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Biomedical subjects

W R Smith

Publications and source records attributed to W R Smith.

At least 19 recordsLinked to original sources
PubMed1997

Physicians' survival predictions for patients with acute congestive heart failure.

BACKGROUND: Current guidelines suggest that patients with low likelihoods of survival may be excluded from intensive care. Patients with new or exacerbated congestive heart failure are frequently but not inevitably admitted to critical care units. OBJECTIVE: To assess how well physicians could predict the probability of survival for acutely ill patients with congestive heart failure, and in particular how well they could identify patients with small chances of survival. METHODS: This was a prospective cohort study done in the emergency departments of a university hospital, a Veterans Affairs medical center, and a community hospital. The study population was consecutive adults for whom new or exacerbated congestive heart failure, diagnosed clinically, was a major reason for the emergency department visit. Physicians caring for the study patients in the emergency departments recorded their judgments of the numeric probability that each patient would survive for 90 days and for 1 year. The patients vital status at 90 days and 1 year was ascertained by multiple means, including interview, chart review, and review of hospital and state databases. RESULTS: By calibration curve analysis, the physicians underestimated survival probability at both 90 days and 1 year, particularly for patients they judged to have the lowest probabilities of survival. Their predictions had modest discriminating ability (receiver operating characteristic curve areas, 0.66 [SE = 0.020] for 90 days; 0.63 [SE = 0.017] for 1 year). The physicians identified only 15 patients they judged to have a 90-day survival probability of 10% or less, whose survival rate was actually 33.3%. CONCLUSIONS: Physicians have great difficulty predicting survival for patients with acute congestive heart failure and cannot identify patients with poor chances of survival. Current triage guidelines that suggest patients with poor chances of survival may be excluded from critical care may be impractical or harmful.

Acute Disease↗
PubMed1997

Psychosocial determinants of health care utilization in sickle cell disease patients.

This article reviews the literature on psychosocial factors associated with sickle cell disease and health care utilization. The Health Belief Model is proposed as a framework that may help guide our understanding about how these variables influence health care utilization. Since the existing literature on psychosocial variables and health care utilization among sickle cell disease patients is scant, studies from related behavioral medicine research will be presented as a basis for future research. This review suggests that identifying modifiable psychosocial variables associated with utilization could aid in the development of interventions aimed at reducing utilization and thereby reducing health care costs.

Adaptation, Psychological↗
PubMed1997

Bacteremia in young urban women admitted with pyelonephritis.

The objective of this study was to determine the rate of bacteremia in young women admitted to the hospital with presumed pyelonephritis and compare it with other published rates. The study design was a retrospective, structured chart review and a review of published reports of bacteremic pyelonephritis. An urban county teaching hospital provided the setting for the study. The patients were nonpregnant women (n = 98) 44 years of age or younger who were without bladder dysfunction and who had not been admitted to an intensive care unit. Further criteria for participation included discharge with the diagnosis of acute pyelonephritis. Blood cultures were ordered for 69 women; the results of 64 were noted in the chart. Twenty-three women (35.9% of those cultured; 23.4% of all patients) were diagnosed with bacteremia. In patients for whom blood culture results were obtained, trends developed between those patients with bacteremia and those with complicated pyelonephritis, defined as a known or newly discovered genitourinary abnormality or a risk factor (P = 0.044), those who were black (P = .044), those with higher pulses on admission (P = .050), those with more white blood cells per high-powered field after urinalysis (P = 0.007), and those whose fever lasted longer (P = 0.033). Blood culture results were positive in two patients whose urine cultures were negative. This comparatively high bacteremia rate supports routine ordering of blood cultures for urban women suspected of having pyelonephritis.

Adolescent↗
PubMed1997

Physicians' judgments of the risks of cardiac procedures. Differences between cardiologists and other internists.

OBJECTIVES: The authors compared judgments of the population risks of invasive cardiac procedures made by cardiologists and other internal medicine physicians. Our main hypotheses were that cardiologists' judgments would differ from those made by the other physicians and that cardiologists' judgments would be more accurate than those of other physicians. METHODS: This was a cross-sectional survey of senior staff and physician-trainees at two teaching hospitals affiliated with a US medical school, Emergency Department physicians at a community hospital in the same metropolitan area, and senior staff and trainees at two teaching hospitals affiliated with a UK school. Judgments of the risks of severe morbidity and death due to Swan-Ganz catheterization, cardiac catheterization, percutaneous coronary angioplasty, and coronary artery bypass grafting were assessed. RESULTS: Nineteen cardiologists judged the risks of severe morbidity due to all procedures and the risks of death due to all procedures except coronary artery bypass grafting to be significantly lower than did the 78 other internists. Cardiologists more frequently made accurate judgments of the rates of morbidity and death due to cardiac catheterization than did the other internists; other internists more frequently made accurate judgments for the rates of morbidity due to Swan-Ganz catheterization. CONCLUSIONS: Disagreements about the risks of procedures may arise from a paucity of published data, or from an over-supply of confusing data.

Angioplasty, Balloon, Coronary↗
PubMed1996

Prediction of survival of critically ill patients by admission comorbidity.

The objective of this study was to determine how well the Charlson index of comorbidity would predict mortality of critically ill patients; and how the predictive ability of the index would compare with that of the comorbidity component (Chronic Health Points) of the APACHE II system. This prospective cohort study included in its setting an intensive care unit (ICU) and intermediate ICU (IICU) in a teaching hospital. Patients included a previously assembled inception cohort of 201 patients consecutively admitted to either unit, followed until death or discharge from the hospital, excluding patients admitted after coronary artery bypass grafting, for planned dialysis, or transferred to the IICU from another intensive care unit. Main outcome measures were recorded as death in hospital versus survival at discharge. For each patient we had prospectively obtained all data necessary to predict the probability of in-hospital death using the APACHE II system, and to classify comorbidity using the Charlson index. The Charlson index had significant ability to discriminate between patients who would live and who would die (ROC curve area = 0.67, SE = 0.05). The Chronic Health Points component of APACHE II had no significant discriminating ability (ROC area = 0.57, SE = 0.05), although the full APACHE II system was an excellent predictor (area = 0.87, SE = 0.04). Logistic regression analyses suggested that the Charlson index could contribute significant (p = 0.03) prognostic information to that obtained from the components of APACHE II other than Chronic Health, i.e., acute physiological derangement, age, and reason for admission, but the Chronic Health Points component of APACHE II could not so contribute to the rest of APACHE II (p = 0.19). Our conclusion is that use of the detailed information about comorbidity captured by the Charlson index could improve prognostic predictions even for critically ill patients.

APACHE↗
PubMed1996

System change: quality assessment and improvement for Medicaid managed care.

Rising Medicaid health expenditures have hastened the development of State managed care programs. Methods to monitor and improve health care under Medicaid are changing. Under fee-for-service (FFS), the primary concern was to avoid overutilization. Under managed care, it is to avoid underutilization. Quality enhancement thus moves from addressing inefficiency to addressing insufficiency of care. This article presents a case study of Virginia's redesign of Quality Assessment and Improvement (QA/I) for Medicaid, adapting the guidelines of the Quality Assurance Reform Initiative (QARI) of the Health Care Financing Administration (HCFA). The article concludes that redesigns should emphasize Continuous Quality Improvement (CQI) by all providers and of multi-faceted, population-based data.

Guidelines as Topic↗
PubMed1995

The impact of nursing home transfer policies at the end of life on a public acute care hospital.

OBJECTIVES: To determine whether nursing homes transferred their terminal care patients to one public hospital, and if so, the impact of these transfers on nursing home and hospital mortality rates. DESIGN: A retrospective cohort study using both Medicare claims and hospital data to construct a mortality prediction model, as well as a cross-sectional descriptive comparison of state nursing home mortality rates. SETTING: A public hospital, one of 32 hospitals designated as overall mortality outliers for each of the first three Medicare mortality reports. PARTICIPANTS: Patients (n = 1235) included in the index hospital's 1988 Medicare mortality report; nursing homes (n = 289) included in state data on 1988 nursing home mortality rates. MEASUREMENTS AND RESULTS: Patients transferred from nursing homes to the index hospital were nearly twice as likely to die as the hospital's other Medicare patients in univariate (P = .0001) as well as multivariate analysis (OR = 1.68, 95% CI = 1.17 - 2.40). Terminal care admissions accounted for 33.9% of deaths from nursing homes but only 16.2% of other deaths (P = .009). The 1988 death/discharge rate at one of two nursing homes responsible for nearly all transfers was 15.2%, less than half the state average. Yet it contributed 59.3% of nursing home deaths and 22.7% of terminal care patients to the hospital. The hospital's 20.0% 1988 Medicare mortality rate was just above the expected range. CONCLUSIONS: Two nursing homes transferred terminal care to a single hospital. This resulted in a lower-than-average mortality rate for one of the nursing homes and a higher-than-expected Medicare mortality for the hospital. Without these end-of-life transfers, the hospital's Medicare mortality rate would have been within the expected range.

Age Factors↗
PubMed1995

Controlling for confounding by indication for treatment. Are administrative data equivalent to clinical data?

There has been controversy about whether confounding by indication for treatment--that is, owing to physicians' conscious efforts to base treatment decisions on patients' pretreatment prognoses--makes nonrandomized, observational comparisons of treatments invalid. Some now believe evidence from studies of practice variation means that physicians' treatment decisions have little relationship to patients' prognostic clinical characteristics. They therefore believe that patients who receive different treatments should vary little in their baseline prognoses, and multivariable statistical methods should easily be able to adjust for any resultant confounding, even when analyses are restricted to administrative rather than clinical data. The objective of this study is to determine whether adjusting for variables found in administrative data sets produces the same results as does adjusting for clinical variables. Data were reanalyzed from a previously enrolled prospective sequential cohort of 227 hospitalized patients with suspected bacteremia who had blood cultures. The treatment under study was aminoglycoside therapy given empirically, that is, before blood culture results were known. The outcome of interest was death during hospitalization. Univariable analyses suggest that empiric aminoglycoside therapy had a positive association with mortality, by univarible logistic regression, odds ratio (OR = 3.1 (95% confidence interval = [1.6, 5.8]). Few administrative variables had univariable associations with aminoglycoside use or death. Multivariable analyses that controlled for them still suggest that aminoglycosides increased mortality; for example, in one model, adjusted OR = 3.2 (1.6, 6.5). Many clinical variables were strongly associated with aminoglycoside use or death. Analyses that controlled for them suggested that empiric aminoglycosides did not increase mortality; for example, in one model, adjusted OR = 1.2 (0.55, 2.7.) Results of adjustment for confounding using administrative data disagreed with the results of adjustment using clinical data. It is concluded that nonrandomized, observational outcome studies that fail to control for prognostic differences between patients receiving different treatments may not always be valid.

APACHE↗
PubMed1994

Deciphering the physician note.

Objective information about legibility of physician handwriting is scant. This retrospective chart review compared handwritten general medicine clinic chart notes from internal medicine faculty and housestaff with their typed counterparts. The written counterparts took 11 seconds (46%) longer to read and 5 seconds (11%) longer to answer comprehension questions. The authors' comprehension measure (developed specifically for ambulatory clinic notes) was only slightly higher for typed notes. The legibility of physician handwriting is not as dismal as assumed; physicians can effectively communicate on paper.

Handwriting↗
PubMed1994

Appropriate and inappropriate prescribing of narcotics for ambulatory HIV-positive patients.

OBJECTIVE: To assess the appropriateness of narcotic-prescribing practices in an ambulatory clinic for patients infected with HIV. DESIGN, SETTING, AND PATIENTS: The medical records of 220 (190 HIV-positive) patients, seen in a clinic primarily designed for the long-term follow-up of ambulatory HIV-infected patients and located in an inner-city, public teaching hospital, were retrospectively reviewed to determine the prevalence and appropriateness of prescribing Drug Enforcement Administration schedule 2 narcotics. Appropriateness was based on published guidelines for the use of narcotics in the treatment of cancer patients. MEASUREMENTS AND MAIN RESULTS: The prevalence of narcotic use among the HIV-positive patients was 15%. Narcotics were prescribed for 38% of the patients who died, 33% of those with AIDS [Centers for Disease Control and Prevention (CDC) clinical class C], 4% of those with AIDS-related complex (ARC) (CDC clinical class B), and 5% of asymptomatic HIV-positive patients (CDC clinical class A). None of the HIV-negative patients seen in the clinic received narcotics. Narcotics were more likely to be prescribed for patients with AIDS than for patients with ARC (p < 0.001) or for HIV-positive patients (p < 0.001). For the three CDC clinical classes, there was no significant difference among the proportions of patients receiving narcotics inappropriately (p = 0.108). Among the risk groups, intravenous drug abusers were more likely to be prescribed narcotics inappropriately than were men who were homosexual (p < 0.001) or individuals who were heterosexual (p = 0.013); transfusion recipients were also more likely to be prescribed narcotics inappropriately than were homosexual men (p = 0.026) or heterosexual men or women (p = 0.032). Narcotics were more likely to be prescribed for patients with disseminated histoplasmosis (p = 0.022), Pneumocystis carinii pneumonia (p = 0.001), candidal esophagitis (p = 0.020), Kaposi's sarcoma (p < 0.001), or wasted appearance (p = 0.043). Inappropriate prescriptions were more likely to be given to patients with dementia (p = 0.005) or wasted appearance (p = 0.019). CONCLUSIONS: Physicians tend to prescribe narcotics inappropriately to patients known to have previously abused drugs and to those who appear wasted or have dementia. Physicians have a duty to prescribe narcotics appropriately as guided by recognized medical indications and the patients' views concerning their current medical needs.

AIDS-Related Complex↗
PubMed1993

Computer-assisted instruction in probabilistic reasoning during the inpatient medicine clerkship.

The acceptability and utility of computer-assisted instruction in probabilistic reasoning was assessed for medicine clerkship students. After a pretest, the experimental (n = 40), but not the control students (n = 39), completed a program that we designed. The program contained the test and its answers. After program exposure, experimental students rated their knowledge of the program's content significantly higher (p = 10(-4)) than control students. On the identical posttest, experimental students also scored significantly higher than control students (p = 10(-4)) and improved their scores significantly more (p = 10(-3)). They rated ease-of-use items significantly higher than content-relevance items (p = 10(-4)). We conclude that computer-assisted instruction in probabilistic reasoning is acceptable to clerkship students, and that it may improve their knowledge and skills in this area. However, students may rate the vehicle of this instruction more highly than its content.

Clinical Clerkship↗
PubMed1992

Developing a computerized ambulatory medical record to document health promotion and disease prevention activities during the clinic encounter.

The authors believe that the computerized medical record may enhance physician-delivered preventive services by providing timely individual feedback. Additionally, we note that interest in health promotion and disease prevention in the medical community as well as the general population has been increasing during the last decade. In response to this increased interest, we believe that health promotion and disease prevention activities should be conducted by every clinician and should include basic measures such as immunizations, appropriate screening tests, and advice and counseling about lifestyle. Additional investigation into the use of computers and computer-generated reminders to enhance the delivery of preventive services is needed.

Ambulatory Care Information Systems↗
PubMed1992

Timing of insemination in dairy heifers.

Data representing 676 AI of 372 virgin dairy heifers during 1984 to 1987 at the University of Illinois were analyzed by analysis of variance to determine the effect of timing of AI on conception rate. Standing to be mounted, bawling, and attempting to mount were the three criteria used for determining the presence of estrus. More than 90% of the observations were conducted by one herdsperson between 0700 and 1600 h daily. Heifers were artificially inseminated with frozen semen from 58 bulls by one of two technicians. Conception rate on first AI was 56%, determined by return to estrus or 33- to 50-d rectal palpation for pregnancy. Conception rate to second and later AI was near 40%. Eighty-six percent of the heifers conceived during the trial. The average interval between first observation of standing estrus and AI was 10.5 h; the range was 15 min to 33 h. The model discussed contained six variables: time interval between first observation of standing estrus and AI (group), breed, sire within breed, year bred, season bred, and inseminator. The analysis of variance of conception to first AI showed timing of AI and service sire as the two most significant effects. Conception to first AI was worst when AI occurred 13.5 to 33 h after first observation of estrus. No factors considered were significant sources of variation for second or later AI.

Animals↗
PubMed1992

Mobilizing affect: a possible effect of day hospital treatment for chronic psychiatric patients.

A study of 82 Psychiatric Day Hospital patients was undertaken to identify the program's specific effects on individuals with longer standing (i.e., chronic) psychiatric disability. Sociodemographic information and self-ratings, staff ratings and significant-other ratings were used to identify changes in functioning during the 3-week treatment as well as during the period 3 months after treatment. Findings suggest (1) that the Day Hospital patients were as seriously psychiatrically impaired as psychiatric inpatients, (2) that, as a group, they demonstrated a significant improvement in symptoms and functioning, and (3) that the more chronic patients displayed a distinctive pattern of decreased hostility and increased anxiety over the course of treatment. Findings are discussed in relation to the proposition that mobilizing the chronic patient's affect is an important factor in reengaging the therapeutic process.

Adolescent↗