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Biomedical subjects

W M Tierney

Publications and source records attributed to W M Tierney.

At least 73 records · Page 4Linked to original sources
PubMed1996

The recognition and treatment of late-life depression: a view from primary care.

OBJECTIVE: Efforts to improve the recognition and treatment of late-life depression in primary care are often based on the assumption that primary care physicians underutilize currently available and effective treatments. This article reviews the validity of this assumption and offers recommendations for future research. METHODS: Clinical trials designed to improve the recognition and treatment of late-life depression in primary care are reviewed. Because studies limited to older adults are rare, we also include studies enrolling younger patients. These data are reviewed in the context of recent reviews on the prevalence of depression in primary care settings and the effectiveness of available treatments. RESULTS: Although depressive symptoms are common among older adults, there is insufficient literature documenting the proportion of these patients who respond to currently available treatments. Patients with uncomplicated major depressive disorder constitute the minority of primary care patients with depressive symptoms. Nearly all available studies of treatment effectiveness of pharmacotherapy or psychotherapy focus on older adults with uncomplicated major depression. Currently available treatment options may apply to less than 15 percent of depressed primary care patients. CONCLUSIONS: More research is needed to help primary care providers manage their depressed patients with comorbid medical conditions, functional disability, or minor or chronic depressions. In addition, more research is needed to identify those patients who would benefit from specialized or interdisciplinary care.

Aged↗
PubMed1996

Computerizing guidelines: factors for success.

Clinical practice guidelines are being touted as a cure for the tension between health care cost and quality. Rather than being just a means of controlling clinicians, guidelines also offer the chance to improve the quality of care by reducing practice variation and adherence to standards of good care. To be operationalized via computers, guidelines must be accepted by the clinicians, who must fully intend to follow them. They must be timely and use available data with minimal additional data entry by clinicians. Finally, they should have a measurable effect and be shown to improve care processes and/or outcomes.

Medical Informatics Applications↗
PubMed1995

Documentation and evaluation of cognitive impairment in elderly primary care patients.

OBJECTIVE: To describe the prevalence of cognitive impairment among elderly primary care patients and to compare diagnostic evaluations and use of health services among patients with and those without cognitive impairment. DESIGN: Prospective cohort study. SETTING: Academic primary care group practice. PATIENTS: 3954 patients aged 60 years and older who completed the Short Portable Mental Status Questionnaire during routine office visits. MEASUREMENTS: Demographics and comorbid illness at baseline, diagnostic evaluations for cognitive impairment, use of standard and preventive health services, use of psychoactive drugs, and death in the year after the screening date. RESULTS: The prevalence of cognitive impairment among all patients aged 60 years and older at baseline was 15.7%; 10.5% had mild impairment and 5.2% had moderate to severe impairment. Patients with moderate to severe impairment were significantly older than patients with no impairment (76.2 years and 67.4 years, respectively), were more likely to be black (85.8% and 61.3%), had fewer years of education (7.3 years and 9.2 years), and were more likely to have cerebrovascular disease (20.4% and 6.3%) and evidence of undernutrition (30.6% and 16.9%). Dementia was recorded as a diagnosis for less than 25% of patients with moderate to severe cognitive impairment, but patients with documented impairment were more likely to have been evaluated for reversible causes. In the year after screening, patients with moderate to severe impairment were more likely than those with no impairment both to be hospitalized (29.1% and 16.5%) and to visit the emergency department (55.8% and 38.5%) but had fewer outpatient visits (6.0 and 7.6) and greater mortality (8.2% and 2.8%). CONCLUSIONS: Cognitive impairment is associated with increased use of health services and increased mortality. Patients with undocumented cognitive impairment were significantly less likely to be evaluated for reversible causes. Research is needed to determine if better documentation of cognitive impairment would improve not only diagnostic evaluations but also patient management, counseling, and outcomes.

Age Factors↗
PubMed1995

Correlates of health care satisfaction in inner-city patients with hypertension and chronic renal insufficiency.

Barriers to effective health care are potential contributors to the increased prevalence of hypertension and hypertension-related renal disease observed in black patients. We have enrolled 333 primarily elderly (mean age 69 years) black (87%) patients with hypertension and chronic renal insufficiency into a prospective randomized trial testing the effect of intense multidisciplinary management on progression of chronic renal insufficiency. These patients have an average 6 years of education and $400-$800 monthly household income: 57% have diabetes. Our baseline data include the Patient Satisfaction Questionnaire administered by home interviewers who also recorded sociodemographic data, medications and questionnaires regarding medication compliance and symptoms related to anti-hypertensive drugs. Inpatient and outpatient vital signs, test results and diagnoses came from patients' computerized medical records. We used multiple linear regression to identify correlates of overall satisfaction. We also analyzed three subscales: access to care, financial aspects and interpersonal manner of physicians. We included only variables with univariate correlations (P < 0.05) in the models. Decreased overall satisfaction correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01), and higher diastolic blood pressure (P = 0.08). Decreased satisfaction with access to care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001) and decreased medication compliance (P = 0.08). Decreased satisfaction with financial aspects of care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01) and more proteinuria (P = 0.02). Finally, decreased satisfaction with interpersonal manner of physicians correlated with lower medication compliance (P < 0.001), lower albumin (P = 0.01) and sodium (P = 0.04), and higher diastolic blood pressure (P = 0.04). These cross-sectional baseline data describe a group of mostly black inner-city patients with hypertension and chronic renal insufficiency in whom decreased satisfaction with care correlates with decreased medication compliance, increased symptoms related to anti-hypertensive drug therapy, higher diastolic blood pressure and more proteinuria. Our prospective study may help determine whether improving satisfaction improves compliance and blood pressure control, and forestalls complications in this high-risk population.

Aged↗
PubMed1995

Is obesity a barrier to physician screening for cervical cancer?

OBJECTIVE: To determine if obese and morbidly obese women are as likely to receive Papanicolaou (Pap) smears as nonobese women. PATIENTS AND METHODS: A secondary analysis was conducted of data collected during a prospective, controlled trial of computer-generated reminders to improve preventive care. The site was a large, academic general medicine practice providing primary care to an urban population at a university-affiliated municipal teaching hospital. Data were analyzed from 15 faculty and 77 resident physicians who delivered care to 1,321 women who were eligible for Pap smears. Patient data were obtained from a computerized medical record system. RESULTS: Outcomes were physician reports of Pap smear performance and reasons for nonperformance of Pap smears in eligible women. Pap smear performance was 21% for nonobese women, 20% for obese women, and 20% for morbidly obese women (P = NS). After adjusting for age and race, odds ratios for omission of Pap smear were 1.20 for both obese (95% confidence interval [CI] 0.86 to 1.67; P = NS) and morbidly obese women (95% CI, 0.58 to 2.47; P = NS). A significant dose-response relationship was found between increasing patient weight and physician responses that the Pap smear was delayed due to patient's acute illness, vaginitis, or menstruation (odds ratios [OR] 1.73 for obese, OR 4.59 for morbidly obese women; P < 0.005). CONCLUSIONS: In our general medicine practice, obesity does not appear to be associated with less Pap smear performance. Physicians are more likely to report delaying obese patients' Pap smears due to acute illness, vaginitis, or menstruation.

Female↗
PubMed1995

Predicting inpatient costs with admitting clinical data.

Hospital cost-containment programs should themselves be cost-effective, targeting high-cost physicians (which requires adjusting for case mix) and patients (which requires early identification). In this study, clinical data available within 24 hours of admission from an electronic medical record system were used to develop statistical models to predict hospital costs. In this retrospective analysis of clinical data and diagnosis-related groups (DRGs), study subjects were 2,355 patients admitted for at least 1 day to the medicine service at an urban teaching hospital with sophisticated electronic medical records. Of these 2,355 patients, 1,663 (71%) had one of the 41 most common DRGs. Predictive models were derived on a random subset of two thirds of the patients and were validated on the remaining third. The following patient data were obtained: admission and prior diagnostic test results, diagnoses, vital signs; demographic data; prior inpatient and outpatient visits; tests and treatments ordered within 24 hours of admission (discretionary data); DRGs; and total inpatient costs (estimated from charges). Diagnosis-related groups explained 24% of the variance in total costs in the derivation patient set and 16% in the validation set. When only nondiscretionary data were used, the models retained only clinical laboratory results and prior diagnoses, explaining 20% of the derivation set variance in total costs and 16% in the validation set. Adding DRGs increased the variance explained in the derivation set to 34%, but decreased to 24% in the validation set. Adding discretionary data substantially increased the explained variance in the derivation and validation patient sets. The models' median predicted costs underestimated true costs by 10% to 13%, with the lowest error in the models using all types of variables. Clinical data gathered during routine clinical care can be used to adjust for case mix and identify high-cost patients early in their hospital stays, when they could be targeted by cost-containment interventions.

Cost Control↗
PubMed1995

Health services use and mortality among older primary care patients with alcoholism.

OBJECTIVE: To describe the prevalence of alcoholism in an older primary care population and to compare rates of health services use and mortality among those with and those without evidence of alcoholism. DESIGN: Baseline screening for alcoholism using the CAGE questionnaire and longitudinal assessment of health services use and mortality using an electronic medical record system. SETTING: An academic primary care group practice at an urban ambulatory care clinic. PATIENTS: A total of 3954 patients aged 60 and older who completed the CAGE alcoholism screening questionnaire during routine office visits. MAIN OUTCOME MEASURES: Comorbidity, preventive health services use, hospital episodes and length of stay, emergency room visits, ambulatory care visits, total outpatient charges, and mortality. RESULTS: The prevalence of current evidence of alcoholism, as defined by a CAGE score > or = 2 and alcohol use in the previous 12 months, was 10.6%. Patients with evidence of alcoholism were younger (66.2 vs 68.3 years), had fewer years of education (8.4 vs 9.1), were more likely to be male (65.8 vs 27.2%), black (71.2 vs 62.6%), smokers (40.4 vs 26.3%), and malnourished (32.5 vs 26.3%). Patients with alcoholism were more likely to have a diagnosis of obstructive lung disease (22.9 vs 18.3%), injuries (14.2 vs 8.3%), and gout (6.7 vs 2.9%) and less likely to have a diagnosis of hypertension (56.9 vs 61.8%), arthritis (23.3 vs 29.3%), and diabetes (15.9 vs 23.3%). Among those with evidence of alcoholism, 41.6% had a diagnosis of alcoholism in their outpatient medical record. Rates of completion of preventive health services did not differ between the two groups, and there was no difference in the number of ambulatory care visits, emergency room visits, or total outpatient charges. Patients with evidence of alcoholism were more likely to be hospitalized (21.5 vs 16.9%) and more likely to die within 2 years (10.6% vs 6.3%). CONCLUSIONS: One of 10 older patients in this primary care practice had current evidence of alcoholism, fewer than half of whom had documentation of alcohol abuse in their medical records. These patients were more likely to be hospitalized and more likely to die but did not consume a greater amount of outpatient resources. Further research is needed to determine if interventions to reduce alcohol use would also reduce excess hospitalizations and mortality among these older patients.

Age Distribution↗
PubMed1995

Multidimensional work sampling in an outpatient pharmacy.

Multidimensional work sampling was performed at a hospital-based outpatient pharmacy. Data were collected from nine full-time and five part-time pharmacists over a 45-day baseline period. Pharmacists wore silent, random-signal generators that permitted continuous work sampling. We introduced the concept of quick codes to allow pharmacists to record their work using a single letter for repetitive activities. Pharmacists recorded 4,687 observations, 90 percent using quick codes. The most common activity was checking prescriptions (36.2 percent). Detection and correction of prescribing errors was the most common reason for their work (39.4 percent). Most work-related activities were performed alone (80 percent) with little time in contact with patients or physicians. These baseline measures will be compared with future measures to assess the effect of the implementation of computerized prospective drug utilization review and clinical treatment guidelines on pharmacists' work. It is expected that these technologic and process changes will increase opportunities for pharmacists to educate patients and consult with physicians.

Classification↗
PubMed1995

Design and implementation of the Indianapolis Network for Patient Care and Research.

We are creating a health care information network that will link a large community medical record system to three hospital emergency departments, fifty community pharmacies, ten clinics, four health-maintenance organization (HMO) offices, and twelve homeless care sites in Indianapolis, Indiana. This project will test the feasibility of linking care providers across organizational boundaries and measure the benefits of such a network. The network will supply three kinds of information services: a "mini-medical library," patient medical record information, and a citywide prescription database incorporating a computer-based prescription-writing system. The use of medical resources, the cost of care, provider time spent giving care, and providers' opinions of the services will be used as outcomes in randomized clinical trials. Through this project, we hope to expand the information base available to the target care sites; reduce unnecessary testing and increase the efficiency of care in emergency departments; improve emergency department, office, and clinic prescribing patterns; enlarge the consortium of health care providers connected by the network; and develop strategies for successfully implementing a comprehensive city medical record resource.

Ambulatory Care Facilities↗
PubMed1994

Depression in late life: the use of clinical characteristics to focus screening efforts.

BACKGROUND: The objective of the study was to identify clinical characteristics associated with depressive symptoms in late life so that screening could focus on elderly patients most likely to benefit from further evaluation. METHODS: We used cross-sectional screening for significant symptoms of depression using the Center for Epidemiologic Studies Depression scale and identification of patients' clinical characteristics from patient interviews and a computerized medical record. The setting was an academic primary care group practice at an urban ambulatory care center. Participants were 1,633 consecutively consenting patients aged 60 and older who visited the center between January and August 1991. Mean age was 70 years; 72% were women, 32% were White, 47% had less than 8 years of education, and 7% had no health insurance. RESULTS: There were 251 (15%) patients with significant symptoms of depression. Antidepressants were prescribed to 1 in 7 patients with such symptoms, with amitriptyline being the most commonly prescribed. Bivariate analyses indicated that patients with significant symptoms of depression were more likely to be White, female, without health insurance, and were more likely to have probable alcoholism, mild cognitive loss, and to receive narcotics, histamine H2 antagonists, and/or benzodiazepines. Depressive symptoms were not significantly correlated with age, education, income, or chronic medical conditions. CONCLUSIONS: Significant symptoms of depression were common and correlated with several readily available clinical variables. However, these variables lack sufficient discriminatory power to allow for the selective screening of elderly patients most likely to suffer from symptoms of depression. Thus, formal screening for depression among all elderly patients in primary care may be necessary to improve the recognition of this morbid illness.

Adrenergic beta-Antagonists↗
PubMed1994

Medical students' and housestaff's opinions of computerized order-writing.

BACKGROUND: Greater use of computers has been touted as one way in which health care quality can be enhanced while reducing costs. The authors assessed factors associated with acceptance of computerized order-writing. METHOD: From April 1990 through October 1991 a survey was administered to 275 medical students and housestaff who used computer workstations to write all their orders on the general medicine wards at Wishard Memorial Hospital. The survey assessed computer literacy, ease of workstation use, effects on practice and time management, and usefulness of information provided. RESULTS: A total of 212 (77%) of the computer-workstation users responded. Opinions were generally positive. Those of junior students were the most positive, with opinions declining progressively for senior students, interns, and residents. The housestaff were most critical of time spent using the workstations, although they required less time to write orders than the students did. CONCLUSION: The favorableness of the respondents' opinions declined as the level of training increased, a trend that was independent of computer literacy. Hence, increasing computer use by physicians will probably require modification of the educational and socialization process rather than mere reliance on increasing computer literacy.

Analysis of Variance↗
PubMed1994

Longitudinal study of depression and health services use among elderly primary care patients.

OBJECTIVE: To describe the prevalence and 9-month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use. DESIGN: Prospective study of depressive symptoms as measured by the Center for Epidemiologic Studies Depression (CES-D) scale and identification of patients' outpatient health services use through an electronic medical record system. SETTING: An academic primary care group practice at an urban ambulatory care clinic. PATIENTS/PARTICIPANTS: 1711 patients aged 60 and older who completed the CES-D at baseline and 9 months later; 935 of these patients also completed the CES-D at 6 months. MEASUREMENT AND MAIN RESULTS: The prevalence of significant symptoms of depression (CES-D > or = 16) was 17.1% at baseline and 18.8% at 9 months; 26.8% of patients exceeded the threshold on the CES-D either at baseline or 9 months, and the 9-month incidence was 11.7%. Among the patients re-interviewed at both 6 and 9 months, the 6-month incidence was 12%, and the incidence between the 6- and 9-month assessments was 10%. Of the 292 patients with depression at baseline, 140 (47.6%) remained depressed at the 9-month follow-up. Baseline and 6-month CES-D score, in addition to perceived health at 6 months, explained 45% of the variance in the 9-month CES-D score. Patients above the threshold on the CES-D at any time were more likely to rate their health as fair or poor (69.8% vs 43.7%) and more likely to have an emergency room visit (40.4% vs 29.4%). These patients also had 38% more outpatient visits (7.7 vs 5.6) and 61% higher total outpatient charges ($1209 vs $751) than patients who never exceeded the CES-D threshold over the 9-month window (all P values < 0.01). CONCLUSIONS: Depressive symptoms were frequent and often persistent in this patient population. We identified patterns of oscillating severity of symptoms within individuals but relatively stable incidence and prevalence rates over a 9-month period. Patients who exceeded the threshold on the CES-D at any time during the study had significantly greater health services use and poorer perceived health.

Aged↗
PubMed1994

Improving treatment of late life depression in primary care: a randomized clinical trial.

OBJECTIVE: Facilitate primary care physicians' compliance with recommended standards of care for late life depression by reducing barriers to recognition and treatment. DESIGN: Randomized controlled clinical trial of physician-targeted interventions. SETTING: Academic primary care group practice caring for an urban, medically indigent patient population. PATIENTS/PARTICIPANTS: Patients aged 60 and older who exceeded the threshold on the Centers for Epidemiologic Studies Depression Scale (CES-D) and the Hamilton Depression Rating Scale (HAM-D) and their primary care physicians. INTERVENTION: Physicians of intervention patients were provided with patient-specific treatment recommendations during 3 special visits scheduled specifically to address the patient's symptoms of depression. In general, physicians were encouraged to establish a diagnosis of depression and educate their patient about the diagnosis, discontinue medications that can cause or exacerbate depressive symptoms, initiate antidepressants when appropriate, and consider referral to psychiatry. Guidelines for prescribing antidepressants were provided. Control physicians received no intervention, and control patients received usual care. MAIN OUTCOME MEASURES: Frequency of recording a depression diagnosis, stopping medications associated with depression, initiating antidepressant medication, and psychiatry referral; mean changes in HAM-D and Sickness Impact Profile (SIP) scores. RESULTS: One hundred three physicians and 175 patients were involved in the clinical trial. Physicians of intervention patients were more likely to diagnose depression and prescribe antidepressants (P < 0.01). There were no differences between the groups in the frequency of stopping medications associated with depression or referrals to psychiatry. Medications with the strongest cause and effect relationship to depression were infrequently used in this cohort of patients. Although both groups showed improvement in HAM-D and SIP scores, we were unable to demonstrate significant differences in HAM-D or SIP scores between the 2 groups. CONCLUSIONS: Intensive screening and feedback of patient-specific treatment recommendations increased the recognition and treatment of late life depression by primary care physicians. However, we were unable to demonstrate significant improvement in depression or disability severity among intervention patients despite the informational support provided to their physicians. Efforts to improve the functional status of these patients may require more integrated interventions and more aggressive attempts to target psychosocial stressors traditionally outside the purview of primary care.

Aged↗
PubMed1994

Tricompartmental knee replacement. A comparison of orthopaedic surgeons' self reported performance rates with surgical indications, contraindications, and expected outcomes. Knee Replacement Patient Outcomes Research Team.

The chance of a person with osteoarthritis of the knee receiving a knee replacement is highly variable. To understand better the reasons for this variation, all practicing orthopaedists in Indiana were surveyed about their management of severe knee osteoarthritis and their perception of tricompartmental knee replacement as a therapeutic option. Their perceptions of indications and outcomes of knee replacement were compared with the self reported annual number of patients for whom they performed (or referred to other surgeons for) tricompartmental knee replacements. A completed survey was returned by 220 (79%) of the 280 orthopaedists surveyed; analyses were limited to the 188 respondents who had cared for at least one patient with osteoarthritis of the knee in the prior 2 weeks (mean = 13). These surgeons reported performing (or referring patients for) a mean of 31 knee replacements in the prior year (SD 45, median 21, range 0-480 knee replacements). There was strong agreement (> 95%) among respondents for seven (21%) of 33 surgical indications and contraindications, and more general agreement (> 60%) for 21 (64%). In the five factors (15%) for which there was disagreement, there was no consistent relationship between opinions and self reported knee replacement performance rate. Surgeons reporting more knee replacements had significantly higher estimates of pain relief and functional improvement following surgery, and lower estimates of prosthesis infection and failure rates. When all responses were considered together, four decision factors correlated independently with the performance of more knee replacements, but these four factors explained only 24% of the variation in self reported knee replacement performance.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Physician inpatient order writing on microcomputer workstations. Effects on resource utilization.

OBJECTIVE: To assess the effects on health care resource utilization of a network of microcomputer workstations for writing all inpatient orders. DESIGN: Randomized controlled clinical trial. SETTING: Inpatient internal medicine service of an urban public hospital. SUBJECTS: A total of 5219 internal medicine patients and the 68 teams of house officers, medical students, and faculty internists who cared for them. INTERVENTION: Microcomputer workstations, linked to a comprehensive electronic medical record system, for writing all inpatient orders. MAIN OUTCOME MEASURES: Total inpatient charges for each admission and charges for specific categories of orders. A time-motion study of selected interns assessed the ordering system's time consumption. RESULTS: Intervention teams generated charges that were $887 (12.7%) lower per admission than did control teams (P = .02). Significant reductions (P < .05) were demonstrated separately for bed charges, diagnostic test charges, and drug charges. Reductions of similar proportion and statistical significance were found for hospital costs. The mean length of stay was 0.89 day shorter for intervention resident teams (P = .11). Interns in the intervention group spent an average of 33 minutes longer (5.5 minutes per patient) during a 10-hour observation period writing orders than did interns in the control group (P < .0001). CONCLUSIONS: A network of microcomputer workstations for writing all inpatient orders significantly lowered patient charges and hospital costs. This would amount to savings of more than $3 million in charges annually for this hospital's medicine service and potentially tens of billions of dollars nationwide. However, the system required more physician time than did the paper charts. Research at other sites and system advances to reduce time requirements are warranted.

Computer Communication Networks↗