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Biomedical subjects

A A Montgomery

Publications and source records attributed to A A Montgomery.

At least 19 recordsLinked to original sources
PubMed2006

Women's experience of decision making about mode of delivery after a previous caesarean section: the role of health professionals and information about health risks.

OBJECTIVE: To explore women's experiences of decision making about mode of delivery after previous caesarean section. DESIGN: A qualitative interview study. SETTING: Two city maternity units in southwest England and Eastern Scotland. SAMPLE: Twenty-one women who had recently delivered a baby and whose previous child was delivered by caesarean section. METHODS: Semi-structured interviews analysed using the framework approach. MAIN OUTCOME MEASURES: Women's views on the influence of uncertainty on decision making, issues concerning information provision and decision-making roles. RESULTS: Experiences of decision making varied considerably. Some women were certain about choosing either vaginal birth after caesarean or repeat elective caesarean section, others were very uncertain and for some this uncertainty persisted after the birth. Information was most commonly provided by hospital doctors (mainly consultants) and more often related to procedural issues rather than possible health risks and benefits. Women felt they had to actively seek information rather than it being provided routinely. Most women were able to make their own decision about mode of delivery. Health professionals generally took a supportive role whichever mode of delivery was chosen. Although many women were comfortable with this approach, some felt they would have liked more guidance. CONCLUSION: On the whole, women experienced having control over the decision about planned mode of delivery. For many, making this decision was difficult and for some it was the cause of prolonged anxiety. Women were often making the decision without being provided with comprehensive and specific information about possible health risks and benefits. We are currently conducting a randomised controlled trial to investigate whether access to a decision aid is beneficial to women in this situation.

Adult↗
PubMed2005

NSAID use and BP in treated hypertensives: a retrospective controlled observational study.

The objective of this study was to investigate the association between NSAID use and blood pressure (BP) among a sample of treated hypertensive patients. A controlled observational study was designed in UK primary care setting. Patients with diagnosed hypertension and currently being prescribed antihypertensive medication registered with four general practices, comparing patients also prescribed NSAIDs (exposed) to those not prescribed NSAIDs (unexposed). Majority of the patients were elderly. Systolic and diastolic pressure were the outcome measures. Data were collected for 184 NSAID users and 762 nonusers with a mean age of 68 years. There was no difference in either systolic (adjusted difference 1.9 mmHg, 95% CI -0.7 to 4.5, P=0.15) or diastolic (adjusted difference 1.0 mmHg, 95% CI -0.3 to 2.3, P=0.15) blood pressure. There was no evidence of any interactions according to categories of age, sex, or number of antihypertensive drugs prescribed. Among NSAID users, there was no evidence of any differences in blood pressure according to NSAID type or dose. In conclusion we found no evidence for an association between NSAID usage and BP control in known hypertensive patients receiving antihypertensive medication in primary care. The reported association between NSAID use and BP control appears much less substantial than has been previously suggested.

Aged↗
PubMed2001

Randomized trial evaluating the framing of cardiovascular risk and its impact on blood pressure control [ISRCTN87597585].

BACKGROUND: The format or frame in which the results of randomized trials are presented has been shown to influence health professional's self-reported practice. We sought to investigate the effect of framing cardiovascular risk as two different formats in a randomized trial. METHODS: We recruited 457 patients aged between 60 and 79 years with high blood pressure from 20 family practices in Avon, UK. Patients were randomized to cardiovascular risk presented either as 1) an absolute risk level (AR) or as 2) the number needed to treat to prevent an adverse event (NNT). The main outcome measures were: 1) percentage of patients in each group with a five-year cardiovascular risk > or = 10%, 2) systolic and diastolic blood pressure, 3) intensity of prescribing of cardiovascular medication. RESULTS: Presenting cardiovascular risk as either an AR or NNT had no impact reducing cardiovascular risk at 12 month follow up, adjusted odds ratio 1.53 (95%CI 0.76 to 3.08). There was no difference between the two groups in systolic (adjusted difference 0.97 mmHg, 95%CI -2.34 mmHg to 4.29 mmHg) or diastolic (adjusted difference 0.70 mmHg, 95%CI -1.05 mmHg to 2.45 mmHg) blood pressure. Intensity of prescribing of blood pressure lowering drugs was not significantly different between the two groups at six months follow up. CONCLUSIONS: Presenting cardiovascular risk in clinical practice guidelines as either an AR or NNT had a similar influence on patient outcome and prescribing intensity. There is no difference in patient outcomes when these alternative formats of risk are used in clinical practice guidelines.

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PubMed2001

Shared decision making in hypertension: the impact of patient preferences on treatment choice.

BACKGROUND: Recent guidelines for treatment of hypertension advocate a multifactorial approach based on absolute risk of a cardiovascular event. However, this does not take any account of individual patient values or preferences for health outcomes that result from having hypertension. OBJECTIVE: Our aim was to investigate the impact of patient preferences on treatment recommendations for hypertension using individual decision analysis. METHODS: We carried out an observational study based on interviews with 52 hypertensive patients. Patient preferences were measured using the standard gamble method. Associations between outcome of the individual decision analyses (recommendation to accept or decline antihypertensive medication) and treatment guidelines based on blood pressure and absolute cardiovascular risk were investigated. Adherence to medication during the 6 months following the interview was also assessed. RESULTS: Individual patient preferences have a substantial impact on the proportion of patients for whom drug treatment would be recommended. In 52 patients interviewed, decision analysis indicated that 29 [56%, 95% confidence interval (CI) 41--70] should be treated, compared with 27 (52%, 38--66) using a cardiovascular risk of > or =10% over 5 years and 19 (37%, 24--51) using a systolic blood pressure of > or =160 mmHG: There was marked disagreement between the decision analysis and these recommendations (kappas 0.18 or less). There was no relationship between outcome of the decision analysis and adherence to medication [chi-square (1 d.f.) = 0.5, P = 0.5]. CONCLUSIONS: Quantifying patients' preferences and using decision analysis as a shared decision-making aid appears to have an impact on whether patients would be recommended for antihypertensive medication. Further evaluation of this method as a shared decision-making tool is warranted.

Antihypertensive Agents↗
PubMed2001

Effects of patients' preferences on the treatment of atrial fibrillation: observational study of patient-based decision analysis.

OBJECTIVE: To investigate the effect of patients' preferences in the treatment of atrial fibrillation by using individualized decision analysis in which probability and utility assessments are combined into a decision tree. DESIGN: Observational study based on interviews with patients. SETTING: 8 general practices in Avon, England. PARTICIPANTS: 260 randomly selected patients aged 70 to 85 years with atrial fibrillation. MAIN OUTCOME MEASURES: Patients' treatment preferences regarding anticoagulation treatment (warfarin sodium) after individualized decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription. RESULTS: Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval, 50%-71%) would prefer anticoagulation treatment, considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappa> or =0.25). Of 38 patients whose decision analysis indicated a preference for anticoagulation, 17 (45%) were being prescribed warfarin; on the other hand, 28 (47%) of 59 patients were not being prescribed warfarin, although the results of their decision analysis suggested they wanted to be. CONCLUSIONS: In the context of shared decision making, individualized decision analysis is valuable in a sizable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published recommendations. Decision analysis as a shared decision-making tool should be evaluated in a randomized controlled trial.

Aged↗
PubMed2001

How do patients' treatment preferences compare with those of clinicians?

The shared model of medical decision making has been proposed as the preferred method of determining patients' treatment. However, agreement may be more difficult to achieve if patients' and clinicians' preferences are polarised. The aim of this paper is to explore how closely patients and clinicians agree in their preferences for different treatment options. Only studies that made quantifiable estimates of preferences were included. There is some evidence that patients and health professionals often do not agree on treatment preference in the areas of cardiovascular disease, cancer, obstetrics and gynaecology, and acute respiratory illness. However, the magnitude and direction of these differences vary and may depend on the condition of interest. Most of the research to date is cross sectional; longitudinal research is required to investigate whether preferences change over time and are related to treatment choice, adherence to medication if taken, and health outcomes.

Attitude of Health Personnel↗
PubMed2000

Birth size and arterial compliance in young adults.

Impaired fetal growth may cause reduced compliance of the aorta and other large arteries, and predispose an individual to higher blood pressure in later life. We found that neither low birth size nor interaction between birth size and adult size were associated with arterial pulse-wave velocity in men and women aged 25 years.

Adult↗
PubMed2000

The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysis.

OBJECTIVE: To investigate the impact of patients' preferences for the treatment of atrial fibrillation, by using individualised decision analysis combining probability and utility assessments into a decision tree. DESIGN: Observational study based on interviews with patients. SETTING: Eight general practices in Avon. PARTICIPANTS: 260 randomly selected patients aged 70-85 years with atrial fibrillation. MAIN OUTCOME MEASURES: Patients' treatment preferences regarding anticoagulation treatment (warfarin) after individualised decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription. RESULTS: Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval 50% to 71%) would prefer anticoagulation treatment-considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappa=0.25 or less). Of 38 patients whose decision analysis indicated a preference for anticoagulation, 17 (45%) were being prescribed warfarin; on the other hand, 28 (47%) of 59 patients were not being prescribed warfarin although the results of their decision analysis suggested they wanted to be. CONCLUSIONS: In the context of shared decision making, individualised decision analysis is valuable in a sizeable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published guideline recommendations. Decision analysis as a shared decision making tool should be evaluated in a randomised controlled trial.

Aged↗
PubMed2000

Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial.

OBJECTIVES: To investigate the effect of a computer based clinical decision support system and a risk chart on absolute cardiovascular risk, blood pressure, and prescribing of cardiovascular drugs in hypertensive patients. DESIGN: Cluster randomised controlled trial. SETTING: 27 general practices in Avon. PARTICIPANTS: 614 patients aged between 60 and 79 years with high blood pressure. INTERVENTIONS: Patients were randomised to computer based clinical decision support system plus cardiovascular risk chart; cardiovascular risk chart alone; or usual care. MAIN OUTCOME MEASURES: Percentage of patients in each group with a five year cardiovascular risk >/=10%, systolic blood pressure, diastolic blood pressure, prescribing of cardiovascular drugs. RESULTS: Patients in the computer based clinical decision support system and chart only groups were no more likely to have cardiovascular risk reduced to below 10% than patients receiving usual care. Patients in the computer based clinical decision support group were more likely to have a cardiovascular risk >/=10% than chart only patients, odds ratio 2.3 (95% confidence interval 1.1 to 4.8). The chart only group had significantly lower systolic blood pressure compared with the usual care group (difference in means -4.6 mm Hg (95% confidence interval -8.4 to -0.8)). Reduction of diastolic blood pressure did not differ between the three groups. The chart only group were twice as likely to be prescribed two classes of cardiovascular drugs and over three times as likely to be prescribed three or more classes of drugs compared with the other groups. CONCLUSIONS: The computer based clinical decision support system did not confer any benefit in absolute risk reduction or blood pressure control and requires further development and evaluation before use in clinical care can be recommended. Use of chart guidelines are associated with a potentially important reduction in systolic blood pressure.

Aged↗
PubMed2000

Estimation of cardiovascular risk in hypertensive patients in primary care.

Assessment of absolute cardiovascular risk is a rational method of managing hypertension. General practitioners and practice nurses were asked to estimate absolute risk in a group of elderly hypertensive patients during clinical practice. Risk was correctly estimated in 21% of patients, underestimated in 63% of patients, and overestimated in 16% of patients. Unless primary health care professionals use cardiovascular risk charts or tables, treatment decisions in primary care may not be made against realistic estimates of patients' susceptibility to cardiovascular disease.

Aged↗
PubMed1999

How accurately do primary health care professionals use cardiovascular risk tables in the management of hypertension?

It has been suggested that use of cardiovascular risk tables in hypertensive patients might improve clinical management. As part of a randomised controlled trial, we evaluated the accuracy of health professionals' use of the New Zealand risk tables in primary care consultations. Chance-corrected agreement between health professionals' assessments of absolute risk was only moderate (weighted kappa = 0.56 at the 12-month follow-up). Inaccurate use of cardiovascular risk tables may be a barrier to effective implementation of research evidence in the management of hypertension.

Cardiovascular Diseases↗
PubMed1998

A systematic review of the use of computers in the management of hypertension.

STUDY OBJECTIVE: To assess the effect of computers and computer-based clinical decision support systems on the management of hypertension. DESIGN: Systematic review of randomised controlled trials. SETTING: Ambulatory hypertension clinics, community-based health centres, and general practices. PARTICIPANTS: 11,962 patients enrolled in seven trials retrieved from a systematic search (electronic databases, contact with authors, reference lists; no restriction on language). MAIN RESULTS: Individual trials report on a diverse population of patients (newly diagnosed or established hypertensive patients), interventions (computers used for case finding, recall and registration, feedback on quality of blood pressure control and prescribing information), and outcomes (administration, physician performance and blood pressure control). Four of five trials reported an improvement in patient administration using a computer. Two of three trials reported an improvement in physician performance using a computer. Two of six trials. reported an improvement in blood pressure control in patients using a computer. However, positive findings in two trials should be regarded cautiously because of the potential effects of cluster randomisation. CONCLUSIONS: It seems that computers have a favourable effect on the uptake and follow up of patients in hypertension management. The effect of computers on physician knowledge, recording of information, and blood pressure control in patients is less conclusive and further studies are required.

Decision Making, Computer-Assisted↗
PubMed1997

Examination of the standard deviation of mean nasalance scores in subjects with cleft palate: implications for clinical use.

OBJECTIVES: To evaluate the standard deviation of the nasalance scores in patients having normal and abnormal nasal resonance and to determine its potential value for clinical use. Additionally, the mean nasalance scores were examined across varying degrees of hypernasality. DESIGN: Prospective study design. SETTING: Pediatric tertiary care hospital. PATIENTS: One hundred and forty-eight subjects, ranging in age from 4;0 to 37;0 years, having repaired cleft lip and/or palate and normal resonance, inconsistent, mild, or moderate/severe hypernasality. PROCEDURES: Oral-nasal acoustic measurements were made using the Nasometer. The standard deviation and mean nasalance scores were calculated for subjects reading three standard passages (Zoo Passage. Rainbow Passage, Nasal Sentences). RESULTS: The major finding in this study showed that the standard deviation score cannot distinguish speakers beyond a gross normal and abnormal resonance diagnostic category. The values obtained could not be used to distinguish among the varying degrees of hypernasality. A secondary finding was that a mean nasalance score in the high 20 s could be used to differentiate speakers with borderline velopharyngeal function from those who were non-nasal. CONCLUSIONS: In general, the standard deviation value serves little overall clinical utility; however, it may be of benefit in some specific clinical situations. In support of previous research, the mean nasalance score continues to be the best measure of nasalance. It should serve as a supplement to but not a substitute for clinical judgments.

Acoustics↗
PubMed1993

Benefit from visual cues in auditory-visual speech recognition by middle-aged and elderly persons.

The benefit derived from visual cues in auditory-visual speech recognition and patterns of auditory and visual consonant confusions were compared for 20 middle-aged and 20 elderly men who were moderately to severely hearing impaired. Consonant-vowel nonsense syllables and CID sentences were presented to the subjects under auditory-only, visual-only, and auditory-visual test conditions. Benefit was defined as the difference between the scores in the auditory-only and auditory-visual conditions. The results revealed that the middle-aged and elderly subjects obtained similar benefit from visual cues in auditory-visual speech recognition. Further, patterns of consonant confusions were similar for the two groups.

Acoustic Stimulation↗
PubMed1990

Visual biasing of normal and impaired auditory speech perception.

Intersensory biasing occurs when cues in one sensory modality influence the perception of discrepant cues in another modality. Visual biasing of auditory stop consonant perception was examined in two related experiments in an attempt to clarify the role of hearing impairment on susceptibility to visual biasing of auditory speech perception. Fourteen computer-generated acoustic approximations of consonant-vowel syllables forming a /ba-da-ga/ continuum were presented for labeling as one of the three exemplars, via audition alone and in synchrony with natural visual articulations of /ba/ and of /ga/. Labeling functions were generated for each test condition showing the percentage of /ba/, /da/, and /ga/ responses to each of the 14 synthetic syllables. The subjects of the first experiment were 15 normal-hearing and 15 hearing-impaired observers. The hearing-impaired subjects demonstrated a greater susceptibility to biasing from visual cues than did the normal-hearing subjects. In the second experiment, the auditory stimuli were presented in a low-level background noise to 15 normal-hearing observers. A comparison of their labeling responses with those from the first experiment suggested that hearing-impaired persons may develop a propensity to rely on visual cues as a result of long-term hearing impairment. The results are discussed in terms of theories of intersensory bias.

Adult↗
PubMed1990

Decision making in rehabilitative audiology.

With the emphasis on quality assurance and patient satisfaction in health care, decision making in rehabilitative audiology is a critical issue. Traditionally, rehabilitative decisions have been based on questionable assessment procedures and unproven treatment methods. In this paper, current strategies for decision making with hearing-impaired adults will be presented. Discussion will focus on nonacoustic factors influencing hearing aid fitting, the decision processes necessary for management of the hearing-impaired adult, and expanded uses of self-assessment inventories of hearing handicap.

Aged↗