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Biomedical subjects

A I Mushlin

Publications and source records attributed to A I Mushlin.

At least 19 recordsLinked to original sources
PubMed2001

Costeffectiveness of diagnostic tests.

We review the principles underlying cost-effectiveness analysis of diagnostic tests and procedures. We use two clinical examples, diagnostic testing for early multiple sclerosis and for Helicobacter pylori to illustrate the methods of analysis and to show how the results can be useful for physicians or payers of health services in making decisions about provision and use of diagnostic services. Economic assessments of diagnostic tests are inherently more difficult than assessments of therapeutic interventions, mainly because of uncertainty about the relation between diagnosis and end results (outcomes) of care. Nonetheless, because of the increasing importance of diagnostic technology in medicine and healthcare, only with such assessments will the most value be gained from restricted medical resources.

Cost-Benefit Analysis↗
PubMed2001

The impact of quality report cards on choice of physicians, hospitals, and HMOs: a midcourse evaluation.

BACKGROUND: Increasing competition in health care markets and ongoing pressures to contain costs raise concerns about possible deterioration in the quality of medical care. Publicly disseminated quality report cards are designed to inform consumers' choice of providers and health plans, thus counteracting incentives to provide low-quality care and improving the functioning of health care markets. METHODS: This article reviews and evaluates the published evidence on the impact of quality report cards on patients' choice of health care providers and health plans. RESULTS: Studies found only minimal effect of quality report cards on patient referral choices. These findings can be explained by several study design issues and by the economic forces governing health care markets. They cannot be construed to imply that quality report cards are not effective. DISCUSSION: Whether report cards are effective or not is still an unanswered question. Further efforts to improve the information contained in report cards and to make them more understandable could increase their effectiveness.

Choice Behavior↗
PubMed2000

Oral versus intravenous: rehydration preferences of pediatric emergency medicine fellowship directors.

OBJECTIVE: The American Academy of Pediatrics (AAP) recommends oral rehydration therapy (ORT) for management of uncomplicated childhood gastroenteritis with mild-moderate dehydration. However, ORT is widely underused relative to their recommendations. We compared ORT use by directors of Pediatric Emergency Medicine (PEM) fellowship training programs with AAP recommendations, and sought to identify their barriers to ORT. METHODS: Mail/fax survey of the directors of U.S. and Canadian PEM fellowship programs. The survey included 10 scenarios of mild or moderately dehydrated children with gastroenteritis, a personal innovativeness scale, self-assessment of ORT experience and knowledge, and open-ended questions regarding perceived barriers to ORT use. RESULTS: 60/67 (89.6%) PEM fellowship program directors responded. All reported experience with and knowledge about ORT. Only 10/58 (17.2%) believe ORT is usually better than intravenous (i.v.) rehydration in all 10 clinical scenarios, and only 4/58 (6.7%) usually use ORT in all 10 scenarios. 18/58 (31%) usually use ORT for all mildly but no moderately dehydrated children. ORT use did not correlate with personal innovativeness scores. Important barriers cited by respondents include additional time requirements for ORT relative to i.v. rehydration (76.7%) and expectation of i.v. rehydration by parents (41.7%) or primary care physicians (10%). CONCLUSIONS: Relative to AAP recommendations, PEM fellowship directors underuse ORT, especially for moderately dehydrated children. Physician innovativeness does not influence ORT use. Further study of effectiveness, length of stay, staff requirements, and ORT acceptance in the emergency department setting, especially in children with moderate dehydration, may influence ORT use.

Attitude of Health Personnel↗
PubMed2000

Do quality report cards play a role in HMOs' contracting practices? Evidence from New York State.

OBJECTIVE: To answer two related questions: (1) Do managed care organizations (MCOs) in New York State (NYS) consider quality when they choose cardiac surgeons? (2) Do they use information about risk-adjusted mortality rates (RAMR) provided in the New York State Cardiac Surgery Reports? DATA SOURCES: (1) Telephone interviews with and contracting data from the majority of MCOs licensed in NYS; (2) RAMR, quality outlier designation, and procedure volume for all cardiac surgeons, as reported in the Cardiac Surgery Reports. STUDY DESIGN: Interview data were analyzed in conjunction with patterns revealed by contracting data. Null hypotheses that MCOs' contracting choices were random with respect to the information published in the Cardiac Surgery Reports were tested. PRINCIPAL FINDINGS: Sixty percent of MCOs ranked the quality of surgeons as most important in their contracting considerations. Although 64 percent of MCOs indicated some knowledge of the NYS Cardiac Surgery Reports, only 20 percent indicated that the reports were a major factor in their contracting decision. Analyses of actual contracting patterns show that in aggregate, the hypothesis of random choice could be rejected with respect to high-quality outlier status and high procedure volume but not for RAMR or poor-quality outlier status. The panel composition of the majority of MCOs (80.2 percent) was within two standard deviations of the expected mean under the null hypothesis. CONCLUSIONS: Despite a professed preference for high-quality surgeons, the use of publicly available quality reports by MCOs is currently low, and contracting practices for the majority of MCOs do not indicate a systematic selection either for or against surgeons based on their reported mortality scores. This study suggests that policy initiatives to increase the effective use of report cards should be encouraged.

Cardiac Surgical Procedures↗
PubMed1999

Association between nurse-physician collaboration and patient outcomes in three intensive care units.

OBJECTIVE: To investigate the association of collaboration between intensive care unit (ICU) physicians and nurses and patient outcome. DESIGN: Prospective, descriptive, correlational study using self-report instruments. SETTINGS: A community teaching hospital medical ICU, a university teaching hospital surgical ICU, and a community non-teaching hospital mixed ICU, all in upstate New York. SUBJECTS: Ninety-seven attending physicians, 63 resident physicians, and 162 staff nurses. PROCEDURE: When patients were ready for transfer from the ICU to an area of less intensive care, questionnaires were used to assess care providers' reports of collaboration in making the transfer decision. After controlling for severity of illness, the association between interprofessional collaboration and patient outcome was assessed. Unit-level organizational collaboration and patient outcomes were ranked. MEASURES: Healthcare providers' reported levels of collaboration, patient severity of illness and individual risk, patient outcomes of death or readmission to the ICU, unit-level collaboration, and unit patient risk of negative outcome. MAIN RESULTS: Medical ICU nurses' reports of collaboration were associated positively with patient outcomes. No other associations between individual reports of collaboration and patient outcome were found. There was a perfect rank order correlation between unit-level organizational collaboration and patient outcomes across the three units. CONCLUSIONS: The study offered some support for the importance of physician-nurse collaboration in ICU care delivery, a variable susceptible to intervention and further study.

APACHE↗
PubMed1998

The cost-effectiveness of automatic implantable cardiac defibrillators: results from MADIT. Multicenter Automatic Defibrillator Implantation Trial.

BACKGROUND: The recently reported Multicenter Automatic Defibrillator Implantation Trial (MADIT) showed improved survival in selected asymptomatic patients with coronary disease and nonsustained ventricular tachycardia. The economic consequences of defibrillator management in this patient population are unknown. METHODS AND RESULTS: Patients were followed up to quantify their use of healthcare services, including hospitalizations, physician visits, medications, laboratory tests, and procedures, during the trial. The costs of these services, including the costs of the defibrillator, were determined in patients randomized to defibrillator and nondefibrillator therapy. Incremental cost-effectiveness ratios were calculated by relating these costs to the increased survival associated with the use of the defibrillator. The average survival for the defibrillator group over a 4-year period was 3.66 years compared with 2.80 years for conventionally treated patients. Accumulated net costs were $97,560 for the defibrillator group compared with $75,980 for individuals treated with medications alone. The resulting incremental cost-effectiveness ratio of $27,000 per life-year saved compares favorably with other cardiac interventions. Sensitivity analyses showed that the incremental cost-effectiveness ratio would be reduced to approximately $23,000 per life-year saved if transvenous defibrillators were used instead of the older devices, which required thoracic surgery for implantation. CONCLUSIONS: An implanted cardiac defibrillator is cost-effective in selected individuals at high risk for ventricular arrhythmias.

Cost-Benefit Analysis↗
PubMed1998

Carotid endarterectomy trends in the patterns and outcomes of care at academic medical centers, 1990 through 1995.

OBJECTIVE: To evaluate whether the patterns of inpatient care and patient characteristics have changed for patients undergoing a carotid endarterectomy across a group of academic medical centers from 1990 through 1995. If changes occurred, we investigated whether they had an impact on patient outcomes. DESIGN: Retrospective evaluation of patients undergoing a carotid endarterectomy using a hospital discharge data set compiled by the Academic Medical Center Consortium. SETTING: Ten academic medical centers. PATIENTS: A total of 7019 hospital admissions for patients who had 1 carotid endarterectomy performed as a principal procedure from January 1990 to December 1995. MAIN OUTCOME MEASURES: Trends in patient demographics, comorbidities, length of stay, days in the intensive care unit, and inpatient cerebral arteriogram use were determined. Patient outcomes included inpatient mortality, discharge to an institution, 30-day readmission rate, and selected diagnoses (postoperative hemorrhage, infection, or seizure; acute myocardial infarction; or cranial nerve palsy) and postprocedure diagnostic tests (computed tomography and magnetic resonance imaging of the head and electroencephalogram) indicative of complications. RESULTS: Over the 6-year study period, the number of carotid endarterectomies performed more than doubled and the percentage of hospital admissions for patients 65 years or older increased from 65% to 75%. The mean and median length of stay halved and the percentage of admissions with transfers to the intensive care unit decreased from 56% to 26% of cases. In addition, the percentage of cases with a cerebral arteriogram during the same admission but prior to the day of the carotid endarterectomy decreased from 52% to 27%. There were no trends in inpatient mortality, discharge to an institution, or 30-day readmission rate. There were no significant trends indicative of poorer quality of care as measured by the frequency of secondary diagnoses or postprocedure diagnostic test use. CONCLUSIONS: Despite dramatic changes that have occurred in patient characteristics and in hospital management practices for patients undergoing a carotid endarterectomy from 1990 to 1995, we were unable to detect any measurable impact on patient outcomes. These data have implications for monitoring and evaluating the impact of systemwide change on the overall quality of care for patients undergoing a carotid endarterectomy.

Academic Medical Centers↗
PubMed1998

Cost-effectiveness of routine antenatal varicella screening.

OBJECTIVE: To evaluate the cost-effectiveness of routine antenatal varicella serologic screening of pregnant women with negative or indeterminate varicella histories. METHODS: Routine antenatal varicella screening was evaluated using a decision analytic model. Outcomes were varicella cases, deaths, and life-years. Probabilities were derived from the literature, and sensitivity analysis was performed when data were imprecise or subject to variation. The analysis was repeated to include the effect of a policy of routine screening and vaccination of all adults. RESULTS: Routine antenatal varicella screening of history-negative women was not cost-effective unless the cost of screening was decreased six-fold, varicella exposure rates were greater than 6%, or there was a greater than three-fold decrease in varicella exposure in women testing nonimmune compared with unscreened women. These results were not sensitive to alterations in varicella-zoster immunoglobulin (Ig) effectiveness, varicella communicability, rates and timing of contact reporting, costs (per case, pneumonia, and death), or serologic test performance. If performed as part of a policy of universal screening of all history-negative adults (with vaccination of the majority of those testing nonimmune), routine antenatal varicella testing became cost-effective. CONCLUSION: Routine antenatal varicella screening of all pregnant women with negative or indeterminate varicella histories is not cost-effective. It could be cost-effective in groups of women with increased exposure risk, or if part of a policy of screening and vaccination of all adults.

Adult↗
PubMed1998

Estimating the accuracy of screening mammography: a meta-analysis.

OBJECTIVE: To estimate the accuracy of mammographic screening. DESIGN: A meta-analysis of published literature. DATA SOURCES: Published English-language randomized controlled trials, case-control studies, and demonstration projects involving screening mammography were identified using recent review articles. We found additional references using MEDLINE searches combining the MeSH terms "mammography," "screening," and/or study authors and locations. STUDY SELECTION: We included all studies that provided information to calculate the true-positive rate (TPR) and the false-positive rate (FPR) for breast cancer screening. DATA EXTRACTION: Reported data were reviewed independently by the authors; calculations were compared and discrepancies resolved. We calculated the sensitivity as the number of breast cancers detected during the first round of screening (true positives) divided by the sum of the true positives and the false negatives (defined as cancer discovered within 1 year of screening). False-positives were determined by biopsy. DATA SYNTHESIS: TPR and FPR values from each study were plotted in receiver operating characteristic (ROC) space. Tests of homogeneity were performed to assess the validity of using summary ROC curves or a single point to summarize the data. The reported TPR and FPR of mammography ranged from 83% to 95% and 0.9% to 6.5%, respectively. The sensitivity of mammography is higher in women over the age of 50 years. CONCLUSIONS: The accuracy of mammography should be recognized and included in discussions about policies for screening for breast cancer. This meta-analysis, by quantifying the expected TPR/FPR, should assist program planners, physicians, and women to understand better the cost and clinical implications of such screening programs.

Adult↗
PubMed1998

Quality of care information makes a difference: an analysis of market share and price changes after publication of the New York State Cardiac Surgery Mortality Reports.

OBJECTIVES: Quality report cards are becoming increasingly more common and receive much publicity. They can have significant impact on competition among providers, costs, and quality of health care. The authors test the hypotheses that hospitals and surgeons with better outcomes reported in the NYS Cardiac Surgery Reports experience a relative increase in their market share and prices. METHODS: Information from the New York State Cardiac Surgery Reports was linked with physicians' claims submitted to Medicare and was used to calculate market shares and average prices for hospitals and physicians performing CABG surgeries. Regression models were estimated to test hypotheses. All 30 hospitals offering coronary artery bypass graft (CABG) were studied as well as a majority of surgeons (114 or approximately 80%) performing CABG surgery in New York State during the 1990-1993 period. RESULTS: Findings indicate that hospitals and physicians with better outcomes experienced higher rates of growth in market shares. Physicians with better outcomes also had higher rates of growth in charges for this procedure. CONCLUSIONS: Patients (and referring physicians) seem to respond to information about quality of individual surgeons and hospitals as expected. The magnitude of the association between reported mortality and market shares varies geographically, potentially reflecting differences in sociodemographic characteristics. The association tends to decline over time, suggesting that it is primarily due to "new" information.

Attitude to Health↗
PubMed1997

The cost-effectiveness of magnetic resonance imaging for patients with equivocal neurological symptoms.

OBJECTIVE: To determine the incremental cost-effectiveness of magnetic resonance imaging (MRI) and computed tomography (CT) in young adults presenting with equivocal neurological signs and symptoms. DESIGNS AND METHODS: A decision analysis of long-term survival using accuracy data from a diagnostic technology assessment of MRI and CT in patients with suspected multiple sclerosis, information from the medical literature, and clinical assumptions. MAIN RESULTS: In the baseline analysis, at 30% likelihood of an underlying neurologic disease, MRI use has an incremental cost of $101,670 for each additional quality-adjusted life-year saved compared with $20,290 for CT use. As the probability of disease increases, further MRI use becomes a cost-effective alternative costing $30,000 for each quality-adjusted life-year saved. If a negative MRI result provides reassurance, the incremental costs of immediate MRI use decreases and falls below $25,000 for each quality-adjusted life-year saved no matter the likelihood of disease. CONCLUSIONS: For most individuals with neurological symptoms or signs, CT imaging is cost-effective while MR imaging is not. The cost-effectiveness of MRI use, however, improves as the likelihood of an underlying neurological disease increases. For selected patients who highly value diagnostic information, MRI is a reasonable and cost-effective use of medical resources when even the likelihood of disease is quite low (5%).

Adult↗
PubMed1997

Nurse-physician collaboration and satisfaction with the decision-making process in three critical care units.

OBJECTIVE: To assess and compare levels of nurse-physician collaboration and satisfaction with the decision-making process as reported by critical care nurses, resident physicians (residents), and attending physicians (attendings) in making decisions to transfer individual patients out of the critical care unit, and to assess if satisfaction predicts nurse retention. DESIGN: Longitudinal descriptive correlational study using self-reporting instruments. SETTINGS: A university hospital's surgical ICU, a community teaching hospital's medical ICU, and a community hospital's mixed ICU. SUBJECTS: Eighty-one nurses, 23 residents, and 37 attendings from the surgical ICU; 44 nurses and 51 residents from the medical ICU; 25 nurses and 45 attendings from the community hospital's ICU, reporting on the transfers of 473, 465, and 494 patients, respectively. MAIN OUTCOME MEASURES: Healthcare providers' reported levels of collaboration and satisfaction with the decision-making process, the correlations between collaboration and satisfaction, and nurse retention. RESULTS: Nurses and physicians within sites (except attendings from the surgical ICU) reported similarly moderate amounts of collaboration, but nurses reported less satisfaction with decision making than did physicians in all sites. Collaboration was related to satisfaction with decision making for all providers, but more strongly for nurses. The strength of the relationship for nurses was similar in all sites. Nurses' satisfaction with decision making did not predict their retention. CONCLUSIONS: Collaboration between nurses and physicians is a more important component of satisfaction with decision making for nurses than for physicians. Any interventions to change the amount of collaboration in practice must take account of this difference.

Adult↗
PubMed1996

The prostate: decreasing cost-effectiveness of biopsy with advancing age.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine the cost-effectiveness of prostate biopsy at different excess prostate-specific antigen (PSA) levels as a function of age. METHODS: Medical decision analysis was performed with standard software (SMLTREE) to determine marginal effectiveness in quality adjusted life years (QALYs) and marginal cost-effectiveness in dollars per QALY of immediate prostate biopsy at different excess PSA levels between 0 ng/mL and 20 ng/mL. The probability of clinically significant cancer with a positive biopsy (pD+Bx+) was assumed to decrease with age from 1.0 at age 50 to 0.2 at age 70. Costs were based on charges at our hospital and were considered over a 2-year time frame. RESULTS: With our base case assumptions there was a decrease in QALYs and an increase in costs doing an immediate prostate biopsy at all excess PSA levels between 0 ng/mL and 20 ng/mL, compared with not biopsying the prostate at > or = 70 years. Doubling pD+Bx+ from 0.2 to 0.4 in the 70-and-older age group resulted in a small increase in QALYs in biopsying the prostate at excess PSA levels between 0 ng/mL and 20 ng/mL. However, the marginal cost-effectiveness of prostate biopsy was very high, ranging from $275,000/QALY biopsying at an excess PSA level of 0 ng/mL to $68,000/QALY biopsying at an excess PSA level of 20 ng/mL. This compared with it being more effective and less costly to biopsy at all excess PSA levels > or = 0 ng/mL in 50-year old patients. CONCLUSION: Immediate prostate biopsy is not cost-effective and can be detrimental in patients > or = 70 years of age at all excess PSA levels between 0 ng/mL and 20 ng/mL.

Aged↗
PubMed1996

Intracranial mass lesions in acquired immunodeficiency syndrome: using decision analysis to determine the effectiveness of stereotactic brain biopsy.

We studied the effectiveness of performing a stereotactic brain biopsy in the individual with acquired immunodeficiency syndrome (AIDS) and an intracranial mass lesion who failed 2 weeks of antitoxoplasmosis therapy. We used a decision analysis to compare two different treatment strategies: biopsy and no biopsy. The analysis estimates the average life expectancy for each choice and investigates the sensitivity of these results by varying parameters within the model. In the base case analysis (diagnostic yield of biopsy, 0.89; operative mortality, 0.015; life expectancy of lymphoma untreated and treated, 42 and 120 days), the life expectancy of the biopsy strategy was 98 days compared with 67 days for the no-biopsy strategy, for a net survival benefit of 31 days. Sensitivity analyses revealed that the life expectancy of the biopsy strategy remained greater than the no-biopsy strategy for a wide range of variable specifications. The net survival benefit, however, was sensitive to the diagnostic success rate, the operative mortality, the likelihood of a lymphoma diagnosis, and the life expectancy of patients being diagnosed and treated for lymphoma. These data allow AIDS patients and physicians to learn more about the potential outcomes of the alternative management strategies when an individual fails to respond to empiric antitoxoplasmosis therapy.

Acquired Immunodeficiency Syndrome↗