Screening sigmoidoscopy and colorectal cancer.
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Case-Control Studies↗
Biomedical subjects
W M Tierney
Publications and source records attributed to W M Tierney.
Generic versus disease specific health status measures: comparing the sickness impact profile and the arthritis impact measurement scales.
Health services researchers frequently must choose between a generic health status measure, such as the Sickness Impact Profile (SIP) and a disease specific health status measure, such as the Arthritis Impact Measurement Scales (AIMS). In a longitudinal study of patients with knee or hip osteoarthritis, we examined the extent to which these 2 measures provide similar information. We found the SIP and AIMS to be significantly (p less than 0.001) correlated for physical (0.75-0.76) and total health (0.70-0.73). Correlations for psychological health were statistically significant, albeit modest (0.37-0.40). We conclude that, for most dimensions, investigators will obtain similar information using either well validated instrument.
Adaptation, Psychological↗
Practice databases and their uses in clinical research.
A few large clinical information databases have been established within larger medical information systems. Although they are smaller than claims databases, these clinical databases offer several advantages: accurate and timely data, rich clinical detail, and continuous parameters (for example, vital signs and laboratory results). However, the nature of the data vary considerably, which affects the kinds of secondary analyses that can be performed. These databases have been used to investigate clinical epidemiology, risk assessment, post-marketing surveillance of drugs, practice variation, resource use, quality assurance, and decision analysis. In addition, practice databases can be used to identify subjects for prospective studies. Further methodologic developments are necessary to deal with the prevalent problems of missing data and various forms of bias if such databases are to grow and contribute valuable clinical information.
Clinical Medicine↗
Validation techniques for logistic regression models.
This paper presents a comprehensive approach to the validation of logistic prediction models. It reviews measures of overall goodness-of-fit, and indices of calibration and refinement. Using a model-based approach developed by Cox, we adapt logistic regression diagnostic techniques for use in model validation. This allows identification of problematic predictor variables in the prediction model as well as influential observations in the validation data that adversely affect the fit of the model. In appropriate situations, recommendations are made for correction of models that provide poor fit.
Benzothiadiazines↗
The Regenstrief medical record: 1991 a campus-wide system.
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Computer Communication Networks↗
Practice randomization and clinical research. The Indiana experience.
Thoughtful preparation of a research laboratory is an early step in designing a program for scientific investigation. The Division of General Internal Medicine at Indiana University has maintained a "laboratory" for outpatient clinical investigation for more than 15 years. In this report, we describe the structure and function of the General Medicine Practice in the Regenstrief Health Center on the campus of the Indiana University School of Medicine in Indianapolis. Specifically, we discuss the ongoing random allocation of subjects, the local resources for data management and tracking of patients' use of clinical services, and how combining this information system into a randomized primary care system has fostered successful ventures in clinical investigation.
Health Services Research↗
The impact of increased contact on psychosocial outcomes in patients with osteoarthritis: a randomized, controlled trial.
After baseline in home interviews, 439 patients with osteoarthritis (OA) were randomly assigned to the control or one of 3 intervention groups which differed only in method of delivery (i.e., phone, clinic, both). Trained nonclinical interviewers reviewed medications, problems with joint pain, gastrointestinal symptoms, early warning signs for common chronic diseases, scheduled outpatient visits, an evening/weekend clinic telephone number, barriers to care, and suggestions to encourage participation during clinic visits. We hypothesized that the intervention would enhance social support, satisfaction with care, morale, and medication compliance. We found that none of the interventions had any effect upon these outcomes.
Aged↗
Time for action.
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Black or African American↗
The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests.
We studied the effect of informing physicians of the charges for outpatient diagnostic tests on their ordering of such tests in an academic primary care medical practice. All tests were ordered at microcomputer workstations by 121 physicians. For half (the intervention group), the charge for the test being ordered and the total charge for tests for that patient on that day were displayed on the computer screen. The remaining physicians (control group) also used the computers but received no message about charges. The primary outcomes measured were the number of tests ordered and the charges for tests per patient visit. In the 14 weeks before the study, the number of tests ordered and the average charge for tests per patient visit were similar for the intervention and control groups. During the 26-week intervention period, the physicians in the intervention group ordered 14 percent fewer tests per patient visit than did those in the control group (P less than 0.005), and the charges for tests were 13 percent ($6.68 per visit) lower (P less than 0.05). The differences were greater for scheduled visits (17 percent fewer tests and 15 percent lower charges for the intervention group; P less than 0.01) than for unscheduled (urgent) visits (11 percent fewer tests and 10 percent lower charges; P greater than 0.3). During the 19 weeks after the intervention ended, the number of tests ordered by the physicians in the intervention group was only 7.7 percent lower than the number ordered by the physicians in the control group, and the charges for tests were only 3.5 percent lower (P greater than 0.3). Three measures of possible adverse outcomes--number of hospitalizations, emergency room visits, and outpatient visits during the study period and the following six months--were similar for the patients seen by the physicians in both groups. We conclude that displaying the charges for diagnostic tests significantly reduced the number and cost of tests ordered, especially for patients with scheduled visits. The effects of this intervention did not persist after it was discontinued.
Ambulatory Care↗
Social support, stress and functional status in patients with osteoarthritis.
We investigated the relationship among social support, stress and functional status in 439 patients with osteoarthritis (OA). OA is among the most prevalent diseases affecting American adults and is a major contributor to functional impairment, morbidity, and utilization of health care resources. This study examines whether the impact of social support upon health was direct or indirect (i.e. it was present only when respondents were exposed to stressors). We also wanted to explore the relationship between functional status and specific dimensions of support (i.e. self-esteem, appraisal, belonging, and tangible support). Functional status (psychological disability, physical disability, pain) was assessed with the Arthritis Impact Measurement Scales (AIMS). Multiple regression suggested that exposure to stressors and low self-esteem support were associated with increased disability along all AIMS dimensions; appraisal support was not correlated with any AIMS score. Also, physical disability was associated with being older and having less tangible support (R2 = 0.17); psychological disability with being younger, caucasian, and having less belonging support (R2 = 0.47); and pain with being younger, caucasian and having less education (R2 = 0.15). In no instance was there empirical support for the buffering model. Self-esteem appeared to be the most, and appraisal the least, consistent social support dimension when predicting functional status. While exposure to stressors negatively affected all AIMS dimensions, its impact was greatest with respect to psychological disability. We conclude that social support had a direct, rather than indirect, impact on functional status. Future research should consider separately the impact of distinct social support dimensions.
Activities of Daily Living↗
Effect of hypertension and type II diabetes on renal function in an urban population.
End-stage renal disease is a devastating complication of essential hypertension and type II diabetes mellitus, conditions that commonly occur together. We and others have previously suggested that the outcome of both conditions may be influenced by more aggressive treatment. We examined a large general medicine outpatient population; 72% were black and 41% were diabetic (95% type II). Decreased renal function, defined as a serum creatinine greater than or equal to mg/dL, developed in 18.1%. A multivariable logistic regression analysis identified glucose control, systolic blood pressure level, and male gender as indicators of decreased renal function. These data suggested that both glucose and blood pressure control may decrease the frequency of impaired renal function. However, when these variables were controlled, blacks still had almost twice the risk for renal dysfunction of whites. The data draw attention to, and elucidate the exceptionally high incidence of renal dysfunction in hypertensive blacks with or without diabetes. Further, they may explain the inordinate numbers of blacks with hypertension requiring dialysis. Prospective trials to test the efficacy of blood pressure and glucose control on the course of renal disease in hypertensive and/or type II diabetic patients are warranted.
Adult↗
Ibuprofen-associated renal impairment in a large general internal medicine practice.
The authors determined the incidence of ibuprofen-associated renal impairment and risk factors for its development in 1908 patients treated with ibuprofen using data from a computerized medical records system. Renal impairment occurred in 343 patients (18%). Multivariable analysis revealed six independent predictors of renal impairment: age, prior renal insufficiency, coronary artery disease, male gender, elevated systolic blood pressure, and diuretic use. They then tested the degree to which ibuprofen contributed to the development of renal impairment by evaluating a control group of 3933 acetaminophen recipients. Neither ibuprofen nor acetaminophen was among the independent predictors of risk when all patients were considered (adjusted odds ratio, 1.05; 95% Cl, 0.88-1.26). However, two subsets of at risk patients had an ibuprofen effect: patients greater than or equal to 65 years of age who received ibuprofen were at greater risk of renal impairment as compared to acetaminophen recipients (adjusted odds ratio, 1.34; 95% Cl, 1.05 to 1.72) as were patients with coronary artery disease (adjusted odds ratio, 2.54; 95% Cl, 1.38 to 4.68). Their results suggest that elderly patients and patients with coronary artery disease are at risk for ibuprofen-associated renal impairment and therefore should have their renal function monitored when ibuprofen and possibly other nonsteroidal anti-inflammatory drugs are prescribed.
Acetaminophen↗
Can the provision of information to patients with osteoarthritis improve functional status? A randomized, controlled trial.
After we assessed the functional status of 439 patients with osteoarthritis, we randomly assigned them to 1 of 3 intervention groups or to a control group. The interventions consisted of providing information, and differed only in the method of delivery: by phone, in person at the clinic, or both. Physical health improved (P = 0.02), pain was reduced (P = 0.02), and psychological health improved marginally (P = 0.10) in patients contacted by phone compared with those not contacted by phone. In those contacted only at the clinic, physical health worsened (P = 0.02), but neither pain (P = 0.80) nor psychological health (P = 0.90) differed from the values in patients not contacted at the clinic. We conclude that telephone contact is a useful intervention that can enhance the functional status of patients with osteoarthritis.
Consumer Behavior↗
Common problems experienced by adults with osteoarthritis.
Functional status and noncompliance were assessed at baseline in 327 patients with osteoarthritis (OA), 96% of whom were interviewed again later either by telephone or at their next scheduled primary care visit. One-third of the sample reported noncompliance at baseline. During the follow-up interviews, commonly identified problems included having an inadequate supply of medicines to last until their next physician visit (47%), experiencing gastrointestinal complaints (36%), and reporting barriers to primary care (32%). For OA patients with hypertension or heart disease (N = 241), 75% reported clinically important symptoms. Patients with poorer functional status at baseline generally reported more subsequent problems. We conclude that patients frequently have correctable problems (e.g., medication noncompliance and side effects, barriers to care). These patients may be identified prospectively by their poor functional status. Arthritis health care professionals may wish to consider patient-oriented interventions to obviate these problems when evaluating functional status.
Chronic Disease↗
Renal disease in hypertensive adults: effect of race and type II diabetes mellitus.
To test the hypothesis that race is a predictor of hypertensive renal disease, we examined a general medicine clinic population of 6,880 hypertensive patients who were treated for at least 1 year (mean, 5.2 years). Their mean age was 55.8 years; 70% were women, 72% were black, and 41% were diabetic (95% type II). Many were already under treatment at the time of enrollment. Their mean blood pressure at entry was 150/92 mmHg; during treatment it was 142/86 mmHg. Decreased renal function, defined as a serum creatinine greater than or equal to 2 mg/dL, developed in 18.1%. A multivariable logistic regression analysis identified diabetes, glucose control, systolic blood pressure levels, heart failure, and male gender as indicators of decreased renal function. These data suggested that glucose and blood pressure control may decrease the frequency of impaired renal function. However, when these variables were controlled, blacks still had almost twice the risk for renal dysfunction (91% greater risk) than whites (P less than 0.0001). With increasing creatinine values, the percentage of black patients increased progressively. The data draw attention to and elucidate the exceptionally high incidence of renal dysfunction in blacks with or without diabetes. Further, they may explain the inordinate numbers of blacks with hypertension requiring dialysis. Finally, these retrospective data suggest that prospective trials to test the effect of blood pressure and glucose control on the course of renal disease in hypertensive and/or type II diabetic patients are warranted.
Black People↗
Information management in clinical prevention.
Good preventive care requires the management of large quantities of patient-specific information in a logical and timely manner with careful monitoring for uncommon but significant clinical events. With an increase of informational pressures on the busy practicing physicians, they are turning to computers for help. This article discusses the evolution of computers in medicine, their current status, the rationale for their use in preventive care and their future roles in clinicians' offices.
Artificial Intelligence↗
Health care policy for urban patients with renal insufficiency: are there better options?
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Delivery of Health Care↗
Computer-stored medical records. Their future role in medical practice.
Over the next few years, computer-stored medical records will become technically and economically feasible on a broad scale. Hybrid systems that include computer and traditional paper versions of the medical record and obtain their data from existing ancillary service systems will soon be widely available. Completely electronic medical records will follow. However, standards for exchanging clinical information between independent computers are needed to eliminate the reentry or interfacing costs otherwise required to obtain data from computerized ancillary services. Three kinds of benefits may be expected: (1) improved logistics and organization of the medical record to speed care and improve care givers' efficiency, (2) automatic computer review of the medical record to limit errors and control costs, and (3) systematic analysis of past clinical experience to guide future practices and policies.
Decision Making, Computer-Assisted↗