs. 14% [n = 88], P = 0.005). After multivariate adjustment, clinical factors independently associated with the occurrence of syncope included a proximal dissection (odds ratio [OR] = 5.5; 95% confidence interval [CI]: 2.5 to 12; P <0.001), cardiac tamponade (OR = 3.1; 95% CI: 1.7 to 5.4; P <0.001), and stroke (OR = 3.5; 95% CI: 1.7 to 7.2; P = 0.001). There was a significant association between in-hospital death and syncope after adjustment for demographic characteristics alone (OR = 2.0; 95% CI: 1.2 to 3.5; P = 0.01), but not after adjustment for dissection type, comorbid conditions, and complications. CONCLUSION: Patients with dissections complicated by cardiac tamponade or stroke are significantly more likely to present with syncope. If these complications are excluded, syncope alone does not appear to increase the risk of death independently.

Acute Disease↗
PubMed2002

The optimal use of diagnostic testing in women with acute uncomplicated cystitis.

Acute uncomplicated cystitis is a common and costly disorder in women, and there is considerable variation in the diagnostic strategies currently used in clinical practice. Because the diagnosis of cystitis can be established in most patients using the history alone, the clinician's responsibility is to determine which patients require additional diagnostic testing. Patients with typical symptoms (i.e., dysuria, frequency, urgency, hematuria), without risk factors for complicated infection or pyelonephritis, and without a history of vaginal discharge, have a very high probability of cystitis and are appropriate candidates for empiric treatment. It is more difficult, however, to rule out infection in patients with suspected cystitis. Because the prevalence of culture-proven infection is very high in women who present with >/=1 symptom, and because the treatment threshold for this condition is low, a urine culture is generally required to rule out infection in patients with atypical symptoms, even in the presence of a negative dipstick test. In population-based, before-and-after studies, use of diagnostic algorithms has been shown to significantly decrease the use of urinalysis, urine culture, and office visits while increasing the percentage of patients who receive recommended antibiotics. These strategies have substantially reduced the cost of managing cystitis without an increase in adverse events or a decrease in patient satisfaction. Randomized controlled trials are needed to more closely examine the outcomes, costs of care, and patient satisfaction from different diagnostic and management strategies.

Acute Disease↗
PubMed2002

Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis.

PURPOSE: Bloodstream infections related to use of catheters, particularly central-line catheters, are an important cause of patient morbidity, mortality, and increased health care costs. This study evaluated the efficacy of skin disinfection with chlorhexidine gluconate compared with povidone-iodine solution in preventing catheter-related bloodstream infection. DATA SOURCES: Multiple computerized databases (1966 to 2001), reference lists of identified articles, and queries of principal investigators and antiseptic manufacturers. STUDY SELECTION: Randomized, controlled trials comparing chlorhexidine gluconate with povidone-iodine solutions for catheter-site care. DATA EXTRACTION: Using a standardized form, two reviewers abstracted data on study design, patient population, intervention, and incidence of catheter-related bloodstream infection from all included studies. DATA SYNTHESIS: Eight studies involving a total of 4143 catheters met the inclusion criteria. All studies were conducted in a hospital setting, and various catheter types were used. The summary risk ratio for catheter-related bloodstream infection was 0.49 (95% CI, 0.28 to 0.88) in patients whose catheter sites were disinfected with chlorhexidine gluconate instead of povidone-iodine. Among patients with a central vascular catheter, chlorhexidine gluconate reduced the risk for catheter-related bloodstream infection by 49% (risk ratio, 0.51 [CI, 0.27 to 0.97]). CONCLUSIONS: These results suggest that incidence of bloodstream infections is significantly reduced in patients with central vascular lines who receive chlorhexidine gluconate versus povidone-iodine for insertion-site skin disinfection. Use of chlorhexidine gluconate is a simple and effective means of reducing vascular catheter-related infections.

Aged↗
PubMed2002

The Safety Case Management Committee: expanding the avenues for addressing patient safety.

BACKGROUND: The greatest gains in patient safety are likely to result from using a multifaceted framework of safety enhancement initiatives. The Safety Case Management Committee, which has been meeting at the VA Ann Arbor Healthcare System since early 1999, is one such initiative; it is directed at broadening organizational involvement in creating a safer clinical environment. The committee's objective is to address fundamental issues related to patient safety and quality of care. The committee aims to develop thematic approaches to improving major systems triggered by unsafe or risky incidents that demonstrate either iatrogenic harm or risk of harm to patients. COMMITTEE STRUCTURE AND FUNCTIONING: Committee members represent top management, middle management, and front-line employees, but membership is weighted toward those in direct patient care roles. The group also includes a consumer representative. Critical issues are addressed through rigorous case discussion, literature review, and expert consultation. RESULTS: In a 3-year period (Feb 1999 through Dec 2001), 85% of the group's 45 recommendations have been implemented. Topics have included reducing medication errors during emergency procedures, enhancing palliative care services, minimizing the risk of missed x-ray findings, optimizing anticoagulation management, reducing the risk of vascular catheter-related infection, and improving pain management. SUMMARY: The Safety Case Management Committee has successfully addressed actual and potential errors and has implemented strategic safety improvements. The dedicated efforts of highly motivated clinicians who serve on such a committee can augment and enhance risk management advances made through other channels.

Case Management↗
PubMed2002

Informal caregiving time and costs for urinary incontinence in older individuals in the United States.

OBJECTIVES: To obtain nationally representative estimates of the additional time, and related cost, of informal caregiving associated with urinary incontinence in older individuals. DESIGN: Multivariate regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people aged 70 and older (N = 7,443). SETTING: Community-dwelling older people. PARTICIPANTS: National population-based sample of community-dwelling older people. MEASUREMENTS: Weekly hours of informal caregiving, and imputed cost of caregiver time, for community-dwelling older people who reported (1) no unintended urine loss, (2) incontinence that did not require the use of absorbent pads, and (3) incontinence that required the use of absorbent pads. RESULTS: Thirteen percent of men and 24% of women reported incontinence. After adjusting for sociodemographics, living situation, and comorbidities, continent men received 7.4 hours per week of care, incontinent men who did not use pads received 11.3 hours, and incontinent men who used pads received 16.6 hours (P <.001). Women in these groups received 5.9, 7.6, and 10.7 hours (P <.001), respectively. The additional yearly cost of informal care associated with incontinence was $1,700 and $4,000 for incontinent men who did not and did use pads, respectively, whereas, for women in these groups, the additional yearly cost was $700 and $2,000. Overall, this represents a national annual cost of more than $6 billion for incontinence-related informal care. CONCLUSIONS: The quantity of informal caregiving for older people with incontinence and its associated economic cost are substantial. Future analyses of the costs of incontinence, and the cost-effectiveness of interventions to prevent or treat incontinence, should consider the significant informal caregiving costs associated with this condition.

Aged↗
PubMed2002

Shifting costs from high-cost to low-cost diagnosis-related groups?

Hospitals are commonly compared with each other within diagnosis-related group (DRG) categories. Administrators infer that hospitals with a higher cost per case within a DRG are less efficient than hospitals with a lower cost per case after case mix and severity adjustment. The authors assess whether hospitals that carry a heavy load of high-cost DRGs potentially distribute the added expenses of treating these patients onto their lower cost DRGs using data gathered from the 47 hospitals in the University Hospital Consortium database between January 1994 and December 1995. The results indicate that given standard hospital allocation practices, some of the costs associated with high-cost patients were likely shifted downward, thereby inflating the cost per case for less expensive patients. As researchers adopt more benchmarking methodologies, it is important to recognize that standard accounting practices in which cost shifting from one class of patient to another may impair the ability to understand the actual cost structure for classes of patients.

Benchmarking↗
PubMed2002

Informal caregiving for chronic lung disease among older Americans.

STUDY OBJECTIVE: To obtain nationally representative estimates of the additional time, and related cost, of unpaid family caregiving (informal caregiving) associated with chronic lung disease among older Americans. DESIGN: Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people > or = 70 years old (n = 7,443). PARTICIPANTS: National population-based sample of the community-dwelling elderly. MEASUREMENTS: Weekly hours of informal caregiving, and imputed cost of caregiver time, for community-dwelling elderly who reported the following: (1) no lung disease, (2) lung disease without associated activity limitations, or (3) lung disease with associated activity limitations. RESULTS: After adjusting for sociodemographic variables, potential caregiver network, and comorbid conditions, individuals with chronic lung disease and associated activity limitations (n = 403) received an additional 5.1 h/wk of informal care when compared to those with no lung disease (n = 6,593; p < 0.001). The associated additional yearly cost of informal care per case was $2,200 USD. This represents a national annual cost of informal caregiving for chronic lung disease of > $2 billion USD. CONCLUSIONS: The quantity and associated economic cost of informal caregiving for elderly individuals with chronic lung disease are substantial. These costs to families and society must be accounted for if the full societal costs of chronic lung disease are to be calculated. Pulmonary physicians caring for elderly individuals with chronic lung disease should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

Aged↗
PubMed2002

Coronary artery bypass grafting in octogenarians: clinical and economic outcomes at community-based healthcare facilities.

BACKGROUND: Results of recent studies from high-volume academic centers suggest that coronary artery bypass grafting (CABG) is becoming safer to perform in octogenarians. Similar data from community-based facilities do not exist. OBJECTIVE: To assess the clinical and economic outcomes of nonemergency CABG in 338 octogenarians at 27 community-based facilities across the United States. STUDY DESIGN: Retrospective cohort analysis. PATIENTS AND METHODS: Multivariate analyses were used to compare (1) in-hospital mortality rates, (2) rates of discharge to extended-care facilities, (3) lengths of stay, and (4) in-hospital costs between octogenarians and younger patients. RESULTS: Of 338 patients 80 years or older, the in-hospital mortality rate was higher (4.7% vs 2.1%; P = .002), the rate of discharge to extended-care facilities was greater (24.9% vs 4.8%; P < .001), the length of stay was longer (9.6 vs 7.9 days; P < .001), and in-hospital costs were higher ($20,188 vs $18,196; P < .001) compared with patients younger than 80 years. After adjusting for several covariates, we found that octogenarians were at significantly greater risk of experiencing in-hospital deaths (odds ratio, 4.6; P = .001), of being discharged to extended-care facilities (odds ratio, 28.4; P < .001), and of having longer lengths of stay (difference, 0.7 days; P = .002) than were patients aged 50 to 59 years. CONCLUSION: At these 27 community-based facilities, the in-hospital mortality for nonemergency CABG in octogenarians was 4.7%; however, nearly 25% of surviving octogenarians were discharged to extended-care facilities.

Aged↗