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Biomedical subjects

William M Tierney

Publications and source records attributed to William M Tierney.

54 records · Page 3Linked to original sources
PubMed2003

Clinically important differences in health-related quality of life for patients with asthma: an expert consensus panel report.

BACKGROUND: Standards for change in health-related quality of life (HRQoL) measures used among asthmatic patients have been established by considering only patient preferences to determine important differences and may not reflect an informed clinical evaluation of change. OBJECTIVE: To establish clinically important difference (CID) standards through the consensus of an expert physician panel for the Juniper Asthma Quality of Life Questionnaire (AQLQ) and Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36, version 2) when used to measure HRQoL among asthmatic patients. METHODS: We organized an 8-person panel of physicians familiar with measuring HRQoL among asthmatic patients with the AQLQ and the SF-36. This expert panel participated in 2 rounds of a modified Delphi process before attending an in-person consensus meeting to establish the CID standards for small, moderate, and large changes in the AQLQ and the SF-36. After the consensus meeting, the panel used an iterative improvement process to cooperatively complete their final report. RESULTS: The expert panel's thresholds for detecting CIDs in the domains of the AQLQ were much higher than previously established levels using patient-perceived changes. CIDs for asthma were also ascertained on the scales of the SF-36, version 2, which were markedly greater than previously cited cross-sectional differences between patient groups. CONCLUSIONS: The CID standards established by this expert panel elucidate a potential distinction between patient and physician perspectives of important HRQoL changes. The many stakeholders of HRQoL difference standards should consider this distinction when adopting standards to evaluate patient change.

Asthma↗
PubMed2003

Clinically important changes in health-related quality of life for patients with chronic obstructive pulmonary disease: an expert consensus panel report.

OBJECTIVE: Without clinical input on what constitutes a significant change, health-related quality of life (HRQoL) measures are less likely to be adopted by clinicians for use in daily practice. Although standards can be determined empirically by within-person change studies based on patient self-reports, these anchor-based methods incorporate only the patients' perspectives of important HRQoL change, and do not reflect an informed clinical evaluation. The objective of this study was to establish clinically important difference standards from the physician's perspective for use of 2 HRQoL measures among patients with chronic obstructive pulmonary disease (COPD). DESIGN: We assembled a 9-person expert panel of North American physicians familiar with the use of the Chronic Respiratory Questionnaire (CRQ), a disease-specific HRQoL measure, or the generic Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36, Version 2.0) among patients with COPD. RESULTS: Using 2 rounds of the Delphi process, 1 in-person meeting, and an iterative improvement process for circulating and correcting the final report, the expert panel established small, moderate, and large clinically important change levels for the CRQ and SF-36. CONCLUSIONS: For this expert physician panel, levels for detecting clinically important differences on the CRQ were equal to or slightly higher than previous studies based on patient-reported differences. Clinically important differences on the SF-36, Version 2.0, were noticeably larger than previous estimates based on cross-sectional differences between clinically defined patient groups.

Health Status Indicators↗
PubMed2003

Mass media release of medical research results: an analysis of antihypertensive drug prescribing in the aftermath of the calcium channel blocker scare of March 1995.

BACKGROUND: Disclosure of medical research results to the public creates tension between lay medical reporters and the medical profession. OBJECTIVE: To explore the early effect of media attention on the risks associated with short-acting calcium channel blockers (CCBs) for treating hypertension after publication at a national meeting and following publication. DESIGN: Time-series analysis of prescription claims data. SETTING AND DATA SOURCE: National third-party pharmaceutical benefits manager. PATIENTS: Employed or retired persons and their families, 18 years of age or older, receiving prescription benefits from 1 of 4 national companies that contracted with the pharmaceutical benefits manager exclusively for prescription drug coverage. MEASUREMENTS: Prescription claims for antihypertensive drugs by fill date converted to a percentage of all cardiovascular drug claims. Data were grouped into weekly intervals before and immediately after the national release of negative information about CCBs on March 10, 1995 and following publication of the results on August 23, 1995. RESULTS: The most prevalent antihypertensive drugs were diuretics (21% of cardiovascular prescription claims) and calcium channel blockers (19%). A 10% decline in prescriptions filled for CCBs occurred 4 weeks following the intense media attention. Only prescriptions for long-acting calcium channel blockers declined. Alpha-1-blocker prescriptions increased by approximately the same amount that prescriptions for CCBs declined, suggesting substitution of one drug for the other. Changes in diuretic or beta-blocker prescriptions filled were not statistically significant. No immediate change in other cardiovascular drug classes occurred following journal publication. CONCLUSIONS: Intense media publicity regarding a controversial study measurably and unpredictably changed prescription claims.

Adolescent↗
PubMed2003

9-11, personal stress, mental health, and sense of control among older adults.

OBJECTIVES: We assessed whether the events of 9-11 affected the personal stress, mental health, or sense of control of older adults participating in an ongoing longitudinal study, and whether baseline characteristics were associated with the magnitude of any such changes. METHODS: Personal stress, mental health, and sense of control were measured at baseline and at six bimonthly follow-up interviews among 1662 patients. Of these, 437 had the opportunity to complete three interviews before and after 9-11, with 291 (67%) completing all six. We performed graphic comparisons, paired t tests, classification based on standard errors of measurement (SEMs), and multiple linear regressions for patients who completed all six interviews. RESULTS: No noticeable changes in aggregate trends for personal stress or mental health were associated with 9-11. However, 9-11 was associated with an aggregate decline in sense of control. This decline in sense of control was greater among those who were working for pay, had more comfortable incomes, and reported greater religiosity. DISCUSSION: Older adults more closely resembling those who died during 9-11 and those with greater levels of religiosity were most likely to have their sense of control affected by this catastrophic event.

Activities of Daily Living↗
PubMed2003

Age, aging, and the sense of control among older adults: a longitudinal reconsideration.

OBJECTIVES: The purpose of this study was to first estimate the crude cross-sectional and longitudinal associations between age and the sense of control, and then to partition any joint variance attributable to a theoretically specified set of potential confounders. METHODS: Sense of control was measured at baseline and at each of six bimonthly follow-up interviews among 1,662 patients at two medical centers. Potential confounders were measured at baseline. Analyses include descriptive assessments of level and normative stability, repeated measures analysis of covariance, and hierarchical multiple linear and change score regressions. RESULTS: Although the sense of control is relatively stable between any two successive waves of data collection, significant gradual changes are observed over a 1-year period. Compelling evidence is found for statistically and substantively significant associations between age and the sense of control at baseline, and between age and changes in the sense of control over time. The only other major predictor of the sense of control is mental well-being. DISCUSSION: Longitudinal studies with repeated assessments over prolonged observation periods are now needed to elucidate age-related trajectories in the sense of control.

Adult↗
PubMed2003

Effects of computerized guidelines for managing heart disease in primary care.

BACKGROUND: Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care). OBJECTIVE: To assess the effects of computer-based cardiac care suggestions. DESIGN: A randomized, controlled trial targeting primary care physicians and pharmacists. SUBJECTS: A total of 706 outpatients with heart failure and/or ischemic heart disease. INTERVENTIONS: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients. MEASUREMENTS: Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians' attitudes toward guidelines. RESULTS: Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients vs 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients. CONCLUSIONS: Care suggestions generated by a sophisticated electronic medical record system failed to improve adherence to accepted practice guidelines or outcomes for patients with heart disease. Future studies must weigh the benefits and costs of different (and perhaps more Draconian) methods of affecting clinician behavior.

Algorithms↗
PubMed2003

A paradigm shift in patient satisfaction assessment.

The authors investigated the relationships between patients' reactions to health care attributes and their overall satisfaction with primary care. The study found the following: (1) patients' overall satisfaction levels are disproportionately influenced by low levels of their reactions (less satisfied) to the primary care attribute, rather than simply averaged out among attribute reactions. This is a noncompensatory relationship. (2) The marginal impact of primary care attributes on overall satisfaction decreases at higher levels of patients' reactions (more satisfied) to primary care attributes, indicating a nonlinear relationship. Patients combine their reactions to the health care attributes by means of noncompensatory and nonlinear models to form their overall satisfaction. Decision makers should selectively concentrate training resources on those areas of attributes showing high dissatisfaction rather than attempt to improve an attribute that showed the largest parameter estimate. This approach would not only save resources but result in better outcomes of patient satisfaction.

Adult↗
PubMed2002

Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial.

CONTEXT: It is not known whether patient outcomes are enhanced by effective pharmacist-patient interactions. OBJECTIVE: To assess the effectiveness of a pharmaceutical care program for patients with asthma or chronic obstructive pulmonary disease (COPD). DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted at 36 community drugstores in Indianapolis, Ind. We enrolled 1113 participants with active COPD or asthma from July 1998 to December 1999. Outcomes were assessed in 947 (85.1%) participants at 6 months and 898 (80.7%) at 12 months. INTERVENTIONS: The pharmaceutical care program (n = 447) provided pharmacists with recent patient-specific clinical data (peak expiratory flow rates [PEFRs], emergency department [ED] visits, hospitalizations, and medication compliance), training, customized patient educational materials, and resources to facilitate program implementation. The PEFR monitoring control group (n = 363) received a peak flow meter, instructions about its use, and monthly calls to elicit PEFRs. However, PEFR data were not provided to the pharmacist. Patients in the usual care group (n = 303) received neither peak flow meters nor instructions in their use; during monthly telephone interviews, PEFR rates were not elicited. Pharmacists in both control groups had a training session but received no components of the pharmaceutical care intervention. MAIN OUTCOME MEASURES: Peak expiratory flow rates, breathing-related ED or hospital visits, health-related quality of life (HRQOL), medication compliance, and patient satisfaction. RESULTS: At 12 months, patients receiving pharmaceutical care had significantly higher peak flow rates than the usual care group (P =.02) but not than PEFR monitoring controls (P =.28). There were no significant between-group differences in medication compliance or HRQOL. Asthma patients receiving pharmaceutical care had significantly more breathing-related ED or hospital visits than the usual care group (odds ratio, 2.16; 95% confidence interval, 1.76-2.63; P<.001). Patients receiving pharmaceutical care were more satisfied with their pharmacist than the usual care group (P =.03) and the PEFR monitoring group (P =.001) and were more satisfied with their health care than the usual care group at 6 months only (P =.01). Despite ample opportunities to implement the program, pharmacists accessed patient-specific data only about half of the time and documented actions about half of the time that records were accessed. CONCLUSIONS: This pharmaceutical care program increased patients' PEFRs compared with usual care but provided little benefit compared with peak flow monitoring alone. Pharmaceutical care increased patient satisfaction but also increased the amount of breathing-related medical care sought.

Adult↗
PubMed2002

Acute low back pain self-management intervention for urban primary care patients: rationale, design, and predictors of participation.

OBJECTIVES: To describe the rationale and design of a self-management program for low-income, urban, primary care patients with acute low back pain. Issues related to recruitment and protocol delivery, and attendance patterns and predictors of program attendance are described. METHODS: Two hundred eleven adult patients (73% female; 60% African American) were recruited from primary care neighborhood health centers. Focus groups were conducted for program development, and participants then completed a baseline interview and were randomized into groups receiving either usual care or a self-management intervention. RESULTS: Twenty-nine percent of the intervention group attended the self-management class. Significant predictors of attendance included being older, reporting less income, and not working for pay. Attendees did not differ from nonattendees on back pain severity, symptoms, health-related quality of life, self-management processes, or satisfaction with care. CONCLUSION: Effective minimal-contact behavioral interventions are needed to reach larger portions of the patient population.

Acute Disease↗
PubMed2002

Using the standard error of measurement to identify important changes on the Asthma Quality of Life Questionnaire.

OBJECTIVES: To establish a link between the minimal important difference (MID) and the standard error of measurement (SEM) for all responsive dimensions of the Asthma Quality of Life Questionnaire (AQLQ). METHODS: Secondary data analysis of baseline and follow-up interview data from 198 outpatients with asthma enrolled in a randomized controlled trial and receiving care at a major urban academic medical center's general medicine clinics. Domain statistics for baseline and follow-up interviews were examined for the AQLQ. The baseline SEM values were compared with established AQLQ MID standards using weighted kappa values. RESULTS: One SEM identified the MID in responsive AQLQ dimensions. Weighted kappa values (0.88-0.93) validated excellent agreement between these two criteria. CONCLUSION: This is the third study to support using one SEM to identify important individual change in health-related quality of life (HRQoL) measures. However, refinement of the process for determining a measure's clinically meaningful differences is still needed to secure a link between the SEM and the identification of relevant HRQoL change over time.

Asthma↗
PubMed2002

Issues in conducting randomized controlled trials of health services research interventions in nonacademic practice settings: the case of retail pharmacies.

OBJECTIVE: To describe unexpected challenges and strategies to overcome them when conducting randomized controlled trials (RCT) of health services research interventions in retail pharmacies. STUDY SETTING: Thirty-six retail drug stores in Indianapolis. STUDY DESIGN: We conducted an RCT to evaluate the effectiveness of an intervention to increase pharmacists' involvement in caring for customers. We describe: (1) our RCT as originally designed, (2) unexpected challenges we faced; and (3) how we resolved those challenges. DATA COLLECTION/EXTRACTION METHODS: Randomized controlled trial. PRINCIPAL FINDINGS: Major modifications in research design were necessitated by factors such as corporate restructuring, heightened sensitivity to patient confidentiality, and difficulties altering employees' behavior. We overcame these barriers by conducting research that is consistent with corporate goals, involving appropriate corporate administrators and technical personnel early in the process, and being flexible. CONCLUSIONS: Health services researchers should conduct RCTs in a variety of non-academic practice settings to increase generalizability and better reflect the true impact of interventions. Pragmatic problems, although significant, can be successfully overcome.

Adolescent↗
PubMed2002

When the physician-researcher gets cancer: understanding cancer, its treatment, and quality of life from the patient's perspective.

The authors, both medical researchers, describe their personal experiences with cancer, its treatment, and its effects on their lives. They discuss the "eight Ds" that represent their concerns as they navigated this permanent disruption in their lives: diagnosis, dying, discomfort, disability, drug and other treatment effects, dependency, doubt, and death. They also discuss the beneficial effects that cancer has had on their lives and end with suggestions for clinicians and outcomes researchers who seek to assess and improve quality of life among persons with cancer.

Adult↗
PubMed2002

Crossing the "digital divide:" implementing an electronic medical record system in a rural Kenyan health center to support clinical care and research.

To improve care, one must measure it. In the US, electronic medical record systems have been installed in many institutions to support health care management, quality improvement, and research. Developing countries lack such systems and thus have difficulties managing scarce resources and investigating means of improving health care delivery and outcomes. We describe the implementation and use of the first documented electronic medical record system in ambulatory care in sub-Saharan Africa. After one year, it has captured data for more than 13,000 patients making more than 26,000 visits. We present lessons learned and modifications made to this system to improve its capture of data and ability to support a comprehensive clinical care and research agenda.

Ambulatory Care↗
PubMedDate not supplied

Quantifying risk of adverse clinical events with one set of vital signs among primary care patients with hypertension.

BACKGROUND: Hypertension is often uncontrolled. One reason might be physicians' reticence to modify therapy in response to single office measurements of vital signs. METHODS: Using electronic records from an inner-city primary care practice, we extracted information about vital signs, diagnoses, test results, and drug therapy available on the first primary care visit in 1993 for patients with hypertension. We then identified multivariable predictors of subsequent vascular complications in the ensuing 5 years. RESULTS: Of 5,825 patients (mean age 57 years) previously treated for hypertension for 5.6 years, 7% developed myocardial infarctions, 17% had strokes, 24% developed ischemic heart disease, 22% had heart failure, 12% developed renal insufficiency, and 13% died in 5 years. Controlling for other clinical data, a 10-mmHg increase in systolic blood pressure was associated with 13% increased risk (95% confidence interval [CI], 6%-21%) of renal insufficiency, 9% (95% CI, 3%-15%) increased risk of ischemic heart disease, 7% (95% CI, 3%-11%) increased risk of stroke, and 6% (95% CI, 2%-9%) increased risk of first stroke or myocardial infarction. A 10-mmHg elevation in mean blood pressure predicted a 12% (95% CI, 5%-20%) increased risk of heart failure. An increase in heart rate of 10 beats per minute predicted a 16% (95% CI, 2%-5%) increased risk of death. Diastolic blood pressure predicted only a 13% (95% CI, 4%-23%) increased risk of first stroke. CONCLUSIONS: Vital signs-especially systolic blood pressure-recorded routinely during a single primary care visit had significant prognostic value for multiple adverse clinical events among patients treated for hypertension and should not be ignored by clinicians.

Blood Pressure↗