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Biomedical subjects

W B Applegate

Publications and source records attributed to W B Applegate.

At least 127 records · Page 7Linked to original sources
PubMed1985

Medical paternalism and patient self-determination.

In response to the common belief that paternalism directed toward a competent patient necessarily transgresses the patient's right of self-determination and is therefore morally suspect, the authors argue that such a general view fails to appreciate the complexity of the patient/physician relationship as it is manifested in various clinical settings. It is the authors' contention that some strongly paternalistic acts may fail to violate the patient's right of autonomy, that other such acts may actually be a function of respect for patient autonomy, and that others may only suspend or momentarily infringe upon patient autonomy. They conclude that if these instances of paternalism differ from the classical examples of strong paternalism, then so also should the moral appraisal.

Informed Consent↗
PubMed1984

Acute myocardial infarction in elderly patients.

We conducted a retrospective chart review on 50 patients under age 65 (average age 52.9 years) and 55 patients over 65 (average age 75.6 years). The older patients were much more likely to have atypical pain or no pain (38% vs 4%, P less than .0001). They were less likely to have electrocardiographic QRS changes (47% vs 72%), but more likely to have congestive heart failure (44% vs 16%, P less than .01). In 25% of the older patients, no diagnosis was made in the first 24 hours, as compared to 8% of the younger group. The increased mortality in the older group (16% vs 4%) approached statistical significance (P = .08). We conclude that the manifestations of acute myocardial infarction are more subtle in the elderly, with a higher proportion of atypical chest pain and nondiagnostic electrocardiograms, but the elderly are more likely to have congestive heart failure.

Adult↗
PubMed1984

Treatment of hypertension in the elderly: a time for caution?

The authors review recent studies of treatment of hypertension and suggest modified guidelines for the treatment of elderly hypertensive patients. Treatment is recommended for elderly persons with systolic-diastolic hypertension if the systolic pressure is consistently above 160 mm Hg or the diastolic blood pressure is consistently above 100 mm Hg. Treatment of isolated systolic hypertension should not be excessively vigorous, and systolic blood pressure should not be lowered much below 160 mm Hg.

Aged↗
PubMed1984

Ordering decision and clinic cost variation among resident physicians.

Physicians vary considerably in the services they order for their patients. We examined ordering variation among 47 resident physicians during 4,991 continuity clinic visits with patients who had specific, chronic medical problems. We ranked the physicians by their average charge per visit and grouped them into three equal categories. High-charge physicians averaged $164 per visit, medium-charge $124 and low-charge $97. In comparing the frequencies with which physicians in each group ordered a wide array of specific laboratory tests, x-ray studies, medications and miscellaneous items, we found that ordering variation among the physician groups was not confined to certain decisions or categories of services. High-charge physicians ordered a little more of nearly every item or service. Although the magnitude of ordering variation for each item was small, the sum over many items was great, suggesting that cost-containment efforts may have to focus on the "little ticket" decision-making style of expensive physicians.

Cost Control↗
PubMed1983

Impact of a cost-containment educational program on housestaff ambulatory clinic charges.

A cost-containment project was established to determine if a broad educational program that coupled clinical logic with feedback of charges to internal medicine residents in an ambulatory clinic setting could alter behavior. The project was evaluated by comparing charge data from a preintervention comparison year with charge data from the intervention year. Decreases in charges for laboratory procedures occurred in six of the seven diagnostic categories during intervention and were significant (t-test) for four categories. Regression analysis evaluated the influence of the intervention and 12 other variables on charges and demonstrated that the intervention was associated with a mean reduction of lab charges of $ 6.30 (p less than 0.0001) and a mean reduction of total encounter charges of $ 10.36 (p less than 0.01). We conclude that our educational program resulted in a decrease in mean laboratory changes and total charges for ambulatory encounters.

Awareness↗
PubMed1983

Comparison of family medicine and internal medicine: charges for continuing ambulatory care.

The authors compared charges for ambulatory and continuing patient care prescribed by residents in internal medicine and family medicine. An analysis of covariance showed that the charges per encounter in internal medicine were $38.83 greater than charges in family medicine after accounting for differences such as patient age, diagnosis, and severity of condition. However, family practitioners scheduled patient encounters more frequently. The median number of days between encounters was 30 for family medicine and 60 for internal medicine. The duration of medical care for each patient (up to 18 months was possible) and the summation of encounter charges over that duration of medical care were evaluated. Because only two out of eight duration-of-medical-care categories were significantly less in family medicine, the differences in charges between the specialties essentially disappeared. Comparative studies which consider only charges per encounter potentially have a large bias.

Analysis of Variance↗
PubMed1983

A geriatric rehabilitation and assessment unit in a community hospital.

This report describes functional status at admission, discharge, and six months later for 100 elderly persons treated at a community hospital assessment and rehabilitation unit. The goal of the unit is to prevent institutionalization of frail elderly persons considered at risk for nursing home placement. Characteristics of the first 100 admissions include the following: average age, 79 years; female, 77 per cent; length of stay, 23 days; average number of admitting diagnoses, 3.4. Ninety-one new diagnoses of treatable conditions were made. On admission, 81 per cent of patients were confined to bed or chair or needed assistance with ambulation, compared with 27 per cent at discharge and 22 per cent at six months. Activities showing significant improvement include dressing, housekeeping, use of toilet, and ambulation. At six months, 15 per cent had died, 67 per cent were living in the community, and 19 per cent were institutionalized. It is concluded that care at the geriatric unit probably resulted in improved function and decreased nursing home placement.

Activities of Daily Living↗
PubMed1982

Evaluation of educational methods in a comprehensive cost-containment project in ambulatory care.

The cost of medical care in the United States is a matter of great concern to many health policy makers and physicians as well as to the seekers of care. At the University of New Mexico, a comprehensive cost-containment education program was devised and put into effect with residents from three primary care disciplines. In addition to documenting the effectiveness of the educational package in reducing patients charges, we asked house staff to state which parts of the package were of most use. Wall posters displaying charges for commonly ordered tests, procedures, and prescription items and the distribution of sample bills for patients seen by the individual resident were rated most highly. A test of knowledge of charges to patients did not show resident improvement after education. Cost-containment education can be effective in reducing patient charges, even if physicians do not internalize the actual charge data. We recommend the inclusion of cost-containment education in all primary care training programs, as these physicians play such an important role in the generation of patient charges.

Ambulatory Care↗
PubMed1982

Control of systolic blood pressure in elderly black patients.

To study what effect the level of control of systolic blood pressure (SBP) has in elderly persons with systolic-diastolic hypertension, 503 elderly black hypertensive patients were followed up for as long as nine years. The combined rate of hospitalizations and mortality for hypertension-related disorders was significantly (P less than 0.01) higher for the group with inadequate control of SPB (mean, 183.6 mm Hg) than for the group with partial (mean, 151.2 mm Hg) or complete (mean, 131.5 mm Hg) control. The group with complete control of SBP had a significantly (P less than 0.005) higher combined rate of hospitalizations and mortality for hypertension-related disorders than did the group with partial control. This suggests that a target goal for control of systolic as well as diastolic blood pressure should be set for elderly black hypertensive patients. However, the control of SBP should not be to rigorous.

Aged↗
PubMed1981

Colorectal cancer screening.

The efficacy of Hemoccult screening for colorectal carcinoma is analyzed utilizing five criteria which a screening test should fulfil before it is used for mass screening. The Hemoccult screening protocol has serious weaknesses. It is at best 83% sensitive for cancer and much less sensitive for polyps. An asymptomatic person with one or more positive Hemoccult slides only has a 12% chance of having cancer. In addition, patient acceptance of mass Hemoccult screening is questionable. There is currently little information on potential survival benefits, and Hemoccult screening is expensive with one quarter of all costs incurred in the diagnostic evaluation of false positives. There is insufficient evidence to recommend Hemoccult colorectal cancer screening in asymptomatic persons as a cost-effective practice.

Colonic Neoplasms↗
PubMed1981

Decision theory for clinicians: uses and misuses of clinical tests.

There is no clear cutoff between normal and abnormal for most clinical measurements and laboratory tests. Since normal limits for many laboratory tests are established by statistical methods, it is imperative that the clinician base his interpretation of the laboratory results on the clinical situation. In addition, a clinician should realize that the prevalence of disease is affected by the setting in which he practices, and the manner in which he uses a clinical test can affect the predictive value of the test used.

Adult↗
PubMed1981

Analysis of the 1980 heat wave in Memphis.

During the heat wave of 1980, average daily temperatures in Memphis first rose above the mean on June 25 and remained elevated for 26 consecutive days. In July, 1980, 83 heat-related deaths were recorded as compared to non in July 1979. Most of these deaths occurred in elderly, poor, black, inner-city residents. There was a statistically significant increase in total mortality rates, death from natural causes, cardiovascular mortality rates, and the rate for persons dead on arrival. Virtually all the excess mortality was in persons over the age of 60. The rise in heat-related emergency room visits occurred three days prior to the rise in heat-related deaths. Local planning for future heat waves should focus on the inner-city black elderly. Heat-related deaths and emergency room visits should be reported to public health officials.

Adolescent↗