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W M Tierney

Publications and source records attributed to W M Tierney.

At least 55 records · Page 3Linked to original sources
PubMed1998

Generic versus disease-specific health status measures. An example using coronary artery disease and congestive heart failure patients.

The objectives of this study were to evaluate and compare the psychometric properties of a generic health status measure, the Medical Outcomes Study SF-36, and a disease-specific health status measure, a modified version of the Chronic Heart Failure Questionnaire (CHQ), among outpatients known to have coronary artery disease (CAD) and/or congestive heart failure (CHF). A cross-sectional analysis of baseline data obtained from 670 outpatients participating in a randomized controlled clinical trial in the general medicine clinics of a major academic medical center was performed. The SF-36 was more comprehensive in its coverage of different health status domains. In contrast, the CHQ had fewer problems with floor and ceiling effects, was more internally consistent, had better dimensional reproducibility, and exhibited less factorial complexity. Although both instruments are appropriate for use among outpatients known to have CAD and/or CHF, the CHQ has significantly better psychometric properties than does the SF-36.

Activities of Daily Living↗
PubMed1998

Relationships between symptom relief, quality of life, and satisfaction with hospice care.

Hospices were founded to alleviate suffering at the end of life. Quality improvement in hospices should, therefore, target patients' subjective assessments of their care and its outcomes. However, little is known about the relationships among subjective measures of care among hospice patients. The aim was to assess the relationships between hospice patients' physical and psychological symptoms, quality of life, and satisfaction with inpatient care. This was achieved with a prospective cohort study of 42 patients admitted to an Australian hospice's inpatient service during a two-month study period. The Edmonton symptom assessment system, McGill quality of life questionnaire, and a new measure of patients satisfaction with hospice inpatient care were used. It was shown that while there were marked variations in symptoms and quality of life scores, most patients were satisfied with their care. Satisfaction on the day after admission was lower among patients with worse quality of life scores (r = -0.40, P = 0.008), but there was no correlation with symptoms (r = -0.12, P = 0.43). Among the 26 patients (62%) with at least one subsequent inpatient interview, satisfaction was correlated with both worse quality of life (r = -0.51, P = 0.01) and symptoms (r = -0.41, P = 0.05). The symptom, quality of life, and satisfaction scales all had sufficient precision to identify patients with significant changes between the two interviews. It can be concluded that satisfaction with hospice care was associated with quality of life more than symptoms, although symptoms became important later during inpatient stays. Patients can assess their care and can provide valuable information for improving palliative care.

Aged↗
PubMed1997

Association of symptoms of depression with diagnostic test charges among older adults.

BACKGROUND: Previous studies have documented greater use of health services by depressed persons and have postulated that health care costs could be reduced overall through better recognition and treatment of depression. OBJECTIVE: To determine whether a greater burden of medical illness contributes to excess charges for diagnostic tests among older adults with symptoms of depression. DESIGN: Prospective cohort study. SETTING: A primary care group practice at an academic institution. PATIENTS: 3767 patients 60 years of age and older who completed testing on the Centers for Epidemiologic Studies Depression Scale (CES-D) during routine office visits. MEASUREMENTS: Charges for all inpatient and ambulatory diagnostic testing for 2 years, including clinical pathology, diagnostic imaging, and special procedures; number of visits to the ambulatory care center or emergency department; and number of hospitalizations. The Ambulatory Care Group case-mix approach, which is based on ambulatory diagnoses, was used as a measure of health status and expected resource consumption. RESULTS: Patients with symptoms of depression (CES-D scores > or = 16) were significantly younger (66.6 compared with 68.1 years; P < 0.001), more likely to be white (50.5% compared with 33.9%; P = 0.001), and more likely to be female (75.8% compared with 67.6%; P = 0.001) than were those without these symptoms (CES-D scores < 16). They also had more nonpsychiatric comorbid conditions, had more visits to the ambulatory care center (9.2 compared with 7.8; P < 0.001), were more likely to use the emergency department (52.3% compared with 40%; P = 0.001), were more likely to be hospitalized (22.4% compared with 17%; P = 0.002), and had greater median total diagnostic test charges for a period of 1 year ($583 compared with $387; P < 0.001). The difference in charges, most of which were clinical pathology charges (54.2%), persisted into the second year. Ambulatory Care Group assignment was independently associated with diagnostic test charges. The CES-D summary score was not independently associated with diagnostic test charges when controlling for Ambulatory Care Group assignment. CONCLUSIONS: Patients with symptoms of depression accrue greater average diagnostic test charges. However, these data suggest that such patients also have a greater burden of comorbid nonpsychiatric illness. Efforts to improve outcome and decrease cost for patients who have late-life depression must target interventions to improve the care of psychiatric and medical illness concurrently.

Aged↗
PubMed1997

Examination of racial differences in management of cardiovascular disease.

OBJECTIVES: We sought to identify the clinical characteristics associated with, and to investigate the impact of cohort selection criteria on, interracial use of invasive cardiac procedures and to determine survival. BACKGROUND: Although interracial differences in the use of invasive cardiac procedures have been previously reported, the underlying reasons are not known. METHODS: A retrospective cohort study was conducted at a Veterans Affairs Medical Center. Study patients were evaluated for cardiovascular disease between January 1 and December 31, 1993. RESULTS: The study included 1,406 male patients (85% white, 58% married), with a mean age of 63.4 years. African Americans were less likely than whites to undergo procedures (cardiac catheterization: odds ratio [OR] 0.37, 95% confidence interval [CI] 0.24 to 0.58; coronary angioplasty: OR 0.60, 95% CI 0.25 to 1.49; coronary bypass surgery: OR 0.22, 95% CI 0.08 to 0.63; any procedure: OR 0.32, 95% CI 0.21 to 0.50). On bivariate analysis, patients who underwent cardiac procedures were more likely to be younger, married and reside nonlocally and less likely to have severe comorbid disease; however, African Americans were less likely to be married and to reside nonlocally and more likely to have severe comorbid disease. Cohorts adjusting for referral status and specified cardiac diagnoses reduced or reversed interracial treatment differences. Thirty-day and 1-year survival rates (96% and 87.6%, respectively) were equivalent. CONCLUSIONS: Racial disparity in invasive cardiac procedure use may be partially explained by clinical differences and cohort selection bias. Despite treatment differences, survival rates were equivalent in African Americans and whites.

Black or African American↗
PubMed1997

Health care use by inner-city patients with asthma.

The purpose of this study was to describe patterns of health care use by inner-city patients with asthma and to identify patients at risk for hospitalization. We performed a retrospective cohort study of 1788 patients with asthma aged 5 to 34 years from a large hospital-based multi-specialty practice in inner-city Indianapolis from 1985 to 1992. Compared with 633 white patients, 1155 African-American patients had fewer outpatient encounters including primary care visits, urgent visits to the emergency department and urgent care centers, and prescription refills. Emergency department use was greater for African-American males compared with white males. With patients 30 years of age as the referent, survival analysis revealed three to sixfold greater relative risk of hospitalization for asthma for younger patient age groups, and greatest risk among young African-American males. Adolescent patients had the highest cumulative percentage hospitalization and the longest lengths of stay. We conclude that inadequate routine primary care among African-American patients may increase their risk of asthma exacerbation requiring hospitalization. Age, gender, and race are all important predictors of hospitalization for asthma. Further studies are needed to explore the relation between sources of care and asthma exacerbation.

Adolescent↗
PubMed1997

Preferences of physicians and their patients for end-of-life care.

OBJECTIVE: Both physicians and patients view advance directives as important, yet discussions occur infrequently. We assessed differences and correlations between physicians' and their patients' desires for end-of-life care for themselves. MEASUREMENTS AND MAIN RESULTS: Study physicians (n = 78) were residents and faculty practicing in an inner-city, academic primary care general internal medicine practice. Patients (n = 831) received primary care from these physicians and were either at least 75 or between 50 and 74 years of age, with selected morbid conditions. Physicians and patients completed identical questionnaires that included an assessment of their preferences for six specific treatments if they were terminally ill. There were significant differences between physicians' and patients' preferences for all six treatments (p < .0001), with physicians wanting less treatment than their patients for five of them. Patients desiring more care (p < .01) were more often male (odds ratio [OR] 1.7). African-American (OR 1.6), and older (OR 1.02 per year). There were no such correlates with physicians' preferences. A treatment preference score was calculated from respondents' desires to receive or refuse the six treatments. Physicians' scores were highly correlated with those of their enrolled primary care patients (r = .51, p < .0001). CONCLUSIONS: Although patients and physicians as groups differ substantially in their preferences for end-of-life care, there was significant correlation between individual academic physicians' preferences and those of their primary care patients. Reasons for this correlation are unknown.

Adult↗
PubMed1997

Assessing inner-city patients' hospital experiences. A controlled trial of telephone interviews versus mailed surveys.

OBJECTIVES: Obtaining accurate and representative patient-centered data may be difficult among poor, inner-city patients because of changing addresses, variable access to telephones, and a higher prevalence of illiteracy than in the populations in which many survey instruments were developed and tested. Assumptions about the usefulness of mailed surveys versus telephone interviews may not hold for the urban poor. Therefore, identifying the most efficient mode of survey administration in this population becomes an important methodological question. METHODS: We conducted a randomized trial of patients discharged from the inpatient medicine service of an urban teaching hospital to compare telephone interview with mailed self-administration of a detailed instrument for measuring patients' experiences with hospital care. Our primary outcomes were response rate, missing data, and data collection costs. Patients were excluded if they were not discharged to home or were mentally or physically unable to complete mailed or telephone interviews. The research assistant contacted eligible patients while hospitalized, informed them of the postdischarge survey, and obtained current phone numbers and addresses. Patients then were randomized to receive a 116-item satisfaction survey via one of two survey methods: mail-first (mailed surveys with follow-up on nonrespondents by telephone) or telephone-first (telephone interviews with follow-up of nonrespondents by mail). RESULTS: Of the 252 patients enrolled, 130 were randomized to the mail-first and 122 to the telephone-first method. Response rates were higher with the telephone-first (73%) compared with the mail-first method (50%; P < 0.0001). Surveys obtained by the telephone-first method had fewer missing data (0.7 +/- 2.39) for those items not involved in skip patterns compared with the mail-first method (7.1 +/- 12.3; P < 0.001) and were 42% less expensive per completed survey ($26.32 versus $37.35; P < 0.0001). CONCLUSIONS: In this survey of patients served by an urban teaching hospital, a strategy of telephone interviews with mail follow-up proved less expensive and yielded a higher response rate with more complete data than using a method where mailed surveys were followed by back-up telephone interviews. In addition, we believe that the improved response rate for telephone interviews compared with those reported in the literature for similar populations is the result of informing inpatients of the survey and obtaining telephone numbers and addresses in the hospital.

Female↗
PubMed1997

Diabetic ketoacidosis charges relative to medical charges of adult patients with type I diabetes.

OBJECTIVE: To determine the medical charges for treating diabetic ketoacidosis (DKA) episodes relative to direct medical care charges of adult patients with type I diabetes. RESEARCH DESIGN AND METHODS: Using data from an electronic medical record system, we identified adult patients with type I diabetes who had received inpatient or outpatient care on at least two occasions between 1 January 1993 and 30 June 1994. Resources and charges for hospitalizations, emergency room visits, outpatient visits, and pharmaceuticals were recorded during this period. One additional year of information was collected to assess the resources and charges associated with multiple DKA episodes. RESULTS: A total of 200 patients were identified, of whom 72 (36.0%) experienced a total of 161 DKA episodes. The direct medical care charges associated with DKA episodes represented 28.1% of the direct medical care charges for the cohort of patients with type I diabetes. The average charge per DKA episode was $6,444. The estimated annual medical care charge for each patient was $7,855 ($13,096 per patient experiencing a DKA episode versus $4,907 per patient not experiencing an episode). Multiple DKA episodes were experienced by 24 (12.0%) of the study patients and accounted for 55.6% of the direct medical care charges for these patients. CONCLUSIONS: DKA episodes represented more than $1 of every $4 spent on direct medical care for adult patients with type I diabetes and $1 of every $2 in those patients experiencing multiple episodes. Interventions that are capable of even a modest reduction in the number of DKA episodes could produce substantial cost savings in a health care system and could be particularly cost-effective in adult patients with recurrent DKA.

Adult↗
PubMed1996

Computer reminders to implement preventive care guidelines for hospitalized patients.

BACKGROUND: Hospitalizations are an opportunity to provide preventive care. OBJECTIVE: To determine if computer reminders, which we have shown to be effective in our ambulatory care setting, increasing the provision of inpatient preventive care. METHODS: Randomized, controlled trial on the general medicine inpatient service of an urban, university-affiliated public hospital. Study subjects were 78 house staff rotating on the 6 general medicine services. The intervention was reminders to physicians printed on daily rounds reports about preventive care for which their patients were eligible, and suggested orders for preventive care provided through the physicians' workstations. The preventive care guidelines were derived from the US Preventive Care Task Force recommendations. Compliance with preventive care guidelines and house staff attitudes toward providing preventive care to hospitalized patients were the main outcome measures. RESULTS: No significant differences were seen between intervention and control physicians in compliance with preventive care guidelines in the aggregate or when individual preventive care actions individual preventive care actions were analyzed. This was true even though most physicians endorsed providing most kinds of preventive care for hospitalized patients. CONCLUSIONS: Despite past success in increasing preventive care in the outpatient setting, we were unable, using a moderately intensive intervention, to increase the provision of preventive care during hospitalizations. The physicians providing care during the hospitalization were not the patients' primary care physicians, which proved to be an important barrier. More intensive interventions, or more direct linkages between inpatient and outpatient care providers, may be required to overcome this resistance.

Adult↗
PubMed1996

The promise of computerized feedback systems for diabetes care.

Feedback control is an important mechanism for reaching a targeted goal. Biologic examples range from achieving the appropriate blood pressure level to glycemia control. Computer-based feedback control systems have many potential applications in medicine. Closed-loop systems directly sense the state of the patient and then deliver an intervention without human action. Closed-loop systems have been used to control postoperative fluid infusion, reduce malignant hypertension to a reasonable range through nitroprusside infusions, and control continuous insulin infusions-in effect, an artificial pancreas. Sensory problems have limited the direct application of closed-loop systems to date; most current medical uses of computer-based feedback control are open loop, where a human is interposed between the suggested intervention and the delivered treatment. Because many variables important to the management of diabetes are objective, many opportunities exist for open-loop control in diabetes management. Open-loop systems have already been used to suggest insulin dosage adjustments and treatment for hypercholesterolemia and to remind physicians of various mellitus. However, existing applications have only scratched the surface. Many more facets of diabetes management could be standardized and assisted by open-loop control systems if the management rules could be more exactly specified, a task requiring substantial time commitments by diabetologists. Efforts to translate existing knowledge bases into precise guidelines will be helpful, but new primary studies and decision analyses are needed to define the optimal use of some interventions.

Computers↗
PubMed1996

Physicians' reasons for failing to comply with computerized preventive care guidelines.

The objective of this study was to assess reasons for physicians' noncompliance with computer-generated preventive care reminders. In an academic general internal medicine practice, a survey of physicians' reasons for noncompliance found that 55% of reminders were not complied with. Reasons included "not applicable" in 22.6% (test done elsewhere, patient too ill, no uterus), "next visit" in 22.5% (physician too busy, patient too ill), and "patient refuses" in 9.9% (test not necessary or too costly, patient too busy or fears result). We conclude that although noncompliance with reminders is sometimes appropriate, making time for prevention and patient education may augment preventive care.

Adult↗
PubMed1996

Using electronic medical records to predict mortality in primary care patients with heart disease: prognostic power and pathophysiologic implications.

OBJECTIVE: To identify high-risk patients with heart disease by using data stored in an electronic medical record system to predict six-year mortality. DESIGN: Retrospective cohort study. SETTING: Academic primary care general internal medicine practice affiliated with an urban teaching hospital with a state-of-the-art electronic medical record system. PATIENTS: Of 2,434 patients with evidence of ischemic heart disease or heart failure or both who visited an urban primary care practice in 1986, half were used to derive a proportional hazards model, and half were used to validate it. MEASUREMENTS: Mortality from any cause within six years of inception date. Model discrimination was assessed with the C statistic, and goodness-of-fit was measured with a calibration curve and Hosmer-Lemeshow statistic. MAIN RESULTS: Of these patients 82% had evidence of ischemic heart disease, 53% heart failure, and 35% both conditions. Mean survival among the 653 (27%) who died was 2.8 years; mean follow-up among survivors was 5.0 years. Those with both heart conditions had the highest mortality rate (45% at 6 years), followed by isolated heart failure (39%) and ischemic heart disease (18%). Of 300 potential predictive characteristics, 100 passed a univariate screen and were submitted to maltivariable proportional hazards regression. Twelve variables contributed independent predictive information: age, weight, more than one previous hospitalization for heart failure, and nine conditions indicated on diagnostic tests and problem lists. No drug treatment variables were independent predictors. The model C statistic was 0.76 in the derivation sample of patients and 0.74 in a randomly selected validation sample, and it was well calibrated. Patients in the lowest and highest quartiles of risk differed more than five-fold in their average risk. CONCLUSIONS: Routine clinical data stored in patients electronic medical records are capable of predicting mortality among patients with heart disease. This could allow increasingly scarce health care resources to be focused on those at highest mortality risk.

Aged↗
PubMed1996

Primary care physicians' medical decision making for late-life depression.

OBJECTIVE: To describe primary care physicians' clinical decision making regarding late-life depression. DESIGN: Longitudinal collection of data regarding physicians' clinical assessments and the volume and content of patients' ambulatory visits as part of a randomized clinical trial of a physician-targeted intervention to improve the treatment of late-life depression. SETTING: Academic primary care group practice. PATIENTS/PARTICIPANTS: One-hundred and eleven primary care physicians who completed a structured questionnaire to describe their clinical assessments immediately following their evaluations of 222 elderly patients who had reported symptoms of depression on screening questionnaires. INTERVENTIONS: Intervention physicians were provided with their patient's score on the Hamilton Depression rating scale (HAM-D) and patient-specific treatment recommendations prior to completing the questionnaire regarding their clinical assessment. MAIN RESULTS: Those physicians not provided HAM-D scores were just as likely to rate their patients as depressed, as determined by specific query of these physicians regarding their clinical assessments. A physician's clinical rating of likely depression did not consistently result in the formulation of treatment intentions or actions. Treatment intentions and actions were facilitated by provision of treatment algorithms, but treatment was received by fewer than half of the patients whom physicians intended to treat. Barriers to treatment appear to include both physician and patient doubts about treatment benefits. CONCLUSIONS: Lack of recognition of depressive symptoms did not appear to be the primary barrier to treatment. Recognition of symptoms and access to treatment algorithms did not consistently result in progression to subsequent stages in treatment decision making. More research is needed to determine how patients and physicians weigh the potential risks and benefits of treatment and how accurately they make these judgments.

Age Factors↗
PubMed1996

Economic evaluation of alternative adjuvant chemotherapy modalities for colorectal carcinoma.

Concerns regarding quality of care, combined with financial constraints, have fostered the growth of health economic analyses. The accompanying cost-effectiveness analysis of intraportal adjuvant chemotherapy by Messori et al. illustrates the strengths and limitations of health economic investigations. The reader of cost-effectiveness studies must examine the relevance and perspective of the cost data, the accuracy and generalizability of the assumed clinical benefits, and the relationship of the investigated treatment strategies to standard clinical practice. As clinicians learn to interpret health economic analyses and other forms of outcomes-based research, unnecessary expenditures will be avoided and the quality of care will improve.

Chemotherapy, Adjuvant↗
PubMed1996

Suicidal ideation among older primary care patients.

OBJECTIVE: To describe the prevalence and sociodemographic and clinical correlates of suicidal ideation among older primary care patients. DESIGN: Baseline screening for depressive symptoms, functional status, and suicidal ideation, with prospective assessment of mortality. SETTING: An academic primary care group practice at an ambulatory care clinic. PARTICIPANTS: 301 patients who screened positive for depression and a random sample of 101 patients who screened negative from among 3767 patients aged 60 and older who completed screening for depression during routine office visits. MEASUREMENTS: Centers for Epidemiologic Studies Depression (CES-D) scale, Hamilton Depression Rating (HAM-D) scale, Sickness Impact Profile (SIP), structured psychiatric interview, sociodemographic and clinical variables, and mortality. RESULTS: Among the 301 patients with CES-D scores > or = 16, 14 (4.6%) reported suicidal ideation and received urgent evaluation by mental health professionals. The estimated prevalence of suicidal ideation in this cohort of older primary care patients was 0.7 to 1.2%. All patients with suicidal ideation had evidence of a current affective disorder, and nearly all had moderate to severe functional impairment. However, even though all 14 patients endorsed suicidal ideation, corresponding HAM-D scores ranged from 3 to 40, and only four of 14 met diagnostic criteria for major depression. The most common suicide plan involved use of a hand gun. Depressed patients with suicidal ideation did not differ significantly from depressed non-suicidal patients on any of the following variables: age, gender, race, education, alcohol abuse, cognitive impairment, or mean CES-D, HAM-D, or SIP scores. None of the suicidal patients had died within 12 months of the screening date. CONCLUSION: The prevalence of suicidal ideation was about 1% among this cohort of older primary care patients, and the prevalence approaches 5% among those older adults who report significant symptoms of depression. However, asking patients directly about the presence of active suicidal ideation appears to be the only effective means of identifying those at risk.

Aged↗
PubMed1996

The role of public opinion in drug resource allocation decisions.

Drug resource allocation decisions have a very real and direct impact on the public, due to cost and availability constraints resulting from these decisions. This presents an opportunity for public opinion to play an important role in influencing decisions that have far-reaching effects. Public opinion regarding pharmaceutical issues is influenced by drug companies, special interest groups, researchers and others. Since these groups often have conflicting goals, they may send contradictory messages to the public. In this article, we examine the issues of who comprises the public, how public opinion is influenced and what impact public opinion does and should have on drug resource allocation decisions. We emphasise that, for appropriate resource allocation decisions to be made, there is a continuing need to conduct high quality outcomes research and to continue the trend of increasing interest in how drugs are used rather than how much is sold or how much they cost. There is also a major role for pharmacoeconomic research to play in this issue, with a real need to make such research accessible and understandable by the public, including patients, physicians, pharmacists and policy makers, so that policy decisions can be based on such research.

Drug Therapy↗