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Biomedical subjects

B G Ewigman

Publications and source records attributed to B G Ewigman.

14 recordsLinked to original sources
PubMed1996

The clinical value of computerized information services. A review of 98 randomized clinical trials.

OBJECTIVE: To review all randomized clinical trials addressing the efficacy of clinical information systems and to determine the clinical settings, types of interventions, and effects studied. DATA SOURCES: Extensive and systematic MEDLINE searches were conducted using a combination of medical subject headings (MeSH) and textword terms to collect trial reports. Manual searches of books and monographs as well as informal contacts were also used. STUDY SELECTION: The eligibility criteria were (1) randomized controlled clinical trial, (2) computerized information intervention in the study group, and (3) effect measured on the process or outcome of care. DATA EXTRACTION: Two research assistants independently abstracted from the selected reports the following structured information: trial sites, computerized interventions, effect variables, and outcomes. Three investigators evaluated the combined list of trial features for setting, intervention, and effect. The statistical analysis included an evaluation of agreement in developing classifications and an analysis of the ratio of positive trial outcomes. DATA SYNTHESIS: Most information services were tested in outpatient care (82%), particularly in primary care (66%). The information intervention targeted the provider in 64% of the trials. The effect was primarily measured for the process of care (76%). Provider prompt/reminder, computer-assisted treatment planner, interactive patient education/therapy, and patient prompt/reminder were significantly successful interventions (sign test, P < .05). CONCLUSIONS: Randomized clinical trials confirm that four generic information interventions are active ingredients of computer systems and can make a significant difference in family medicine (physician and patient reminders, treatment planner, and patient education). To manage care and improve quality, primary care computer systems should incorporate these effective information services.

Information Systems↗
PubMed1995

Methods of randomized controlled clinical trials in health services research.

The randomized controlled clinical trial is an increasingly used method in health services research. Analysis of methodology is needed to accelerate practical implementation of trial results, select trials for meta-analysis, and improve trial quality in health services research. The objectives of this study are to explore the methodology of health services research trials, create and validate a streamlined quality evaluation tool, and identify frequent quality defects and confounding effects on quality. The authors developed a quality questionnaire that contained 20 evaluation criteria for health services research trials. One hundred one trials from the Columbia Registry of Controlled Clinical Trials were evaluated using the new quality tool. The overall agreement between independent reviewers, Cohen's kappa, was 0.94 (+/- 0.01). Of a possible score of 100, the trials received an average score of 54.8 (+/- 12.5). Five evaluation criteria indicated significant quality deficiencies (sample size, description of case selection, data on possible adverse effects, analysis of secondary effect variables, and retrospective analysis). The quality of study characteristics was significantly weaker than the quality of reporting characteristics (P < 0.001). The total average scores of Medline-indexed journals were better than the non-Medline-indexed journals (P < 0.001). There was a positive correlation between the overall quality and year of publication (R = 0.21, P < 0.05). The authors conclude that the new quality evaluation tool leads to replicable results and there is an urgent need to improve several study characteristics of clinical trials. In comparison to drug trials, site selection, randomization, and blinding often require different approaches in health services research.

Evaluation Studies as Topic↗
PubMed1995

Validating a model developed to predict prenatal care utilization.

BACKGROUND: Many pregnant women in the United States do not obtain adequate prenatal care. While it is essential to provide women with access to prenatal care, access alone is insufficient to guarantee that all women will receive adequate prenatal care. Previous research has identified a number of personal and cultural barriers to prenatal care. We have integrated these barriers into an explanatory model called the Social Pregnancy Interaction Model, the centerpiece of which is the concept of a "social pregnancy identity," as distinct from the physiologic reality of pregnancy. The purpose of this study was to validate the dimensions of this model. METHODS: Based on previous qualitative work, a questionnaire was developed. It was administered by interview to a convenience sample of 287 pregnant women receiving prenatal care in 11 practices in central Missouri. Item analysis and factor analysis were used to define scales and validate the relationships predicted by the model. RESULTS: With some modifications, the following dimensions of the model were confirmed as distinct and significant: awareness of pregnancy, acceptance of pregnancy, self-care, communication with family, communication with partner, social attitudes toward prenatal care, and attitudes toward the health care provider. CONCLUSIONS: The model has potential for predicting the utilization of prenatal care. The results also suggest that a woman's relationship with her prenatal care provider is important to obtaining adequate prenatal care.

Adolescent↗
PubMed1994

Geographic patterns of fatal abuse or neglect in children younger than 5 years old, United States, 1979 to 1988.

OBJECTIVE: To examine geographic patterns of fatal child abuse or neglect (CAN) among children younger than 5 years old. DESIGN: A death certificate-based model to estimate the occurrence of fatal CAN. SETTING: United States, 1979 to 1988. PARTICIPANTS: The population of children younger than 5 years old. INTERVENTIONS: None. MAIN RESULTS: We estimate that from 868 to 1815 deaths annually occur among children younger than 5 years old from CAN. The lower figure is the estimate of confirmed CAN, and the higher is the estimate of the sum of confirmed, probable, and possible CAN. Death rates were highest in the South and West, intermediate in the North Central, and lowest in the Northeast. A threefold difference was noted between rates in the lowest- and highest-ranking states (ie, Connecticut, 2.9 to 5.2 per 100,000, and Nevada, 6.7 to 15.4 per 100,000, respectively). When the 39 largest metropolitan areas were ranked, a similar variation between the lowest and the highest was observed (ie, Boston, Mass, 2.7 to 5.5 per 100,000, and Phoenix, Ariz, 6.6 to 15.5 per 100,000, respectively). CONCLUSION: Understanding the sizable geographic variation in CAN deaths rates could lead to effective interventions. If the US fatality rate were reduced to that of Connecticut, between 434 and 908 fewer CAN deaths might occur annually.

Cause of Death↗
PubMed1994

A randomized trial of prenatal ultrasonographic screening: impact on the detection, management, and outcome of anomalous fetuses. The RADIUS Study Group.

OBJECTIVE: The objective of this randomized clinical trial was to test the hypothesis that ultrasonographic screening would significantly alter perinatal outcome as a result of the antenatal detection of fetal congenital malformations. STUDY DESIGN: Pregnant women without a specific indication for ultrasonography were randomly assigned to have either two screening sonograms (15 to 22 weeks and 31 to 35 weeks) or conventional obstetric care with ultrasonography used only as determined by the clinical judgment of the patient's physician. The frequency of birth defect detection in the screened and control populations was compared, as was the impact of discovery on pregnancy outcome. RESULTS: Major congenital malformations occurred in 2.3% of the 15,281 fetuses and infants in this study. Antenatal ultrasonography detected 35% of the anomalous fetuses in the screened group versus only 11% in the control population (relative detection rate 3.1; 95% confidence interval 2.0 to 5.1). Ultrasonography screening did not, however, significantly influence the management or outcome of pregnancies complicated by congenital malformations. Specifically, only 9 abortions were performed for anomalies among 7685 fetuses in the screened group whereas 4 pregnancies were terminated for fetal anomalies detected among 7596 control subjects. Ultrasonography screening also had no significant impact on survival rates among infants with potentially treatable, life-threatening anomalies despite the opportunity to take precautionary measures such as delivery in a tertiary center. CONCLUSIONS: Ultrasonography screening in a low-risk pregnant population had no significant impact on the frequency of abortion for fetal anomalies. Survival rates for anomalous fetuses were also unaffected by screening.

Abortion, Induced↗
PubMed1994

Effect of physician reminders on preventive care: meta-analysis of randomized clinical trials.

The objective of this study was to assess the clinical value of the physician reminder, an information intervention, in increasing compliance for selected preventive health care measures. Meta-analysis was used to combine the quantitative evidence from randomized controlled clinical trials meeting the eligibility criteria. The trials included in this meta-analysis were conducted in a family or internal medicine clinic. Physician reminders were used in the trials to influence utilization and compliance of preventive health care activities. The use of physician reminders for preventive health care activities resulted in a homogeneous effect for the subcategories of cervical cancer screening (test for heterogeneity X2(2) = 4.122, non-significant) and tetanus immunization (test for heterogeneity X2(2) = 3.139, non-significant). Similarly, the odds ratio from the combination of evidence from the three cervical cancer screening trials was significant (1.180, 95 percent CI: 1.020 to 1.339). The resulting odds ratio from the combination of evidence from the three tetanus immunization trials was significant (2.819, 95 percent CI: 2.664 to 2.975). The results of the meta-analyses for cervical cancer screening and tetanus immunizations indicate that physician reminders are an effective information intervention and can improve compliance for these two preventive health care procedures. Based on the results of this meta-analysis, further trials testing the effect of physician reminders on tetanus immunization would be unnecessary and probably unethical.

Female↗
PubMed1994

A decision-support system for the analysis of clinical practice patterns.

Several studies documented substantial variation in medical practice patterns, but physicians often do not have adequate information on the cumulative clinical and financial effects of their decisions. The purpose of developing an expert system for the analysis of clinical practice patterns was to assist providers in analyzing and improving the process and outcome of patient care. The developed QFES (Quality Feedback Expert System) helps users in the definition and evaluation of measurable quality improvement objectives. Based on objectives and actual clinical data, several measures can be calculated (utilization of procedures, annualized cost effect of using a particular procedure, and expected utilization based on peer-comparison and case-mix adjustment). The quality management rules help to detect important discrepancies among members of the selected provider group and compare performance with objectives. The system incorporates a variety of data and knowledge bases: (i) clinical data on actual practice patterns, (ii) frames of quality parameters derived from clinical practice guidelines, and (iii) rules of quality management for data analysis. An analysis of practice patterns of 12 family physicians in the management of urinary tract infections illustrates the use of the system.

Artificial Intelligence↗
PubMed1993

Effect of prenatal ultrasound screening on perinatal outcome. RADIUS Study Group.

BACKGROUND: Many clinicians advocate routine ultrasound screening during pregnancy to detect congenital anomalies, multiple-gestation pregnancies, fetal growth disorders, placental abnormalities, and errors in the estimation of gestational age. However, it is not known whether the detection of these conditions through screening leads to interventions that improve perinatal outcome. METHODS: We conducted a randomized trial involving 15,151 pregnant women at low risk for perinatal problems to determine whether ultrasound screening decreased the frequency of adverse perinatal outcomes. The women randomly assigned to the ultrasound-screening group underwent one sonographic examination at 15 to 22 weeks of gestation and another at 31 to 35 weeks. The women in the control group underwent ultrasonography only for medical indications, as identified by their physicians. Adverse perinatal outcome was defined as fetal death, neonatal death, or neonatal morbidity such as intraventricular hemorrhage. RESULTS: The mean numbers of sonograms obtained per woman in the ultrasound-screening and control groups were 2.2 and 0.6, respectively. The rate of adverse perinatal outcome was 5.0 percent among the infants of the women in the ultrasound-screening group and 4.9 percent among the infants of the women in the control group (relative risk, 1.0; 95 percent confidence interval, 0.9 to 1.2; P = 0.85). The rates of preterm delivery and the distribution of birth weights were nearly identical in the two groups. The ultrasonographic detection of congenital anomalies had no effect on perinatal outcome. There were no significant differences between the groups in perinatal outcome in the subgroups of women with post-date pregnancies, multiple-gestation pregnancies, or infants who were small for gestational age. CONCLUSIONS: Screening ultrasonography did not improve perinatal outcome as compared with the selective use of ultrasonography on the basis of clinician judgment.

Adolescent↗
PubMed1993

A randomized trial of prenatal ultrasonographic screening: impact on maternal management and outcome. RADIUS (Routine Antenatal Diagnostic Imaging with Ultrasound) Study Group.

OBJECTIVES: This randomized clinical trial of 15,530 women was designed to test the hypothesis that screening ultrasonography in low-risk pregnancies would improve perinatal outcome. A secondary hypothesis addressed in this article was that screening ultrasonography would have a favorable impact on maternal management or outcome. STUDY DESIGN: Pregnant women without a specific indication for ultrasonographic examination in early pregnancy were randomly assigned to have either two screening sonograms or conventional obstetric care. Pregnancy interventions and maternal outcomes were compared in the two groups. RESULTS: No significant differences were found in maternal outcomes. Use of ultrasonography was markedly higher in the screened group. The rates of induced abortion, amniocentesis, tests of fetal well-being, external version, induction, and cesarean section and the distribution of total hospital days were similar in the two groups. Use of tocolytics and the rate of postdate pregnancy were both slightly lower in the screened group. CONCLUSION: Screening ultrasonography resulted in no clinically significant benefit.

Female↗
PubMed1993

Estimates of fatal child abuse and neglect, United States, 1979 through 1988.

The results of recent surveys in the United States have suggested a rising tide of fatalities due to child abuse or neglect (CAN). Because these surveys lack consistency in case definition and are incomplete in coverage, the use of death certificate data to estimate the number of CAN deaths was explored. To estimate these deaths among children 0 through 17 years old for 1979 through 1988, three models were formulated, each comprising six coding categories: (1) deaths coded explicitly as due to CAN, (2) homicides, (3) injury deaths of undetermined intentionality, (4) accidental injury deaths, (5) sudden infant death syndrome fatalities, and (6) natural-cause deaths. Research studies and crime data were relied on to estimate the proportions of deaths in categories 2 through 6 that were actually due to CAN, and other assumptions were varied to create a range of estimates. For the 10-year period, the estimated mean annual CAN fatalities ranged from 861 to 1814 for ages 0 through 4, and from 949 to 2022 for ages 0 through 17. Child abuse and neglect death rates did not increase over the period; in fact, they were relatively stable for ages 0 through 17 and showed a modest decline for 0 through 4. Ninety percent of fatal CAN occurs among children younger than 5 years old, and 41% occurs among infants. About 85% of CAN deaths are recorded as due to other causes.(ABSTRACT TRUNCATED AT 250 WORDS)

Abstracting and Indexing↗
PubMedDate not supplied

The Columbia Registry of Information and Utilization Management Trials.

OBJECTIVE: T systematically locate, register, and abstract information used in comparing effects of various information services (computerized and noncomputerized) and utilization management interventions on the process and outcome of patient care. DESIGN: Manual and electronic database searches located reports that met three main criteria: 1) randomized controlled trial; 2) information or utilization management intervention in the study group with no similar intervention in the control group; and 3) effect of the intervention on the process and/or outcome of patient care had been measured. Published reports were registered in the Columbia Registry. RESULTS: Nearly 600 reports were collected from 24 countries and 189 different publications. Frequently tested interventions included patients or physician education, telephone follow-up, patient or physician reminders, and home care services. Frequently reported effect variables included hospitalization rate, length of stay, immunization rate, and mortality rate. Standardized formal tools were developed for the separation and abstraction of practical information and methodologic details from the collected trial reports. CONCLUSIONS: The registry provides a new source of information for meta-analyses, traditional reviews, and executive summaries of quality improvement of health services. The streamlined knowledge engineering process of quality evaluation and abstraction of critical information can generate helpful information for practitioners and researchers simultaneously.

Cost-Benefit Analysis↗
PubMedDate not supplied

Efficacy of an intervention to promote use of hearing protection devices by firefighters.

Numerous cases of hearing loss consistent with noise-induced damage were noted among firefighters in the city of Columbia, MO. A survey of firefighting vehicles in operation showed that the firefighters were exposed to excessive noise levels and put at risk for noise-induced hearing loss (NIHL). Audiologic evaluation showed that 36 percent of the firefighters had moderate or severe hearing loss (a threshold of 40 decibels (dB) or more at 3,000, 4,000, or 6,000 hertz (Hz) in either ear). An educational program on NIHL was then carried out to increase the use of hearing protection devices (HPDs) by firefighters, followed by an evaluation of the intervention. The educational intervention successfully increased knowledge of NIHL, positive attitudes toward HPDs, and resulted in more frequent use of HPDs. After the intervention, 85 percent of firefighters regularly used HPDs compared with 20 percent before the intervention. Recommendations are made for fire departments to reduce the risk of NIHL.

Audiometry↗