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T Heeren

Publications and source records attributed to T Heeren.

At least 55 records · Page 3Linked to original sources
PubMed1992

A method for screening the quality of hospital care using administrative data: preliminary validation results.

Applying a computerized algorithm to administrative data to help assess the quality of hospital care is intriguing. As Iezzoni and colleagues point out, there are major differences of opinion as to the worth of such efforts. This article significantly advances the state of the art in using administrative data to screen for potential quality-of-care problems. In addition, this work on identifying complications of care goes well beyond the emphasis of many government organizations on hospital mortality rates. One question, however, not raised in the paper is: What is a practical upper limit to the sensitivity and specificity in comparing computerized screen results with the consensus judgments of a group of independent physicians? Advanced statistical techniques (such as bootstrapping) might be used to estimate the stability of consensus judgments by physician groups. When the judgments of two groups of physicians are compared with each other, the resulting sensitivity and specificity will not be .99! In addition, more training of members of the physician panels would probably have increased interrater reliability. While acknowledging this problem, the researchers' detailed analysis of the panel results is intriguing and represents a model for such studies. It is hoped that the authors will follow up on the avenues opened here. Furthermore, what degree of accuracy is necessary to identify facilities with higher-than-expected rates of complications? The authors discuss problems involved in using administrative data to target hospitals and departments for more costly in-depth reviews of quality. It is hoped that the promising findings that are reported here will be validated in other studies. Certainly their algorithms should find a ready audience in insurers and hospitals willing to try them out. Finally, should we expect additional research to lead to improvement in the authors' algorithms? I believe the algorithms will prove difficult to improve upon; but perhaps we should not worry about this. At some point, however, the cost of trying to identify and correct quality problems in "minimally outlier" hospitals will exceed the benefits, particularly given alternative uses for the funds. Might we now be close the the "flat of the curve" in the development of such systems for identification of quality problems? This issue should be discussed much further in future studies.

Abstracting and Indexing↗
PubMed1992

Depressive affect in "normal" adolescents: relationship to life stress, family, and friends.

Self-reported depressive affect was examined in high school students in relation to stress and the quality of relationships with family and friends. Higher levels of depressive affect were connected with stress around sexuality and achievement, lower levels of family cohesion, and more problematic peer relationships. The effects of high stress were buffered for boys by positive peer relationships, and for girls by cohesive family relationships.

Achievement↗
PubMed1991

A randomized trial of treatment options for alcohol-abusing workers.

BACKGROUND: Employee-assistance programs sponsored by companies or labor unions identify workers who abuse alcohol and refer them for care, often to inpatient rehabilitation programs. Yet the effectiveness of inpatient treatment, as compared with a variety of less intensive alternatives, has repeatedly been called into question. In this study, anchored in the work site, we compared the effectiveness of mandatory in-hospital treatment with that of required attendance at the meetings of a self-help group and a choice of treatment options. METHODS: We randomly assigned a series of 227 workers newly identified as abusing alcohol to one of three rehabilitation regimens: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings, and a choice of options. Inpatient backup was provided if needed. The groups were compared in terms of 12 job-performance variables and 12 measures of drinking and drug use during a two-year follow-up period. RESULTS: All three groups improved, and no significant differences were found among the groups in job-related outcome variables. On seven measures of drinking and drug use, however, we found significant differences at several follow-up assessments. The hospital group fared best and that assigned to AA the least well; those allowed to choose a program had intermediate outcomes. Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group (63 percent) and the choice group (38 percent) than by subjects assigned to initial treatment in the hospital (23 percent). The differences among the groups were especially pronounced for workers who had used cocaine within six months before study entry. The estimated costs of inpatient treatment for the AA and choice groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment. CONCLUSIONS: Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone or a choice of programs, although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse.

Adult↗
PubMed1991

Larynx preservation using induction chemotherapy plus radiation therapy as an alternative to laryngectomy in advanced head and neck cancer. A long-term follow-up report.

Since 1977, we have used induction chemotherapy (CT) plus radiation therapy (RT) with curative intent in 35 advanced head and neck cancer (Ca) patients who otherwise would have required total laryngectomy. Fourteen patients had advanced Ca of the larynx or supraglottic larynx (SGL); 21 patients had Ca of the hypopharynx. In six patients the Ca was Stage III; in 26 patients it was Stage IV. Three patients had Stage II disease--2 with cancer of the pyriform sinus and one patient with Stage II SGL Ca who refused surgery. Chemotherapy consisted of platinum (P) + bleomycin in 18 patients until 1982, then P + fluorouracil in the next 17 patients. Total response rate was 77%--complete (CR) in 26% and partial (PR) in 51%. There were two toxic deaths. Surgery was limited to tracheostomy in 4 patients prior to CT and to radical neck dissection after CT in 4 others. Two patients required salvage laryngectomy at 11 and 31 months, respectively. One patient underwent partial laryngectomy with voice preservation. Thirty-two patients were evaluable for overall response after RT. Final disease-free status was achieved in 20/34. One long-term survivor was lost to follow-up (44 months) and 8 patients remained alive at 13+ to 109+ months. Median failure-free survival for all patients was no less than 24 months. Not counting 4 early deaths free of disease, 2-year local control using only chemotherapy plus radiation was 52% (16:31). Overall, 33 of 35 patients retained their voices. Sixteen patients (46%) have survived 2 years or longer. Survival of patients who achieved CR after induction chemotherapy was 48 months versus 14 months for those with less than a CR (p = 0.001). Patients with a hypopharyngeal primary had only a 33% 2-year local control rate with chemotherapy and radiation and a median survival of only 12 months versus 77% control and a minimum 39-month survival for those whose tumor arose in the larynx (p = 0.009). Induction chemotherapy plus radiation therapy is an effective strategy which can produce a high rate of larynx preservation, local control, and long-term survival in patients with advanced cancer of the larynx. Patients with hypopharyngeal primaries have a lesser rate of long-term survival and local control, despite similar overall response rates.

Aged↗
PubMed1990

Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents.

In August 1988, 1,773 Massachusetts 16-19-year-olds were surveyed by telephone using anonymous random digit dialing; response rate 82 percent. Logistic regression tested whether alcohol and drug use, perceived susceptibility to human immunodeficiency virus (HIV), severity of HIV if infected, effectiveness of condoms in preventing infection, barriers to condom use, and behavioral cues such as exposure to media or personal communication about acquired immunodeficiency syndrome (AIDS) were independently related to condom use. Among sexually active respondents, (61 percent of those interviewed) 31 percent reported always using condoms. Respondents who believed condoms are effective in preventing HIV transmission and worried they can get AIDS were 3.1 and 1.8 times, respectively, more likely to use condoms all the time. Respondents who carried condoms and who had discussed AIDS with a physician were 2.7 and 1.7 times, respectively, more likely to use them. Those who believed condoms do not reduce sexual pleasure and would not be embarrassed if asked to use them were 3.1 and 2.4 times, respectively, more likely to use condoms. Teens who averaged five or more drinks daily or used marijuana in the previous month were 2.8 and 1.9 times, respectively, less likely to use condoms. Among respondents who drink and use drugs, 16 percent used condoms less often after drinking and 25 percent after drug use. Those counseling adolescents about HIV should assess and discuss beliefs outlined in the Health Belief Model, as well as their alcohol and drug use.

Acquired Immunodeficiency Syndrome↗
PubMed1990

Acculturation and marijuana and cocaine use: findings from HHANES 1982-84.

We examined the relation between acculturation and illicit drug use among Hispanics in the United States employing data from the 1982-84 Hispanic Health and Nutrition Evaluation Survey (HHANES). Across all Hispanic groups, acculturation into US society, as reflected in English language use, was associated with higher rates of illicit drug use even after sociodemographic variables such as gender, age, income, and education were considered. Significant interactions between language and education indicated that the predominant use of English was more strongly associated with marijuana and cocaine use among Mexican Americans and Puerto Ricans of lower educational attainment than among those of higher educational attainment. Significant interactions between language use and other factors such as sex, marital status, and place of birth were also associated with marijuana and cocaine use. These results suggest that the experience of acculturation, especially as it relates to drug use, is closely tied to the social and economic context in which an individual lives.

Acculturation↗
PubMed1989

Suicidal behavior in "normal" adolescents: risk and protective factors.

Risk and protective factors were examined in suicidal and nonsuicidal public high school students. With life stress and depression as independent risk factors, family cohesion was found to offset the effect of stress, and friendships to have a more indirect effect. Differential effects of ten sources of stress were analyzed from a developmental perspective, and the probability of suicidal behavior associated with clusters of factors was estimated for the general population.

Achievement↗
PubMed1988

Repeal of the Massachusetts seat belt law.

In November 1986, the Massachusetts mandatory seat belt use law repealed in a referendum by a 53 per cent to 47 per cent vote. In an anonymous random digit telephone survey of 1,046 adults in Massachusetts in summer 1986, while the law was in effect, 61 per cent of respondents had said they would vote in favor of the law. A post-repeal follow-up of 80 per cent of these persons revealed initial supporters and opponents of the law were equally likely to vote, but 15 per cent of the summer supporters switched their opinions and voted for repeal, compared to only 4 per cent of summer opponents who switched. In addition, a separate survey of 167 households that had refused to answer the summer survey indicated that survey nonrespondents were more likely to vote against the law than for it. Those opposing the law saw it as an infringement on personal liberty and believed it was not effective in reducing injury and death.

Choice Behavior↗
PubMed1987

Health problems reported by residents of a neighborhood contaminated by a hazardous waste facility.

A symptom prevalence survey was conducted of a neighborhood exposed to airborne hazardous wastes. Residents' responses were compared to those of a nearby control population. The results revealed that the exposed group had more self-reported complaints referable to the respiratory system (wheezing, shortness of breath, chest discomfort, persistent colds, coughs), constitutional complaints (always fatigued, bowel dysfunction), and irregular heart beat. When the effect of a documented irritant source in a small portion of the control population was removed, the exposed group also complained more often of irritation of the eyes and nose. There was a biological gradient for several of these effects. Efforts to eliminate the influence of confounding and recall bias are discussed. The results suggest either that the general population reacts to chemicals at levels much lower than the available occupational literature would indicate or that the effects are more long lasting than previously thought.

Adolescent↗
PubMed1987

Effects of Maine's 1981 and Massachusetts' 1982 driving-under-the-influence legislation.

In 1981, Maine passed a drunk driving law with mandatory penalties and a new civil charge to increase the conviction rate. One year later, Massachusetts increased drunk driving penalties, particularly for repeat offenders and intoxicated drivers involved in fatal crashes. In Maine, single-vehicle nighttime fatal crashes declined 22 per cent the year before passage of the law, and 33 per cent the year after. Maine's rates returned to pre-law levels by the third post-law year. Prior to Massachusetts' new law, single-vehicle nighttime and overall fatal crashes there also declined 20% and 22%, whereas after this law fatal crash rates did not decline further compared with the pre-law year or other New England states. Pre- and post-law surveys indicate that both laws were followed by some increases in public perceptions that drunk drivers stopped by police would be arrested, convicted, and receive automatic penalties. But, few believed it was very likely that drunk drivers would be stopped. For only two of three years studied after Maine's law did more people there report decisions not to drive because they had drunk too much. In Massachusetts, reported driving after heavy drinking declined as much the year before as the three years after its law.

Accidents, Traffic↗
PubMed1987

Commercial discharge packs and breast-feeding counseling: effects on infant-feeding practices in a randomized trial.

A randomized controlled trial was conducted to evaluate two interventions for prolonging the duration of breast-feeding in a multiethnic sample of 343 low-income urban women. One intervention compared research breast-feeding bedside counseling by a trained counselor, who also made eight telephone calls during the first 3 months of the infant's life, with the routine breast-feeding counseling provided in the hospital by nurses. The other intervention compared commercial discharge packs provided by formula companies with research discharge packs designed to be consistent with the WHO Code of Marketing of Breastmilk Substitutes. When infants were 4 months old, a telephone interviewer unaware of treatment status contacted 95% (324/343) of the women to determine the infants' feeding and health histories. Compared with routine counseling, research counseling delayed the first introduction of solid foods to the infant's diet (P = .03, one-tailed) but did not exert a statistically significant effect on breast-feeding by 4 months' postpartum. Women who received the research discharge pack, compared with those who received the commercial pack, were more likely to prolong exclusive breast-feeding (P = .004, one-tailed), to be partially breast-feeding at 4 months postpartum (P = .04, one-tailed), and to delay the daily use of solid foods in the infant's diet (P = .017, one-tailed). Among the women who received research counseling, the research discharge pack was associated with lower rates of rehospitalization of infants than was the commercial pack (1% v 14%; P = .014, two-tailed). We conclude that in high-risk maternity populations, commercial discharge materials for breast-feeding women should be replaced by materials consistent with the WHO Code.

Adult↗
PubMed1985

A new method for the prediction of peripheral vascular resistance from the preoperative angiogram.

The preoperative angiogram is widely used to estimate runoff prior to infrainguinal bypass grafting, but the traditional method of angiographic scoring (0, 1, 2, or 3 based on the number of patent tibial vessels) correlates poorly with measurements of peripheral vascular resistance. We assigned a score of 0, 1, or 2 to each of four parameters (anterior and posterior tibial arteries [AT and PT], peroneal artery [PER], and plantar arch [ARCH]) on the preoperative angiograms of 39 patients admitted for elective femoral bypass grafting. These scores were then examined for their ability to correlate with the peripheral vascular resistance measured in each patient at the time of surgery. Multiple linear regression suggested that the scores assigned to the AT, PT, and ARCH were significantly correlated with observed resistance, but the PER subscore was not. Multiple linear regression of the AT, PT, and ARCH subscores suggested that resistance could be predicted from the equation: In (Resistance [mm Hg/ml/min]) = 0.786 - 0.268(AT) - 0.25(PT) - 0.358(ARCH), for which r = 0.78 and p less than 0.001. The ability of this relationship to predict resistance was tested by a division of the patient population into two roughly equal groups based on their observed resistance at surgery. When tested in this fashion, this equation had a sensitivity of 88% and a specificity of 82%. These findings suggest that the preoperative angiogram can be graded in a simple, yet unambiguous way, which allows a reasonable prediction of peripheral vascular resistance.

Angiography↗
PubMed1984

Sex of provider as a variable in effective genetic counseling.

Selected aspects of the interaction in genetic counseling sessions, as reported by women patients seen by a female provider, were compared to the interaction reported by women patients seen by a male provider. Although counseling sessions were comparable in terms of length of time, significantly more in-depth discussion of selected medical and genetic topics was reported when the provider was female; more discussion was reported of medical and genetic topics which patients came to counseling to discuss when the provider was female; and women patients reported a greater willingness to raise issues of concern in counseling when the provider was female. Women patients also were more likely to report the explanations offered by female providers as clearer than those offered by male providers. In general the data suggest that women patients in genetic counseling receive a somewhat different and less comprehensive type of counseling when seen by a male as opposed to a female provider. Analysis suggests that the differences observed may be due less to variation between male and female providers in terms of professional preparation than to variation in how male as opposed to female providers orient themselves to women patients, as well as to how women patients orient themselves to female as opposed to male providers.

Congenital Abnormalities↗
PubMed1984

Sudden death in the Framingham Heart Study. Differences in incidence and risk factors by sex and coronary disease status.

The frequency of and risk factors for sudden death in men and women with and without prior coronary heart disease were investigated in the population-based Framingham Heart Study. The cohort initially consisted of 2,336 men and 2,873 women. Over 26 years, 146 men died suddenly (46% of all male coronary heart disease deaths). A total of 69 men without and 77 men with prior evidence of coronary heart disease were victims of sudden death. Out of 50 sudden deaths in women (34% of female coronary heart disease deaths), 34 occurred in women without prior coronary disease and 16 in women with prior coronary disease. Incidence rates for sudden death were substantially greater in men than in women and in both men and women with, as opposed to without, prior coronary heart disease. The classic coronary heart disease risk factors, left ventricular hypertrophy, age, serum cholesterol, number of cigarettes smoked daily, relative weight, and systolic blood pressure, emerged from multiple logistic regression analysis of sudden death in men without prior coronary heart disease. However, in men with prior coronary disease, only left ventricular hypertrophy and intraventricular block, and no other classic risk factors, were positive predictors of sudden death. For women without prior coronary disease, significant factors were age, vital capacity, hematocrit, serum cholesterol (marginal), and serum glucose (marginal). In women with prior coronary disease, only hematocrit was a consistent predictor. Reasons for the substantial differences in sudden death risk profiles between men and women are not entirely clear, but limitations in data may partially account for these sex differences.

Adult↗
PubMed1984

Legislation raising the legal drinking age in Massachusetts from 18 to 20: effect on 16 and 17 year-olds.

The 1979 Massachusetts law raising the legal drinking age from 18 to 20 is examined--the effects on the drinking, drinking and driving, and nonfatal and fatal crash involvement of 16-17 yr-olds, teenagers immediately younger than those targeted by the law. Data from Massachusetts are compared with those from New York State, where the drinking age remained at 18. A total of 3 yr of survey data from the two states and 6 yr of data from the Department of Transportation's Fatal Accident Reporting System provide for pre- and postlaw comparisons. The findings suggest that raising the drinking age had minimal effects on the drinking behavior of Massachusetts teenagers. Although there was a significant reduction in nonfatal crashes in Massachusetts compared with New York, no decline in single-vehicle nighttime fatal crashes or in overall fatal crashes was observed. It is suggested that changes in the drinking age may offer some reduction in teenage driving after drinking and traffic crash involvement, but that teenage drinking and driving after drinking remain serious problems even in states that raise their drinking ages.

Accidents, Traffic↗
PubMed1984

Multiple testing of hypotheses in comparing two groups.

Researchers frequently encounter studies that compare two groups on many variables. We discourage the use of multiple tests of hypotheses on individual variables, an approach that ignores the correlation among the variables and increases the chance of a type I error. Instead of examining each variable separately, we recommend using multivariate procedures that integrate all measures on a person into a unified analysis of the differences between the two groups. We describe three multivariate procedures: Hotelling's T2, discriminant analysis, and logistic regression. We also discuss the use of Bonferroni's adjustment to preserve the overall chance of a type I error in conducting individual tests on each variable after doing the multivariate procedures. We review the underlying assumptions and relative merits and disadvantages of the three multivariate methods and recommend which method to use in various circumstances.

Analysis of Variance↗