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Biomedical subjects

T S Inui

Publications and source records attributed to T S Inui.

At least 91 records · Page 5Linked to original sources
PubMed1984

Epidemiology of no-code orders in an academic hospital.

Relatively little is known about the circumstances in which decisions not to resuscitate, documented by no-code orders, are made. By review of medical records and interviews with house staff officers, we studied all medical service patients for whom no-code orders were written and those patients who received cardiopulmonary resuscitation (CPR) between October and December 1980 in the Portland Veterans Administration Medical Center. Among 1,780 patients admitted, 56 (3.1%) received no-code orders. All decisions were reportedly made by groups of individuals usually including the intern (98% of cases) and resident (93%), but not attending physician (39%). Many patients (43%) were disoriented or obtunded at the time of the no-code decision and 80% of oriented patients did participate in the decision.Thirty-seven of the 56 no-code patients died during the study. Comparing these with 20 patients who experienced cardiac arrest and did receive CPR, cancer, dementia, incontinence, non-ambulatory, divorced-separated and unemployed statuses were all more prevalent among no-code patients (P<.05).No-code orders in this Veterans Administration teaching hospital were relatively common and appeared to be made collectively. Participation of patients and attending physicians in the decisions, however, was limited.

Decision Making↗
PubMed1984

Toward clinical applications of health status measures: sensitivity of scales to clinically important changes.

While the validity and reliability of many newer health status instruments have been reported, few data are available regarding the sensitivity of these instruments to clinically discernible changes in patient status. We studied this feature of the Sickness Impact Profile (SIP) in a group of patients with rheumatoid arthritis, comparing it with more traditional measures of functional status (the American Rheumatism Association (ARA) functional classification and a patient self-rating scale). Four different approaches were devised to measure "sensitivity to clinical change." These involved comparisons of functional score changes with clinical changes in patient status which were independently agreed upon by both clinician and patient, and also comparisons with several clinical disease severity indicators. When applied to groups of patients, the SIP and the patient self-rating scale were modestly superior to the ARA scale, but neither the SIP nor the self-rating scale was clearly superior to the other. For considering individual patients, all of the scales were relatively insensitive, and predictive accuracy for clinically estimated change was low. New strategies for assessing sensitivity to small changes should be developed and applied to health status and functional scales. Attention to this characteristic should allow refinement of existing scales and may enhance their clinical usefulness.

Adult↗
PubMed1983

Prediction of awakening after out-of-hospital cardiac arrest.

To develop a model that would forecast neurologic recovery after out-of-hospital cardiac arrest, we reviewed charts on 389 consecutive patients who were not awake on admission to the hospital after resuscitation from asystole or ventricular fibrillation. The outcome variable was "awakening," which was defined as having comprehensible speech or the ability to follow commands. Predictor variables that we considered included both preadmission and admission data. Using discriminant analysis, we derived models from a 60 per cent random sample of cases and tested the models on the remaining 40 per cent. We judged that the best model contained four variables from the admission examination: motor response, pupillary light response, spontaneous eye movements, and blood glucose (levels below 300 mg per deciliter predicted awakening). Overall correct classification was 80 per cent in the derivation sample and 77 per cent in the test sample. In a simplified form, the model's predictions of awakening had a sensitivity of 0.92, a specificity of 0.65, a positive predictive value of 0.80, and a negative predictive value of 0.84. This rule should be clinically useful in estimating the neurologic prognosis of patients resuscitated after out-of-hospital cardiac arrest.

Blood Glucose↗
PubMed1983

Responsiveness to maternal concern in preventive child health visits: an analysis of clinician-parent interactions.

Clinician-parent interactions in preventive child health visits should reflect parental concern. Variations in this visit process according to the level of maternal concern were explored. Forty initial visits to a pediatric clinic were videotaped. Mothers were interviewed before the visits to determine their concerns about their infants. Videotapes were analyzed using Resource Exchange Analysis, a clinically based method of interaction analysis. Highly concerned mothers had longer visits, initiated more interaction, sought more information, talked more about their infants, expressed more worry, and received more clinician empathy (all p less than 0.05). Analysis also showed significant differences in visit process according to clinician type and sex. Stepwise multiple regressions, controlling for clinician type and sex, revealed persistent contribution by maternal concerns to variance in visit process variables (all p less than 0.004), change in R2 0.16 to 0.32). It was concluded that clinician-parent interactions in the preventive child health visits are responsive to parental concerns.

Adult↗
PubMed1983

Measuring functional outcomes in chronic disease: a comparison of traditional scales and a self-administered health status questionnaire in patients with rheumatoid arthritis.

A new "health-status" questionnaire, the Sickness Impact Profile (SIP), was examined to determine whether it offered measurement advantages over the traditional American Rheumatism Association (ARA) functional scale or patient self-ratings of function. Seventy-nine outpatients with rheumatoid arthritis (RA) administered the SIP to themselves and provided self-ratings on a 7-point functional scale. Clinicians independently rated patients on the ARA functional scale, and repeated measures were obtained over a 6-month period. Scores on the SIP or its subscales showed stronger correlations than the other scales with hematocrit, sedimentation rate, grip strength, morning stiffness, duration of RA, anatomic stage, work status, and psychiatric status. Validity of the SIP appeared to be maintained with repeated administrations, and the SIP was more reliable than either of the other scales. These findings, as well as the comprehensiveness and feasibility of the self-administered SIP, suggest that this (and perhaps similar health status instruments) may be a useful supplement to more traditional measures of chronic disease outcome.

Admitting Department, Hospital↗
PubMed1983

Systematic analysis of clinician-patient interactions: a critique of recent approaches with suggestions for future research.

Clinician-patient interactions are an important, but poorly understood, feature of our personal health care system. Attributes of these interactions have been shown to affect the health care process and appear as well to be amenable to change, furnishing a rationale for their study. Communications theory provides useful guidelines for systematic analysis. Systems of interaction analysis should take account of information transfer occurring on different levels through a variety of behaviors, incorporate interaction context and sequence into categorization schemes, deal with the unique characteristics of clinical encounters, and lend themselves to clinical teaching. Application of these guidelines to three representative systems (Bales' Interaction Process Analysis, Stiles' Verbal Response Modes, and Katz's Resource Exchange Analysis) illustrates diverse strengths and weaknesses. Future research on clinician-patient interactions should include the development of new analysis systems, a broader research time frame, increased emphasis on antecedents of interactions, and implementation of controlled trials.

Communication↗
PubMed1983

"The best laid plans . . .": an evaluation of a patient education program.

Graphic instructions for the collection of clean-voided urine specimens were posted in outpatient clinic bathrooms. These signs were intended to supplant clinic staff verbal instructions and to improve patients' ability to perform this procedure correctly. To assess the impact of the signs, the contamination rates were determined for urine culture specimens for the 6-month periods immediately preceding and following their introduction. The contamination rate for 306 consecutive specimens submitted before the signs were hung (12 per cent) was significantly lower (p = 0.004) than for the 360 specimens submitted afterward (20.6 per cent). Further, the incidence of true bacteriuria was significantly higher before the signs were posted (21.8 per cent) than afterward (15.2 per cent) (p = 0.02). There was no reported change in the provision of verbal instructions by clinic personnel, and the signs provoked some negative reactions from patients and visitors. This unexpected adverse outcome of a well-intended patient education effort is reported so that others may profit from the authors' mistakes.

Evaluation Studies as Topic↗
PubMed1983

Neurologic recovery after out-of-hospital cardiac arrest.

A retrospective cohort study of the neurologic sequelae of out-of-hospital cardiac arrest was done using 459 consecutive patients resuscitated and admitted to a teaching hospital over 10 years. Awakening was defined as having comprehensible speech or following commands. One hundred and eighty patients (39%) never awakened and 279 (61%) awakened, 188 without and 91 with persistent neurologic deficits. Fifty-nine patients had cognitive deficits and 32 patients had motor and cognitive deficits. Patients who did not awaken died, with a median survival of 3.5 days. The longer a patient survived without awakening, the smaller the probability of ever awakening and awakening without deficits. Fourteen patients awakening after 4 days had some deficits, and after 14 days six had severe deficits. Neurologic sequelae of cardiac arrest are common and related to awakening. The probability of future awakening and neurologic sequelae for patients not awake at specific times after cardiac arrest can be estimated.

Adolescent↗
PubMed1982

Physical activity and primary cardiac arrest.

To explore the relationship between vigorous physical activity and primary cardiac arrest (PCA), we identified, through emergency service incident reports, 163 cases of PCA aged 25 to 75 years. Control subjects matched for age, sex, residence, and the absence of prior clinical heart disease or major comorbidity were identified from the community. Spouses of subjects were interviewed to quantify leisure-time activity (LTA) during the prior year. Energy expended in high-intensity LTA, requiring 60% of maximum oxygen intake, was determined. The risk of PCA was 55% to 65% lower in persons in the two upper quartiles of high-intensity LTA than in persons without high-intensity LTA (95% confidence interval of relative risk, 0.22 to 0.85). Because this association was demonstrated in a clinically healthy population without prior morbidity, our data support the hypothesis that high-intensity LTA protects against PCA.

Adult↗
PubMed1982

Sociocultural determinants of the help-seeking behavior of patients with mental illness.

This descriptive study employed semistructured interviewing and questionnaire administration to delineate the sociocultural determinants of the help-seeking process in 48 psychiatric patients. The help-seeking process is considered in two stages. The first stage starts from the recognition of initial symptoms and ends in the first contact with a mental health professional. The second stage is defined as that time between the first contact and actual participation in a planned treatment program. In both stages, patients typically go through phases of lay consultation, nonpsychiatric professional consultation, and referral. The multiple steps which are usually involved in help seeking often result in significant delay of both mental health contact and treatment. The help-seeking process was found to correlate strongly with ethnicity. Both Asians and Blacks showed more extended family involvement, and the involvement of key family members tended to be persistent and intensive in Asians. Ethnicity was also associated with the length of delay, with Asians showing the longest delay and Caucasians the least. These ethnic differences were also reflected in help-seeking pathway assignment using Lin's criteria. Although modernity and parochialism, as measured by the level of modernization and the cohesiveness of the social network system of the subjects, were also found to be correlated with delay, they appeared to exert an influence independent from that of ethnicity.

Adult↗
PubMed1982

Outcome-based doctor-patient interaction anaylsis: I. Comparison of techniques.

Interactional analysis (IA) systems have been devised and applied to doctor-patient dialogues to describe encounters and to relate process to outcomes. Prior work in this area has been typified by the use of a single taxonomy for classifying verbal behaviors and limited outcomes (compliance and/or satisfaction). We applied three different IA systems (Bales, Roter's modified Bales with affective ratings, and Stiles' "Verbal Response Modes") to 101 new-patient visits to a general medical clinic for which multiple outcomes had been determined: several measures of patient knowledge of problems at conclusion of visit; patient compliance with drugs (over the ensuing three months); and patient satisfaction with the visit (perceived technical, interpersonal and communication quality). Within IA systems, cross tabulations and multiple regressions were performed to relate encounter events to outcomes. Across IA systems, multiple regression R2 and R2 adjusted (R2a) for the number of independent variables entering were used to characterize strength of relationships. Roter's IA system showed stronger relationships to outcomes of knowledge (41% R2, 27% R2a) and compliance (44% R2, 28% R2a) than did Bales' or Stiles' systems. R2 for patient satisfaction was identical for Bales and Roter (35%), and greater than R2 for Stiles (14%). We conclude that choice of IA system for research or teaching purposes should be based on behaviors and outcomes of particular interest and importance to the user. Based on audioreview of tapes, Roter's approach is less time-consuming and may perform as well as more complex systems requiring transcript analysis.

Communication↗
PubMed1982

Outcome-based doctor-patient interaction analysis: II. Identifying effective provider and patient behavior.

Three interactional analysis (IA) systems (Bales', Roters modified Bales and Stiles' "Verbal response modes") were used to characterize behavioral elements of provider-patient dialogues of 101 new-patient visits in a general medical clinic. In a previous article, the explanatory power of these IA systems was compared. In this article, specific provider and patient behaviors within segments of the encounter (introduction-history, physical examination and conclusion), which were shown to be related to encounter outcomes of knowledge, compliance and satisfaction, were examined. Review of interactional behaviors entering regression analysis with a significant F-to-enter (p less than or equal to 0.05) and supplementary contextual analyses suggested the importance of several categories of physician and patient behavior. Behaviors manifesting tension bear important and complex relationships to encounter outcomes. For example, patient and physician expressions of tension generally bear strong negative relationships to patient satisfaction, while patient expressions interpreted as tension release are positively related to both satisfaction and compliance. The timing of other behaviors appears to be critical to subsequent outcomes. If patient requests for medication occur early in the encounter, this behavior is positively related to subsequent patient satisfaction. However, if they occur in the concluding segment, a negative relationship results. Finally, several relationships taken together indicate that physician teaching in the concluding segment may be important. While useful observations may emerge from application of currently available IA techniques, the resulting information is best characterized as hypothesis-generating. These IA systems have many limitations, and research is needed to derived more clinically oriented systems that may permit more consistent demonstrations of critical process-outcome relationships.

Behavior↗
PubMed1982

Screening for depression in geriatric medical patients.

Depression, a common and treatable psychiatric disorder in later life, is often overlooked in geriatric medical patients. The authors evaluated the validity of two self-rating depression scales, the Zung Self-Rating Depression Scale and the Popoff Index of Depression, for 55 elderly patients. They compared these ratings with the diagnosis assigned by a psychiatrist who was blind to scale results and who interviewed these patients using DSM-III criteria. The two scales correctly classified 80% and 69% of the subjects, respectively. The authors identify six items from the two scales that may serve as a simple screening instrument for the detection of depression in geriatric medical patients.

Aged↗
PubMed1982

Variability in physician bioethical decision-making. A case study of euthanasia.

A patient management problem was developed to assess differences in case information processing and variability in physicians' decisions to withhold supportive therapy. An interview was done to assess physicians' values and elicit reasons for their decisions. Two hundred and five residents, attending physicians, and community practitioners in internal medicine and family medicine were interviewed. Internal medicine residents were most inclined to allow the patient to die, private practitioners to provide respirator support. Residents and attending physicians gave higher value to, and sought significantly more, socioeconomic information about the patient than did private practitioners, and also estimated a shorter life expectancy for the patient. "End-stage disease" and "poor quality of life" were common explanations for withholding respirator support. Physicians' decisions to intubate were attributed to the perceived "acute reversible" nature of the medical problem.

Aged↗
PubMed1982

Physical and psychosocial function in rheumatoid arthritis. Clinical use of a self-administered health status instrument.

The treatment of chronic disease is often directed at preservation of function, but most functional measures are crude, and rarely include indicators of psychosocial status. The Sickness Impact Profile (SIP) is a newer "health status" measure designed to comprehensively assess such outcomes. The functional and psychosocial impacts of rheumatoid arthritis and their relation to disease duration were measured by having 79 patients self-administer the SIP. Disease impacts were pervasive, including effects on leisure, social, and sexual activities, as well as physical function. While physical and psychosocial disease impacts were positively correlated, the association diminished with longer duration of disease. The self-administered SIP appears to be practical and useful in clinical settings. Specific results may help to target patient education, increase physician awareness of the distress patients experience, suggest that the need for social rehabilitative services, and help monitor responses to therapy.

Activities of Daily Living↗
PubMed1981

Critical reading seminars for medical residents. Report of a teaching technique.

The purpose and structure of a "critical reading seminar" series for second-year residents in medicine is described. This seminar has been a useful and popular forum for teaching research methodology and critical reading skills to physicians-in-training. Seminar content has emphasized the strength and limitations of research design, sampling and subject allocation, measures and techniques of analysis. Explanations for the popularity of these teaching sessions are briefly discussed.

Internship and Residency↗
PubMed1981

Screening for noncompliance among patients with hypertension: is self-report the best available measure?

The substantial prevalence of noncompliance with drugs in populations of patients with treated hypertension suggests that a reliable, clinically applicable screening test for this behavior is needed. Among employed white males, patient response to a nonjudgmental clinician inquiry has been reported to be highly predictive of noncompliance when positive but relatively insensitive (40 per cent). We assessed the performance of patient self-report in a demographically different population and confirmed the generalizability of prior observations. A compound decision rule combining blood pressure and verbal inquiry observations, however, had higher sensitivity (83 per cent) for noncompliance in our population than self-report alone (55 per cent) and could be considered for use when the prevalence of noncompliance among uncontrolled hypertensives is sufficiently high. Because 40 per cent of well-controlled hypertensives in our test population were noncompliant by pill-count, a question is raised regarding the need for "stepping down" drug therapy in some individuals under treatment for high blood pressure.

Female↗