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Biomedical subjects

W M Tierney

Publications and source records attributed to W M Tierney.

At least 127 records · Page 7Linked to original sources
PubMed1986

The Medical Gopher--a microcomputer system to help find, organize and decide about patient data.

We have developed a microcomputer-based medical workstation that does some of physicians' "gopher" work of fetching, organizing, reviewing and recording. For two years physicians have used the first version of this system to order all diagnostic tests in a general medicine clinic. They are about to use a newer version to write prescriptions and office visit notes and to find general medical and patient-specific information. Users can enter data into this system by "pointing" with a "mouse" to menu items displayed on a video terminal. In the course of a computer activity, a physician can obtain information about drugs, tests and different diagnoses, as well as about the patient. The microcomputer workstations are linked to each other and to a central hospital information system through a high-speed network link. Our physicians have accepted the initial order-entry system, and early experience suggests they prefer this faster and more sophisticated system.

Computer Systems↗
PubMed1985

The impact of reading on physicians' nonadherence to recommended standards of medical care.

In order to increase physicians' adherence to recommended standards of medical care and to examine factors presumed to contribute to such changes, we conducted a randomized, controlled trial using reading materials targeted to specific practice recommendations. Seventy-nine internal medicine residents completed baseline questionnaires stating their intentions to follow 13 common preventive care actions. They were randomly assigned to receive one of two different sets of readings covering these care actions. Thus, each physician was in the experimental group for one set of readings (A or B) while serving as a control for the other set. The impact of the reading was determined by: the physicians' knowledge of the recommended care actions detailed in the combined readings, their post-reading intentions, and clinical behavior when faced with patients having indications for the recommended actions. The 73 residents (92%) who read the material judged 39% of the information to be new and 72% useful. Residents had significantly better performance on the knowledge questions based on their own readings than did their control group peers for both sets of readings. For the Group A physicians, reading significantly (P less than 0.05) increased intentions to follow one of the seven clinical actions while Group B residents increased their intentions in three out of six. Step-wise multiple regression analyses were used to predict physicians' post-reading adherence to the recommended actions. For the Group A actions, pre-reading actions accounted for most of the variance in their post-reading actions.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Competence↗
PubMed1985

Predictors of myocardial infarction in emergency room patients.

To develop a decision rule to aid in the diagnosis of myocardial infarction, we evaluated clinical and ECG data on 540 adults treated in an urban hospital emergency room for acute chest pain. Of 62 (11.5%) patients who had acute infarctions, 54 were admitted to intensive care (sensitivity 87%); 103 of 478 patients without infarctions were also admitted to intensive care (specificity 78%). Thirty-four percent of all patients admitted had infarctions. Multivariate analysis identified only four clinical variables which carried independent information predicting infarction: two from the ECG and two from the clinical history. A predictive model based on these four variables had significantly greater specificity (86% vs. 78%, p = .003) and accuracy of overall patient classification (88% vs. 79%, p = .013) but somewhat lower sensitivity (81% vs. 87%, p = .46) than physician judgments. However, a decision rule which would have admitted to intensive care those patients with a high probability of infarction who were not admitted by the emergency room physicians, would have increased the sensitivity for detecting infarction to 95% with no appreciable decrease in specificity or yield of infarctions among patients admitted to intensive care.

Adult↗
PubMed1985

After-hours telephone access to physicians with access to computerized medical records. Experience in an inner-city general medicine clinic.

The authors examined the effect of after-hours telephone access to physicians and physician access to computerized medical records on hospitalizations and emergency room (ER) visits in an inner-city, adult, general medicine clinic. Patients were randomly assigned to a control (C) and two study groups (S1 and S2). Patients in study groups S1 and S2 had after-hours telephone access to physicians. Computerized medical records were accessible to physicians only for callers in study group S2. During the initial 18 months of study, only 7.6% of eligible patients called the after-hours service, a rate of 6 calls/1,000 patients/month (200 calls/1,849 patients/18 months). Repeated promotion of the service was subsequently undertaken, and 19.4% of the patients used the service during the final 12 months of study, a rate of 24.1 calls/1,000 patients/month (467 calls/1,616 patients/12 months). There were no significant differences in hospitalizations or ER visits among the control and two study groups.

Computers↗
PubMed1985

Serum potassium testing in diuretic-treated outpatients. A multivariate approach.

We evaluated risk factors for abnormal serum potassium (K+) concentrations in 5817 outpatients on chronic diuretic therapy. Hypokalemia (K+ less than 3.5 meq/L) occurred in 18.8 percent at the last clinic measurement. Hyperkalemia (K+ greater than 5.5) was rare (0.5%) and was even less common in those also taking KCl or a K+ sparing drug (0.2%). Hypokalemic patients were younger, healthier, more often hypertensive, more commonly taking a thiazide diuretic, and more likely to have been hypokalemic in the past. Hyperkalemic patients were older, more often suffering from heart or renal failure, and more commonly taking furosemide. Logistic regression analysis yielded eight variables that contributed significantly to the prediction of hypokalemia: mean and most recent serum K+, thiazide use, the use and duration of use of potassium-sparing diuretics, age, and most recent serum sodium and bicarbonate determinations. The regression equation allowed us to identify a group of patients (63% of the total) at low risk for hypokalemia (K+ less than 3.5 in 9.4%; K+ less than 3.0 in 0.5%) and another group (37% of the total) at high risk for hypokalemia (K+ less than 3.5 in 35%; K+ less than 3.0 in 5%). Information about the risk of hypokalemia can be used to decide when to measure serum potassium concentration in individual diuretic-treated outpatients.

Benzothiadiazines↗
PubMed1984

Jehovah's Witnesses and blood transfusion: physicians' attitudes and legal precedents.

Patients with significant medical problems who refuse some aspects of their medical care present medicolegal and management problems for their physicians. The selective refusal of transfusion of blood products by Jehovah's Witnesses typifies such situations. To explore physicians' reactions to these constraints, we sent a questionnaire to medical students, residents, and faculty wherein we asked them to respond to case simulations involving Jehovah's Witnesses and refusal of transfusion. Fifty percent of all respondents, including 84% of the faculty, reported experience in dealing with Jehovah's Witnesses. Overall, respondents were more likely to give transfusion to an infant or an incompetent adult than to competent adults. Only educational level made a significant difference in response: faculty members most frequently mentioned obtaining a court order when giving transfusion against a patient's will. Case law, upon which legal grounds such decisions stand, is often conflicting and is evolving toward allowing patients a freer hand in their choices of therapy. We sketch the history and present status of these precedents and offer a framework for dealing with patients' refusal of care.

Attitude of Health Personnel↗
PubMed1984

Reminders to physicians from an introspective computer medical record. A two-year randomized trial.

We developed a computer-stored medical record system containing a limited set of the total clinical data base--primarily diagnostic studies and treatments. This system responds to its own content according to physician-authored reminder rules. To determine the effect of the reminder messages generated by 1490 rules on physician behavior, we randomly assigned practitioners in a general medicine clinic to study or control groups. The computer found indications for six different actions per patient in 12 467 patients during a 2-year study: 61 study group residents who received computer reminders responded to 49% of these indications; 54 control group residents, to only 29% (p less than 0.0001). Preventive care (occult blood testing, mammographic screening, weight reduction diets, influenza and pneumococcal vaccines) was affected. The intentions of the study group to use a given action for an indication predicted their response to the indications (p less than 0.03, r2 = 0.33). The intentions of the control residents did not.

Computers↗
PubMed1982

The development of physician norms in the United States. The treatment of Jehovah's Witness patients.

According to their religious dogma, Jehovah's Witnesses (JW) are unwilling to accept blood transfusions, even if their own lives are at stake. This belief puts physicians, who have no consistent legal norms to guide their behavior, in an ambiguous situation. To examine the socialization process regarding the development of norms under legal uncertainty, we asked medical students, house staff and faculty physicians to discuss their actions regarding each of four case simulations (one minor child, one incompetent adult, and two competent adults). In our sample, 84% of faculty and half of the respondents overall report having had personal experience with JWs. Despite patient or parental requests to the contrary, physicians were most likey to transfuse the child (80%), followed by the imcompetent adult (63%) and the two competent adults (25 and 15%). This ordering reflects the consistency of court decisions. In addition, the physicians' decisions regarding whether or not to transfuse did not vary with either their experience with JWs or level of training; however, experienced physicians appeared to learn to take precautions to protect themselves and their hospital from legal action. The study also indicates lack of formal medical education as an information source from which medical students learn about this ethical problem.

Blood Transfusion↗
PubMed1980

Intravenous leiomyomatosis of the uterus with extension into the heart.

A 42 year old woman presented with impaired filling of the right atrium and right ventricle two years after removal of uterine leiomyomas. At the time of hysterectomy, intravenous leiomyomatosis was noted, with extension of the tumor into the inferior vena cava. The tumor subsequently extended into the right atrium and coronary sinus, and protruded through the tricuspid orifice. It was successfully removed from the heart, and proved to be histologically benign.

Adult↗
PubMedDate not supplied

Multiple imputation in public health research.

Missing data in public health research is a major problem. Mean or median imputation is frequently used because it is easy to implement. Although multiple imputation has good statistical properties, it is not yet used extensively. For two real studies and a real study-based simulation, we compared the results after using multiple imputation against several simpler imputation methods. All imputation methods showed similar results for both real studies, but somewhat different results were obtained when only complete cases were used. The simulation showed large differences among various multiple imputation methods with a different number of variables for creating the matching metric for multiple imputation. Multiple imputation using only a few covariates in the matching model produced more biased coefficient estimates than using all available covariates in the matching model. The simulation also showed better standard deviation estimates for multiple imputation than for single mean imputation.

Asthma↗
PubMedDate not supplied

The value of serum iron studies as a test for iron-deficiency anemia in a county hospital.

To evaluate the performance of serum iron studies as a diagnostic test for iron-deficiency anemia in a county hospital, the authors identified retrospectively all general medicine patients who had had bone-marrow aspirates for the work-up of non-macrocytic anemias from 1978 through 1983. Re-reading a sample of aspirates from the 254 study patients (42 with iron deficiency) verified the presence or absence of iron. Analysis with logistic regression, likelihood ratios, and receiver operating characteristic curves demonstrated that the total iron-binding capacity (TIBC) performed markedly better as a diagnostic test than did the transferrin saturation test. While no single TIBC level was diagnostic, the TIBC provided a good estimate of the probability of iron-deficiency anemia.

Anemia, Hypochromic↗
PubMedDate not supplied

The prognosis of hyponatremia at hospital admission.

To assess the risk of mortality in patients with hyponatremia at the time of hospital admission, the authors studied data for 13,979 patients admitted over a 46-month period. Of the 763 (4%) admitted with hyponatremia, 757 (99%) were matched by age, gender, and admitting date with normonatremic control patients. Hyponatremic patients were more than seven times as likely to die in the hospital than the control patients, and they were more than twice as likely to die after discharge (p less than 0.0001 for both). This relationship with in- and outpatient mortality held when controlling for the diagnoses found more often in the hyponatremic patients. Hyponatremia appears to be an indicator of increased risk of death regardless of the disease with which it is associated.

Adult↗
PubMedDate not supplied

Depression of elderly outpatients: primary care physicians' attitudes and practice patterns.

OBJECTIVE: To determine primary care physicians' attitudes and practice patterns concerning the diagnosis and treatment of depression in elderly outpatients. DESIGN: Survey of primary care physicians' attitudes using a 22-item questionnaire. Current practice patterns were identified from a computerized medical record system. SETTING: Academic primary care group practice at an urban ambulatory care clinic. PATIENTS/PARTICIPANTS: Thirty-five faculty general internists and 118 resident internal medicine physicians who had cared for 2,759 patients 65 years of age and older in the previous year. MEASUREMENTS AND MAIN RESULTS: Attitudes: Eighty percent of all physicians considered the diagnosis and treatment of depressed elderly patients to be their responsibility. Fifty-five percent of the internists felt confident in accurately diagnosing depression, and 35% felt confident in prescribing antidepressants for this population. Residents reported more difficulties in dealing with depressed elderly patients than did faculty. Practice patterns: Of patients greater than or equal to 65 years old, 8% were prescribed antidepressants, 5.4% had current diagnoses of depression, and 2% were seen for evaluation by psychiatry professionals. Age was negatively correlated with depression diagnosis, antidepressant drug use, and psychiatry evaluation. CONCLUSIONS: Internists in this primary care group practice accept responsibility for the treatment of depressed elderly patients but perceive their clinical skills as inadequate and are frustrated with their practice environment. Interventions aimed at improving the diagnosis and treatment of depressed elderly patients may be more effective if they are able to improve knowledge, attitudes, and the practice environment.

Aged↗
PubMedDate not supplied

Using clinical data to predict abnormal serum electrolytes and blood cell profiles.

OBJECTIVE: To identify clinical predictors of five abnormalities on the serum electrolyte panel and two abnormalities on the blood cell profile, to study which data elements carried predictive information, and to measure the predictive accuracy and stability of the resulting predictive equations. DESIGN: Prospective data collection from a computerized medical database supplemented by data entered by physicians who ordered outpatient tests into microcomputers. Equations were derived during an eight-month period and later validated twice in the same setting. SETTING: Academic primary care practice affiliated with a county hospital. PATIENTS AND PARTICIPANTS: Patients were mostly black women; physicians were full-time academic general internists and medical residents. MEASUREMENTS AND MAIN RESULTS: There were 6,570 electrolyte and blood cell profile panels ordered during the equation derivation period. The mean receiver operating characteristic (ROC) curve area for the seven equations was 0.849. For the 4,977 tests ordered during ten months of prospective validation, the mean ROC curve area was only 3% less. For three equations, ROC curve areas were lower for patients with unscheduled visits than for those with scheduled visits (p less than 0.05). Except for two equations involving abnormalities with very low prevalences, the equations were also well calibrated. Prior results for the abnormality being considered were the strongest predictors, followed by other laboratory results, diagnoses, and the physicians' estimate of the probability that the test would be abnormal. CONCLUSIONS: Clinical data can accurately predict abnormal results of common outpatient laboratory tests. Computers can help find the necessary data and produce estimates of risk.

Blood Cells↗
PubMedDate not supplied

Pharmaceutical care in chain pharmacies: beliefs and attitudes of pharmacists and patients.

OBJECTIVE: To discuss with pharmacists and patients with reactive airways disease their beliefs about pharmaceutical care and the pharmacist's role in health care, obstacles to providing pharmaceutical care in community pharmacies, and strategies to overcome these obstacles. DESIGN: Two focus groups of patients, two focus groups of pharmacists. PARTICIPANTS: Thirteen patients with reactive airways disease and 11 chain pharmacists. MAIN OUTCOME MEASURES: Qualitative reports on the pharmacist's role in health care delivery and obstacles to implementing pharmaceutical care programs. RESULTS: Pharmacists wished to provide pharmaceutical care, and patients were supportive of pharmacists' involvement in their health care. Both viewed counseling as an important role for pharmacists and believed that pharmacists should work with patients' physicians. Reported obstacles included lack of time, inadequate privacy, and pharmacists' lack of direct access to patients' physicians. Pharmacists and patients believed pharmacists should have access to patient-specific clinical data. CONCLUSION: Focus groups provided valuable information for designing pragmatic pharmaceutical care. The obstacles and possible solutions identified through the discussions represent fertile ground for designing innovative pharmaceutical care programs.

Asthma↗