Biomedical subjects

Steven R Feldman

Publications and source records attributed to Steven R Feldman.

At least 145 records · Page 8Linked to original sources

PubMed2003

Analysis of factors associated with increased prescription illegibility: results from the National Ambulatory Medical Care Survey, 1990-1998.

OBJECTIVE: To estimate the incidence of, and the variables affecting, illegible drug prescriptions in the United States. METHODS: Illegible notations of medications (ie, drug mentions) on the patient record form used for data collection in the National Ambulatory Medical Care Survey from 1990 to 1998 were used as a proxy for the incidence of illegible prescriptions in the United States. RESULTS: The average incidence of illegible mentions was 1.44%. Increased age of patient, female sex, urban practice setting, increased number of diagnoses and prescriptions written during the visit and seeing a family physician or internist were associated with an increased probability of at least 1 illegible drug mention. CONCLUSION: Distinct characteristics are associated with a higher incidence of illegible prescriptions. Multiple diagnoses and an increased number of prescriptions, both of which contribute to the complexity of a patient visit, are especially likely to be associated with at least 1 illegible prescription per visit. Physicians need to recognize factors contributing to illegible prescriptions to maintain high standards of care.

Adolescent↗

PubMed2002

Effects of systematic asymmetric discounting on physician-patient interactions: a theoretical framework to explain poor compliance with lifestyle counseling.

BACKGROUND: This study advances the use of a utility model to model physician-patient interactions from the perspectives of physicians and patients. PRESENTATION OF THE HYPOTHESIS: In cases involving acute care, patient counseling involves a relatively straightforward transfer of information from the physician to a patient. The patient has less information than the physician on the impact the condition and its treatment have on utility. In decisions involving lifestyle changes, the patient may have more information than the physician on his/her utility of consumption; moreover, differences in discounting future health may contribute significantly to differences between patients' preferences and physicians' recommendations. TESTING THE HYPOTHESIS: The expectation of differences in internal discount rate between patients and their physicians is discussed. IMPLICATIONS OF THE HYPOTHESIS: This utility model provides a conceptual basis for the finding that educational approaches alone may not effect changes in patient behavior and suggests other economic variables that could be targeted in the attempt to produce healthier behavior.

Age Factors↗

PubMed2002

Use of transcutaneous nerve stimulation wristband to treat methotrexate-induced nausea.

BACKGROUND: Although methotrexate is a highly effective treatment for psoriasis, nausea and vomiting may be dose-limiting side effects. Various approaches have been used to improve the tolerability of methotrexate therapy, including changing the dose or form of administration of the methotrexate or concomitant administration of folic acid or an antiemetic. OBJECTIVE: The objective of this case report is to present the use of a novel, nonpharmacologic approach for controlling the nausea associated with methotrexate therapy. RESULTS: A 47-year-old patient with long-standing psoriasis was treated with methotrexate. She developed nausea refractory to standard antiemetic measures. She noted almost immediate relief of her nausea when using a transcutaneous nerve stimulation wristband. CONCLUSIONS: Nerve stimulation may be a valid alternative to other first-line antiemetic therapies.

Female↗

PubMed2002

Psoriasis and pregnancy.

BACKGROUND: Women comprise half of all psoriasis patients and because the majority of psoriasis cases present before age 40 the disease affects women who may become pregnant. Information regarding the heritability of psoriasis can be used in counseling patients who inquire about the potential risk to their children. Patients with psoriasis who become pregnant will likely notice an associated improvement of their symptoms if any change is noted at all. OBJECTIVE: Because of potential fetal effects, the treatment of chronic psoriasis in pregnancy involves prudent consideration of whether the severity of the disease warrants treatment and selection of the safest treatments available. CONCLUSION: Topical corticosteroids and topical calcipotriene as well as topical anthralin and topical tacrolimus appear to be safe choices for control of localized psoriasis in pregnancy. UVB is the safest treatment for extensive psoriasis during pregnancy, particularly when topical application of other agents is not practical. Short-term use of cyclosporine during pregnancy is probably the safest option for management of severe psoriasis that has not responded to topical or UVB treatment.

Adult↗

PubMed2002

Diagnostic codes associated with hypnotic medications during outpatient physician-patient encounters in the United States from 1990-1998.

STUDY OBJECTIVES: This investigation tabulates the most common diagnostic codes associated with use of hypnotic medications during physician-patient encounters in the U.S. DESIGN: Estimates were derived from the National Ambulatory Medical Care Survey (NAMCS) from 1990 through 1998. Diagnoses were coded according to the International Classification of Disease-Clinical Modification-9th Edition (ICD-9-CM). SETTING: The NAMCS collects outpatient visit data from nonfederal physicians of all specialties, except anesthesiology, pathology, and radiology. PARTICIPANTS: N/A. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Hypnotic medications were more commonly associated with psychiatric codes than with the symptom of insomnia. Primary insomnia did not appear among the codes most commonly associated with a hypnotic prescription. CONCLUSIONS: Hypnotics were more commonly associated with psychiatric codes than with insomnia codes, but it is unknown whether the coding accurately reflects the true diagnoses. Still, since there is minimal data on the efficacy and safety of hypnotics in persons with psychiatric disorders, these findings may signal a critical knowledge gap in the treatment of insomnia.

Drug Administration Schedule↗

PubMed2002

In the United States, blacks and Asian/Pacific Islanders are more likely than whites to seek medical care for atopic dermatitis.

BACKGROUND: There have been population-based studies conducted in England and the United States that suggest an increase in prevalence of atopic dermatitis among black and/or Asian children. OBJECTIVE: To assess whether health care utilization for atopic dermatitis differs among different ethnic groups in the United States. DESIGN: Weighted data on representative office visits by whites, blacks, and Asian/Pacific Islanders were analyzed using a cross-sectional study, the National Ambulatory Medical Care Survey (NAMCS), from 1990 through 1998 using statistical software. SETTING: The NAMCS is an ongoing data collection effort by the Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention. The survey samples representative visits to US office-based physicians during a representative week of practice. PATIENTS: All outpatient visits were analyzed and compared with those for patients diagnosed as having atopic dermatitis (International Classification of Diseases, Ninth Revision, Clinical Modification, code 691.80). MAIN OUTCOME MEASURE: Diagnosis of atopic dermatitis by race. RESULTS: Of 570 million estimated visits for skin conditions, 7.9 million were for atopic dermatitis. The numbers of per capita visits for atopic dermatitis among blacks and Asian/Pacific Islanders were 2-fold and 6-fold higher, respectively, than among whites. The odds ratios (95% confidence intervals) for atopic dermatitis visits by blacks and Asian/Pacific Islanders relative to whites were 3.4 (2.5-4.7) and 6.7 (4.8-9.5), respectively. CONCLUSIONS: Blacks and Asian/Pacific Islanders are much more likely to visit physicians for atopic dermatitis than are whites and may benefit from education and early intervention efforts concerning the disease.

Asian↗

PubMed2002

Follow-up survey of 308-nm laser treatment of psoriasis.

BACKGROUND AND OBJECTIVES: UVB treatment with a 308-nm excimer laser is a new treatment modality for localized psoriasis. The purpose of this study is to assess patients' impressions and satisfaction with 308-nm laser treatment of mild to moderate psoriasis. STUDY DESIGN/MATERIALS AND METHODS: Telephone survey data were obtained from patients after participation in a case series study of 124 patients with mild to moderate psoriasis treated with 308-nm UVB laser treatment for a target plaque and other lesions. The survey included information on changes in the target plaque, remission time, changes in other areas of psoriasis, satisfaction with the result, side effects of treatment, and efficacy relative to other treatments. RESULTS: Patients (55% of total) reported overall satisfaction with the treatments, and 63% of patients thought they needed additional laser treatments, including for maintenance. Subjects (25%) reported that the laser treatments were better than any other treatment they had tried. Adverse effects were mild and had either disappeared or were significantly decreased in 86% of patients. Self reported length of remission compared favorably to those for other therapies for localized disease. CONCLUSIONS: UVB laser treatments provide a well-tolerated means to clear psoriasis plaques. The treatment provides a high level of patient satisfaction.

Follow-Up Studies↗

PubMed2002

Visual discrimination testing of ultraviolet transmitting and ultraviolet blocking acrylic thermoplastics.

BACKGROUND: Visual perception has hindered the development of blinded, placebo-controlled ultraviolet light exposure conditions in humans. New acrylic thermoplastics that block or transmit ultraviolet light have visual properties that may provide a solution. METHODS: In a series of triangle taste tests, 60 subjects were tested for the ability to visually perceive ultraviolet light transmission by two of four types of acrylic thermoplastics. RESULTS: Forty-six of sixty (67%) subjects were unable to visually detect ultraviolet light transmitting acrylics among ultraviolet blocking acrylics in both an ambient light background condition and an ambient light background condition with ultraviolet A light supplementation. CONCLUSION: Acrylic thermoplastics allow for the production of blinded, placebo-controlled ultraviolet light exposure conditions by eliminating visual discrimination differences between active and control groups.

Acrylic Resins↗

PubMed2002

A randomized, double-blind, placebo-controlled study of clobetasol propionate 0.05% foam in the treatment of nonscalp psoriasis.

BACKGROUND: Topical corticosteroids are the primary treatment for mild to moderate psoriasis. Foam preparations of corticosteroids offer potential cosmetic and pharmacodynamic advantages over cream and ointment vehicles. A clobetasol propionate foam product is as effective as clobetasol propionate solution in the treatment of scalp psoriasis. AIM: To evaluate the safety and efficacy of clobetasol propionate foam in the treatment of psoriasis involving sites other than the scalp. METHODS: Eighty-one subjects with mild to moderate psoriasis were randomized in a 3 : 1 ratio to receive clobetasol propionate foam vs. placebo foam treatment in this double-blind study of psoriasis involving nonscalp sites. The investigator's and subject's global assessment of the response at week 2 (or at the end of treatment) and at week 4 (follow-up) and the severity of erythema, scaling, and plaque thickness were assessed. Safety was assessed from reported adverse events. RESULTS: After 2 weeks of treatment, there was significantly greater improvement with clobetasol propionate foam compared with placebo foam in both investigator's and subject's global assessment of the response (P < 0.0005). The improvement with clobetasol propionate foam was still present at the 4-week follow-up visit. Adverse effects were generally limited to mild to moderate application site reactions. No subjects withdrew because of adverse events. CONCLUSIONS: Clobetasol propionate foam is more effective than placebo in the treatment of nonscalp psoriasis. Twice-daily applications are well tolerated, compliance exceeds 90%, cosmetic characteristics are acceptable, and the medication may eliminate the need for separate scalp and body prescriptions.

Administration, Topical↗

PubMed2002

The safety of liposuction: results of a national survey.

BACKGROUND: Liposuction procedures are increasing in frequency and may be performed in hospitals, ambulatory surgery centers, or physician offices. Deaths associated with liposuction and previous surveys of liposuction safety have raised concern about the safety of office-based surgery. OBJECTIVE: To determine the safety of office-based, tumescent liposuction among dermatologic surgeons. METHODS: A survey mailed out to dermatologic surgeons in August 2001 requested retrospective information regarding the number of patients undergoing liposuction, the setting in which the procedures were performed, and the complications that occurred during the 7-year period from 1994 to 2000. A detailed complication record was requested for each serious adverse event or death reported. Surveys were mailed to 517 worldwide members of the American Society for Dermatologic Surgery (ASDS) listed as performing liposuction; 505 had adequate contact information. The main outcome mesure was the rate of serious adverse events (SAEs) or deaths per 1000 liposuction procedures for each service setting and for each level of conscious sedation. RESULTS: The overall response rate was 89% (450/505), and of these, 78% (349/450) perform liposuction. A total of 267 dermatologic surgeons completed the survey; 261 provided data on 66,570 liposuction procedures. No deaths were reported. The overall serious adverse event rate was 0.68 per 1000 cases. The SAE rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. SAE rates were also higher for tumescent liposuction combined with intravenous or intramuscular sedation than combined with oral or no sedation. CONCLUSION: Office-based tumescent liposuction performed by dermatologic surgeons is safe, with a lower complication rate than hospital-based procedures. Future legislation should recognize the proven safety of this procedure as performed by dermatologic surgeons in their offices.

Adult↗

PubMed2002

Phototherapy utilization for psoriasis is declining in the United States.

Phototherapy is an established treatment modality for psoriasis. The use of phototherapy for psoriasis appears to be in decline in nonfederal and non-university-based settings. We used data from the National Ambulatory Medical Care Survey to estimate the number of visits for phototherapy and psoralen ultraviolet A-range (PUVA) light therapy from 1993 to 1998. There were 873,000 visits for UV light therapy in 1993-1994, 189,000 in 1995-1996, and 53,000 in 1997-1998 (P <.0001). There were 175,000 psoralen visits in 1993-1994, 61,000 in 1995-1996, and 25,000 in 1997-1998 (P =.0053). Similar decreases in phototherapy visits occurred in our university-based practice. The decline in phototherapy represents decreased utilization of a safe and effective treatment for psoriasis.

Health Care Surveys↗

PubMed2002

Efficacy of the 308-nm excimer laser for treatment of psoriasis: results of a multicenter study.

OBJECTIVE: Our purpose was to demonstrate the efficacy of the 308-nm excimer laser for treatment of psoriasis. METHODS: This study was a multicenter open trial from 5 dermatology practices (one university-based and 4 private practices). Up to 30 patients per center with stable mild to moderate plaque-type psoriasis constituted the study population. Patients received 308-nm ultraviolet B doses to affected areas. The initial dose was based on multiples of a predetermined minimal erythema dose. Subsequent doses were based on the response to treatment. Treatments were scheduled twice weekly for a total of 10 treatments. The main outcome measure was 75% clearing of the target plaque. Time to clearing was analyzed by Kaplan-Meier methods, accounting for truncated observations. RESULTS: One hundred twenty-four patients were enrolled in the study, and 80 completed the entire protocol. The most common reason for exiting from the study was noncompliance. Of the patients who met the protocol requirements of 10 treatments or clearing, 72% (66/92) achieved at least 75% clearing in an average of 6.2 treatments. Eighty-four percent of patients (95% confidence interval [CI], 79%-87%) reached improvement of 75% or better after 10 or fewer treatments. Fifty percent of patients (95% CI, 35%-61%) reached improvement of 90% or better after 10 or fewer treatments. Common side effects included erythema, blisters, hyperpigmentation, and erosions, but they were well tolerated. CONCLUSIONS: Monochromatic 308-nm excimer laser treatment appears to be effective and safe for psoriasis. It requires fewer patient visits than conventional phototherapy, and, unlike those treatments, the laser targets only the affected areas of the skin, sparing the surrounding uninvolved skin.

Adolescent↗

PubMed2002

Off-label prescribing in the treatment of dermatologic disease.

BACKGROUND: It is common practice for physicians to treat dermatologic conditions with medications that are not indicated for the specific condition being treated. These "off-label" prescriptions are often for medications that have both well accepted therapeutic value in the medical community and proven efficacy on the basis of results of clinical trials. OBJECTIVE: Our purpose was to quantify the use of off-label prescriptions for dermatologic disease by a representative sample of physicians in the United States. METHODS: Data from the 1990-1997 National Ambulatory Medical Care Survey, performed by the National Center for Health Statistics, were used to assess medications prescribed at office visits for dermatologic disease. We identified the most common diagnoses listed at office visits in which the primary and only diagnosis listed was dermatologic. For the leading 10 dermatologic conditions for which medications are indicated, we categorized each primary drug mention by indication. RESULTS: We found that the range of off-label prescribing varied from 17% to 73%, with a weighted mean (+/- SD) of 32% +/- 18%. The conditions most frequently managed with off-label prescriptions were acne rosacea (73%) and actinic keratosis (52%), whereas those with the fewest off-label prescriptions were atopic dermatitis (17%) and psoriasis (16%). The use of off-label prescriptions by dermatologists in the diseases studied ranged from 7% to 73% with a weighted mean (+/- SD) of 24% (+/- 24%), whereas the range for nondermatologists was 18% to 96% with a weighted mean (+/- SD) of 34% (+/- 18%). CONCLUSION: Off-label prescribing is common in the management of dermatologic conditions. From these data, we conclude that it is currently within the standard of care to use off-label prescriptions in the treatment of dermatologic disease.

Drug Labeling↗

PubMed2002

Characteristics of office-based physician visits for cutaneous fungal infections. an analysis of 1990 to 1994 National Ambulatory Medical Care Survey Data.

To our knowledge, visits in the ambulatory setting due to cutaneous fungal infections have not been recently characterized. To provide descriptive epidemiology on ambulatory cutaneous fungal infection visits, we analyzed office-based physician visits for cutaneous fungal infections recorded in the National Ambulatory Medical Care Survey (NAMCS) from 1990 to 1994. The International Classification of Diseases (ICD-9) was used to define the cutaneous fungal infections. Sampling weights were applied to achieve the nationally representative estimates. From 1990 to 1994, an estimated 21.6 million physician office visits at an estimated cost of $216 million/y (office visit plus medication costs) were made for cutaneous fungal infection diagnoses. The total cost of office visits (without medication costs) was approximately $116 million/y. The total cost of the top 5 medications was approximately $68 million/y. According to an analysis of visits per physician specialist, dermatologists had the largest proportion of visits for cutaneous fungal infections. The cost associated with the diagnosis and management of cutaneous fungal infections is significant. Of all the physician specialists, dermatologists treated the most cutaneous fungal infections.

Adolescent↗

PubMed2002

Capitation payment, length of visit, and preventive services: evidence from a national sample of outpatient physicians.

OBJECTIVE: To test the hypothesis that capitation payment to physicians reduces the length of physician-patient encounters but increases use of preventive and health counseling services. STUDY DESIGN: Cross-sectional analysis of data from the National Ambulatory Medical Care Survey of outpatient physicians and their office staff (1997 and 1998). PATIENTS AND METHODS: A random national sample of 46,320 ambulatory care visits was used. Weight-adjusted multivariate regression techniques were utilized to examine the effects of capitation on duration of physician visit and number of preventive and health counseling services. RESULTS: Physicians spent 5.6% less time (P < .01) with patients in capitated plans than with those in noncapitated plans. The effect of payment method on length of visit was 3.5 times stronger among physicians receiving only capitated payment, compared with physicians receiving only noncapitated payment. Patients in capitated plans were 17% more likely to receive health counseling services (P < .01) than patients in noncapitated plans. Patients under capitation were 3% more likely to receive preventive services compared to patients in non-health maintenance organizations, noncapitated plans (P < .05). CONCLUSIONS: Capitation is associated with a modest decrease in the amount of time physicians spend with their patients and with increased receipt of preventive and health counseling services, on average. These trends are driven by physicians who receive capitated payment predominantly. Physicians with a mix of patients from capitated and noncapitated plans spend approximately equal time with each type of patient, which reflects an ethic of impartiality in medical judgment.

Aged↗

PubMed2002

A survey of office visits for actinic keratosis as reported by NAMCS, 1990-1999. National Ambulatory Medical Care Survey.

Although actinic keratosis (AK) has been linked to the development of nonmelanoma skin cancer (NMSC), particularly squamous cell carcinoma (SCC), increased awareness regarding diagnosis and treatment may be an important component for reducing morbidity and even mortality from AK and NMSC. We used the National Ambulatory Medical Care Survey (NAMCS) data from 1990 to 1999 to evaluate the diagnosis and treatment of AKs among a wide variety of patients by physicians across the United States. To our knowledge, no widespread surveys of North American populations have been performed recently to determine the epidemiology of AK. AK was diagnosed in more than 47 million visits over the 10-year period surveyed and was found to occur in 14% of patients visiting dermatologists. The diagnosis of AK as determined by NAMCS does not reflect the true prevalence of AK because only patients seeking physician diagnosis were surveyed. This suggests that the actual number of patients in the United States with AK is much higher than 14%. Rates of AK diagnosis in the standard metropolitan statistical areas (SMSAs) and non-standard metropolitan statistical areas (non-SMSAs) of the West states are higher than in other states, but geographic location may not be a direct risk factor for the development of AKs. Procedures were undertaken at 70% of visits where AK was the primary diagnosis. Destruction of lesions was the most frequently performed procedure found in the survey considering only the 1993 and 1994 NAMCS data. Biopsy was the second most frequently performed procedure.

Adolescent↗

PubMed2002

Patients with psoriasis prefer solution and foam vehicles: a quantitative assessment of vehicle preference.

Psoriasis patients' acceptance of the vehicles used in topical therapy contributes to adherence to treatment plans and outcomes, but patient preferences for different vehicles have not been assessed. The purpose of this study was to develop a quantitative measure of patient preferences for different vehicles and to assess these preferences. Focus group sessions were conducted of patients with psoriasis to determine patient perceptions of the advantages and disadvantages of different topical psoriasis therapies. This information was used to derive a vehicle preference measure to assess different topical therapies. Twenty patients with psoriasis sampled different topical psoriasis medications, assessed the effects of the vehicles on quality of life (QOL), and completed the preference measure for each vehicle. The focus group sessions resulted in the development of a 7-item preference measure. The validity of the vehicle preference measure was demonstrated by good correlation with patient expectations of effects on QOL and by test-retest reliability. The foam and solution vehicles were preferred over the cream, gel, and ointment vehicles (P < .01). There was no significant difference between preferences for daytime and nighttime application of vehicles. Although validated measures of adherence to topical therapy are not yet available, the results of this study suggest that the characteristics of solution and foam may favor improved adherence to topical therapy.

Administration, Topical↗

PubMed2002

Pediatricians who prescribe clotrimazole-betamethasone diproprionate (Lotrisone) often utilize it in inappropriate settings regardless of their knowledge of the drug's potency.

Clotrimazole-betamethasone diproprionate (C-BMV) is a fluorinated, high potency topical steroid that has been formulated with clotrimazole in the brand-named product, Lotrisone. The product is frequently used inappropriately in intertriginous areas, particularly in children. The following evaluates the use of this combination based upon a survey of 106 US-based pediatricians with at least two years post-residency, who attended the 1999 American Academy of Pediatrics. Of pediatricians who prescribe C-BMV, 23% prescribe it for diaper dermatitis. 11% of C-BMV prescriptions exceed the recommended duration of therapy. Only 18% of prescribing pediatricians correctly identify "Lotrisone" as a high potency steroid. There is no significant association between knowledge of C-BMV potency and frequency of use (p>.1). These self-reported data confirm and complement the findings of previous studies that used representative national data to assess the use of C-BMV. Pediatricians continue to utilize C-BMV in inappropriate settings, such as diaper dermatitis, regardless of their knowledge of the agent's potency. Our advice is to refrain from using high-potency steroids, such as C-BMV, in pediatric cases as there are more appropriate, safer alternatives with many fewer side effects.

Administration, Topical↗