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Biomedical subjects

A G Mulley

Publications and source records attributed to A G Mulley.

At least 19 recordsLinked to original sources
PubMed1992

Developing shared decision-making programs to improve the quality of health care.

We strongly believe in the importance of patient involvement in a medical decision. The interactive SDPs appear to be an effective way to facilitate this involvement. One key to the acceptance of these programs by patients and physicians is that they be--and be perceived as--fair, accurate, and balanced. Herein we have described the well-defined protocol for developing, evaluating, and updating SDPs. The first of the foundation's programs dealing with benign prostatic hyperplasia has been well received by patients and clinicians and has been demonstrated to have an impact on practice patterns. Efforts are under way to evaluate four additional programs, leading to widespread availability of the first five SDPs by fall of 1992.

Decision Making↗
PubMed1991

Variations in length of stay and outcomes for six medical and surgical conditions in Massachusetts and California.

OBJECTIVES: --To determine the extent to which interinstitutional variations in length of stay are explained by differences in patient characteristics and to determine whether patients in hospitals with shorter lengths of stay had worse outcomes. DESIGN: --We reviewed patients' medical records and surveyed patients between 3 and 12 months after hospital discharge using a questionnaire. SETTING: --Six teaching hospitals in California and Massachusetts. PATIENTS: --A cohort of 2484 selected patients who had been hospitalized for acute myocardial infarction or to rule out acute myocardial infarction, coronary artery bypass graft surgery, total hip replacement, cholecystectomy, or transurethral prostatectomy. Between 73% and 84% of the patients with each condition completed a follow-up questionnaire. OUTCOME MEASURES: --In-hospital complications, deaths, length of stay, functional status after hospital discharge, readmission, and patient satisfaction with hospital care were analyzed. RESULTS: --Significant interinstitutional differences in length of stay were noted for all conditions except rule-out acute myocardial infarction. Statistical adjustment for case-mix differences accounted for most of the interinstitutional differences in length of stay for total hip replacement but explained little of the differences in the other conditions. When we controlled statistically for other predictors, length of stay did not have a significant impact on deaths, functional status after hospital discharge, the probability of readmission, or patient satisfaction with hospital care. CONCLUSION: --More research is needed to determine the medical practices that are related to variations in lengths of stay. Routinely available outcome data may help preserve quality in the face of efforts to decrease costs by effecting more standardized practices of care.

Adult↗
PubMed1991

The evaluation of homicidal patients by psychiatric residents in the emergency room: a pilot study.

The authors report the results of a preliminary prospective study involving 110 patients who were involuntarily committed from the emergency room. The study was designed to clarify the process of how psychiatric residents evaluate homicidal patients. Eighteen patients (16%) were committed for homicidal ideation, of whom 89% were psychotic. Surprisingly, for patients committed because of a risk of homicide, vital signs were obtained for only 11%, during a mean evaluation time of 2.5 hours. Aspects of an appropriate physical examination and laboratory studies that enable the clinician to distinguish organic from functional illness are described. The authors conclude that patients with homicidal ideation may receive inadequate assessment prior to their involuntary commitment. Possible explanations and solutions for this, and recommendations for further studies are offered.

Adolescent↗
PubMed1990

Quantitative serum toxic screening in the management of suspected drug overdose.

Data were collected on 176 consecutive cases of drug overdose evaluated in an emergency department. Quantitative serum toxic screening (TS) was performed for 164 (93%) of these patients; positive results were noted for 133 patients (81%). Six classes of drugs (ethanol, benzodiazepines, salicylates, acetaminophen, barbiturates, and tricyclic antidepressants) were responsible for nearly 70% of all drug detections and were associated with 80% of all admissions in this patient sample. Only two patients (1%) had drug-specific treatment initiated because of TS results. In 12 patients (7%), TS confirmed substances for which specific treatments had been initiated on clinical grounds. Four patients (2%) had drug-specific treatment discontinued because of TS results. Thirty-two patients (19%) were admitted to a medical service; however, only seven patients (4%) were admitted primarily because of TS results. All other patients were admitted because of clinical abnormalities that required inpatient care. It is concluded that only a few drugs are responsible for most drug overdoses. Moreover, TS results rarely change the treatment or disposition of overdose patients; these decisions are typically based on clinical parameters.

Acetaminophen↗
PubMed1990

Cost-effectiveness study of the extracorporeal shock-wave lithotriptor.

We performed a cost-effectiveness analysis to examine the relative efficacy and costs of percutaneous ultrasonic lithotripsy (PUL), extracorporeal shock-wave lithotripsy (ESWL), and surgery for the treatment of upper urinary tract stones. We developed a Markov model with 35 states, cycles of 3 months, and a time frame of 5 years. Probability estimates were derived from a meta-analysis of the published literature. For stones less than or equal to 2 cm, ESWL is preferred to PUL, since it prevents 2 additional days of morbidity and saves $440. For larger stones, PUL is preferable to ESWL, avoiding 4 days of morbidity, and saving $722. Both ESWL and PUL were superior to surgery. Sensitivity analysis showed that the results are sensitive to ESWL efficacy rates, the stone recurrence rate, and the hospital component of the ESWL cost. Our analysis suggests that although ESWL is preferable, relatively small changes in the efficacy and cost can shift the preferred strategy; in addition, these findings underscore the need for more reliable data.

Cost-Benefit Analysis↗
PubMed1989

Assessing patients' utilities. Can the ends justify the means?

Each of the elements of a utility assessment strategy--defining and describing health states of interest, identifying subjects, choosing a scaling task, aggregating across subjects, determining reliability and validity--is controversial. The controversy is in part explained by the interdisciplinary nature of the problem; different disciplinary conceptualizations of utility lead to different priorities for methodologic problem solving. Controversy is further explained by widely divergent potential applications of utility assessments, including individual decisions made with and without (or by) an agent, and decisions made for populations that may be homogeneous or heterogeneous with regard to utilities for the same health states. Issues can be clarified by focusing on the purpose of the utility assessment and, in the case of clinical decision making, on the most relevant disease-specific outcomes. The prostatectomy decision is an example. Although questions of measurement validity need continuing attention, more attention should be paid to validating uses of utility assessments: Can utility assessments distinguish prospectively, among patients who subsequently experience the same health outcome, those for whom it is associated with a high or low level of well-being? Can utility assessments be used to predict behavior? Can a decision process that includes utility assessments affect decisions in a manner that improves overall well-being? Approaches to such questions are complicated by changes in utilities over time, departures from the normative model of decision making, the effects of decision-making responsibility, and biases introduced by the decision-making process.

Attitude to Health↗
PubMed1988

Watchful waiting vs immediate transurethral resection for symptomatic prostatism. The importance of patients' preferences.

The rate of resection for benign prostatic hypertrophy shows considerable variability among small geographic areas. To help inform the decision to recommend prostatectomy to men with prostatism without signs of chronic retention, we performed a decision analysis to compare the expected outcomes with immediate transurethral resection and watchful waiting. Data used in the model originated from the medical literature, Medicare claims data, and patient interview studies. In our base-case analysis for 70-year-old men, immediate surgery resulted in the loss of 1.01 months of life expectancy, but when adjustments were made for quality of life, immediate surgery was favored with a net utility benefit of 2.94 quality-adjusted life-months. However, the analysis was particularly sensitive to the degree of disutility attributed to the index symptoms of prostatism. We conclude that patient preferences should be the dominant factor in the decision whether to recommend prostatectomy.

Age Factors↗
PubMed1988

Symptom status and quality of life following prostatectomy.

When prostatectomy is proposed as treatment for the symptoms of prostatism, the decision to operate should depend on how patients evaluate their symptoms and on objective information about the outcomes. We undertook a health interview study to determine the probabilities for symptom relief, improvement in the quality of life, and complications following surgery and to evaluate patient concern about the symptoms of prostatism. The operation was effective in reducing symptoms: 93% of severely and 79% of moderately symptomatic patients experienced improvement; however, a statistically significant improvement in indices of quality of life occurred only among patients with acute retention or severe symptoms prior to surgery. Short-term complications of varying severity occurred in 24% of patients; in addition, 4% reported persistent incontinence and 5%, impotence. Patients with similar symptoms reported considerable difference in the degree to which they were bothered by their symptoms. The result emphasizes the importance of patient participation in the decision to undergo prostatectomy.

Aged↗
PubMed1988

Management of nephrolithiasis: new approaches to "surgical" kidney stones.

The majority of kidney stones that come to clinical attention are large enough to cause symptoms but small enough to pass spontaneously. Recent technological developments have revolutionized the approach to kidney stones that heretofore required surgery. Percutaneous removal of stones through a nephrostomy tract, with or without ultrasonic or electrohydraulic lithotripsy, and extracorporeal shock wave lithotripsy (ESWL) have all but eliminated indications for open surgical procedures. These new techniques have their own advantages and are complementary. Despite these advances, any change in accepted indications for stone removal should await further evidence of the long-term safety of percutaneous techniques and ESWL.

Fluid Therapy↗
PubMed1988

Left ventricular ejection fraction. Physician estimates compared with gated blood pool scan measurements.

Gated blood pool scanning (GBPS) is an expensive, frequently used test to assess the left ventricular ejection fraction (LVEF). To determine whether a simpler method of evaluating LVEFs was reliable, we compared the LVEFs derived by GBPS with those estimated in a cardiologist's examination in 125 hospitalized patients. Of the physician estimates, 56% were accurate to within 7.5%, while 17% were underestimates and 27% were overestimates. The variables that were most predictive of reduced LVEF included cardiomegaly and pulmonary venous congestion on chest roentgenogram and S3 gallop, hypotension, and sustained left ventricular apex beat on examination. Prior hypertension was correlated with an increased LVEF. Variables associated with physician error in estimating the LVEF included a history of hypertension, bronchodilator therapy, and right bundle-branch block seen on the electrocardiogram. These data suggest that although qualitatively accurate estimates of the LVEF can sometimes be made on the basis of clinical findings, GBPS should be performed when management decisions hinge on a precise knowledge of this value.

Aged↗
PubMed1987

Dipyridamole-thallium scanning in patients undergoing vascular surgery. Optimizing preoperative evaluation of cardiac risk.

Dipyridamole-thallium imaging has been suggested as a method of preoperatively assessing cardiac risk in patients undergoing major surgery. To define more clearly its proper role in preoperative assessment, we prospectively evaluated 111 patients undergoing vascular surgery. In the first set of 61 patients, our data confirmed the value of preoperative dipyridamole-thallium scanning in identifying the patients who suffered postoperative ischemic events. Events occurred in eight of 18 patients with reversible defects on preoperative imaging, compared with no events in 43 patients with no thallium redistribution (confidence interval for the risk difference: 0.624, 0.256). The results also suggested that clinical factors might allow identification of a low-risk subset of patients. To test the hypothesis that patients with no evidence of congestive heart failure, angina, prior myocardial infarction, or diabetes do not require further preoperative testing, we evaluated an additional 50 patients having vascular procedures. None of the 23 without the clinical markers had untoward outcomes, while ten of 27 patients with one or more of these clinical markers suffered postoperative ischemic events (confidence interval for the risk difference: 0.592, 0.148). In the clinical high-risk subset, further risk stratification is achieved with dipyridamole-thallium scanning.

Aged↗
PubMed1987

Effect of workup strategy on the cost-effectiveness of fecal occult blood screening for colorectal cancer.

Physicians respond to a positive fecal occult blood test with a variety of workup strategies. To study the effect of the choice of strategy on the net costs and health benefits of colorectal cancer screening using this test, we used a decision analysis model to compare seven strategies that physicians might choose to examine a positive "screenee." Strategies using rigid or flexible sigmoidoscopy alone are not only insensitive, but also have high cost-effectiveness ratios. The strategy of air contrast barium enema alone had the lowest cost-effectiveness ratio. Rigid sigmoidoscopy combined with barium enema had a lower cost-effectiveness ratio than primary colonoscopy, but the strategy of primary colonoscopy could have an equal or better ratio depending on assumptions about test costs and the benefit of removing benign polyps. The primary colonoscopy strategy is both more effective and less costly than the combination of flexible sigmoidoscopy and barium enema. The optimal strategy will vary with local factors, and with the perspective of the decision-maker.

Aged↗