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Biomedical subjects

C P Gross

Publications and source records attributed to C P Gross.

11 recordsLinked to original sources
PubMed2001

The impact of practice guidelines in the management of Barrett esophagus: a national prospective cohort study of physicians.

BACKGROUND: Surveillance of patients with Barrett esophagus (BE) is recommended to detect dysplasia and early cancer. In 1998, practice guidelines for the surveillance of patients with BE were developed under the auspices of the American College of Gastroenterology (ACG). Our objective is to assess physicians' awareness of agreement with and adherence to these guidelines. METHODS: A national prospective cohort study of practicing gastroenterologists who completed a self-administered questionnaire containing case studies prior to the release of the guidelines and another survey 18 months later. Analysis of adherence to the guidelines was done using the McNemar chi(2) test. RESULTS: Of the 154 gastroenterologists (66%) who responded to the follow-up survey, more than half (55%) were aware of the guidelines, and members of the ACG were more likely to know of their existence than nonmembers (61% vs 38%; P =.01). Overall, about 27% of physicians reported practicing in accordance with the guidelines at baseline; adherence increased modestly to 38% in the 18-month follow-up (P =.04) and was inversely related to fee-for-service reimbursement. Awareness was not associated with an increased likelihood of adherence, but agreement with the guidelines was strongly correlated with adherence (P<.001). The most frequent reasons for disagreement were concerns about liability, cancer risk, and inadequate evidence. CONCLUSIONS: Awareness of the guidelines published by the ACG was low. Guideline awareness did not predict adherence. Improvement in guideline adherence will require steps beyond mere dissemination and promotion. Addressing disagreements about liability, disease risk, and scientific evidence as well as restructuring payment incentives may help achieve optimal practice.

Adult↗
PubMed2000

Relation between prepublication release of clinical trial results and the practice of carotid endarterectomy.

CONTEXT: Little is known about how clinical practice is affected by disseminating results of clinical trials prior to publication in peer-reviewed journals. OBJECTIVE: To determine whether prepublication release of carotid endarterectomy (CEA) trial results via National Institutes of Health Clinical Alerts was associated with prompt changes in patient care that were consistent with the new medical evidence. DESIGN, SETTING, AND PATIENTS: Longitudinal data series analysis using acute care hospital discharge data from the Healthcare Cost and Utilization Project for patients who had CEA performed in acute care hospitals in 7 states (New York, California, Pennsylvania, Florida, Colorado, Illinois, and Wisconsin). The trials were the North American Symptomatic Carotid Endarterectomy Trial (NASCET clinical alert released February 1991) and the Asymptomatic Carotid Atherosclerosis Study (ACAS clinical alert released September 1994). MAIN OUTCOME MEASURE: Carotid endarterectomy rate during each month from 1989 (2 years before the NASCET clinical alert) to 1996 (2 years after the ACAS clinical alert), adjusted for age and sex. Because both trials were limited to patients 80 years or younger in hospitals with low mortality, we also stratified CEA rates by patient age and hospital mortality rate. RESULTS: From 1989 through 1996, 272849 CEAs were performed in the acute care hospitals in these 7 states, with the annual number increasing from 22300 to 51 495. Afterthe NASCET clinical alert, the adjusted CEA rate increased 3.4% per month (95% confidence interval [CI], 1.6%-5.3%) during the following 6 months and then increased 0.5% per month (95% CI, 0.2%-0.8%; P<.04) after journal publication of the NASCET study. After the ACAS clinical alert, the CEA rate increased 7.3 % per month (95% CI, 6.0%-8.5%) during the following 7 months and then decreased by 0.44% per month (95% CI, -0.86% to -0.0002%; P<.04) after journal publication of the ACAS study. After the ACAS clinical alert, the CEA rate increased more in patients aged 80 years or older than in younger patients; whereas, after journal publication of ACAS, the CEA rate decreased more rapidly in the older population. The overall proportion of CEAs performed in low-mortality hospitals did not change substantially after release of the clinical alerts or after journal publication. CONCLUSION: In this study, prepublication dissemination of CEA trial results with clinical alerts was associated with prompt and substantial changes in medical practice, but the observed changes suggest that the results were extrapolated to patients and settings not directly supported by the trials.

Aged↗
PubMed2000

Physician, heal Thyself? Regular source of care and use of preventive health services among physicians.

BACKGROUND: Little is known about the regular source of care (RSOC) among physicians, a group whose self-care may reflect the attitudes and recommendations they convey to their patients. METHODS: We performed a cohort study of physicians who graduated from the Johns Hopkins School of Medicine from 1948 through 1964 to identify predictors of not having an RSOC, and to determine whether not having an RSOC was associated with subsequent receipt of preventive services. The RSOC was assessed in a 1991 survey; use of cancer screening tests and the influenza vaccine was assessed in 1997. RESULTS: The response rate in 1991 was 77% (915 respondents); 35% (312) had no RSOC. Internists (odds ratio [OR], 3.26; 95% confidence interval [CI], 1.58-6.74), surgeons (OR, 2.42; 95% CI, 1.17-5.02), and pathologists (OR, 5.46; 95% CI, 2.09-14.29) were significantly more likely to not have an RSOC than pediatricians. Not having an RSOC was inversely related to the belief that health is determined by health professionals (OR, 0.45; 95% CI, 0.29-0.68) and directly related to the belief that chance (OR, 1.90; 95% CI, 1.28-2.82) determines health. Not having an RSOC in 1991 predicted not being screened for breast, colon, and prostate cancer, as well as not receiving an influenza vaccine at 6 years of follow-up. CONCLUSIONS: A large percentage of physicians in our sample had no RSOC, and this was associated with both medical specialty and beliefs about control of health outcomes. Not having an RSOC was significantly associated with failure to use preventive services several years later. Arch Intern Med. 2000;160:3209-3214.

Aged↗
PubMed1999

Resident expectations of morning report: a multi-institutional study.

BACKGROUND: Morning report, a cornerstone of inter nal medicine residency programs for many years, involves a diverse group of teachers and learners with heterogeneous learning goals. METHODS: We distributed a self-administered, cross sectional survey to internal medicine residents to clarify the objectives of the learners at morning report. We selected a convenience sample of internal medicine residents at community- and university-based programs Questions were answered in a Likert scale or multiple-choice format. RESULTS: Residents from 13 residency programs in 7 states participated. We received 356 completed surveys, which represented a 63% response rate. The house staff in our sample preferred that half of the guest attending physicians be generalists. They indicated that the primary function of morning report should be educational, and preferred to discuss the management of a few interesting cases rather than review all patients admitted the previous day. The majority of respondents (60.8%) favored a stepwise presentation of cases to simulate the chronology of receiving information. Disease process, diagnostic workup, and evaluation of tests and procedures were all considered important topics for discussion, while medical ethics and research methods were viewed as less important. Responses varied little when stratified by sex, postgraduate year, type of residency program, subspecialty fellowship plans, or location of medical school. CONCLUSIONS: Residents from a diverse group of programs expressed remarkably similar opinions about morning report. Consistent with the recently increased emphasis on ambulatory care and general internal medicine in residency training, they expressed a desire for about 50% of the guest attending physicians to be generalists. In addition, they preferred a style in which challenging cases were presented in a stepwise manner.

Adult↗
PubMed1999

The relation between funding by the National Institutes of Health and the burden of disease.

BACKGROUND: The Institute of Medicine has proposed that the amount of disease-specific research funding provided by the National Institutes of Health (NIH) be systematically and consistently compared with the burden of disease for society. METHODS: We performed a cross-sectional study comparing estimates of disease-specific funding in 1996 with data on six measures of the burden of disease. The measures were total mortality, years of life lost, and number of hospital days in 1994 and incidence, prevalence, and disability-adjusted life-years (one disability-adjusted life-year is defined as the loss of one year of healthy life to disease) in 1990. With the use of these measures as explanatory variables in a regression analysis, predicted funding was calculated and compared with actual funding. RESULTS: There was no relation between the amount of NIH funding and the incidence, prevalence, or number of hospital days attributed to each condition or disease (P=0.82, P=0.23, and P=0.21, respectively). The numbers of deaths (r=0.40, P=0.03) and years of life lost (r=0.42, P=0.02) were weakly associated with funding, whereas the number of disability-adjusted life-years was strongly predictive of funding (r=0.62, P<0.001). When the latter three measures were used to predict expected funding, the conclusions about the appropriateness of funding for some diseases varied according to the measure used. However, the acquired immunodeficiency syndrome, breast cancer, diabetes mellitus, and dementia all received relatively generous funding, regardless of which measure was used as the basis for calculating support. Research on chronic obstructive pulmonary disease, perinatal conditions, and peptic ulcer was relatively underfunded. CONCLUSIONS: The amount of NIH funding for research on a disease is associated with the burden of the disease; however, different measures of the burden of disease may yield different conclusions about the appropriateness of disease-specific funding levels.

Biomedical Research↗
PubMed1999

Factors affecting prophylactic oophorectomy in postmenopausal women.

OBJECTIVE: Prophylactic oophorectomy performed concomitantly with hysterectomy may prevent ovarian cancer. Our goal was to better understand the basis for performing concomitant oophorectomy and to determine whether this procedure is associated with increased morbidity. METHODS: Our cross-sectional study used a hospital discharge database to identify women 50 years and older who, between 1994-1996, had hysterectomies in Maryland for a benign condition. We used multiple logistic regression to examine the independent effect of physician and patient factors on the likelihood of receiving a concomitant oophorectomy. RESULTS: Concomitant oophorectomy was performed in 61% of the 6227 women in our sample. Patients undergoing total abdominal hysterectomy (odds ratio [OR] 11.42; 95% confidence interval [CI] 9.65, 13.51) and laparoscopically assisted vaginal hysterectomy (OR 11.34; 95% CI 8.13, 15.81) were substantially more likely to have an oophorectomy than patients treated with vaginal hysterectomy, after adjusting for diagnosis and other covariates. We also found significant variation in the likelihood of receiving oophorectomy for women undergoing vaginal hysterectomy in different geographic regions. Additionally, physicians who performed many vaginal hysterectomies were significantly more likely to perform a concomitant oophorectomy. After adjusting for type of procedure, diagnosis, comorbidities, and age, oophorectomy was not associated with increased surgical morbidity. CONCLUSION: These results suggest that there are marked variations in physician practice style for concomitant oophorectomy. The variation across geographic regions and with case volume suggests the influence of nonclinical factors on oophorectomy rates.

Aged↗
PubMed1999

Management of Barrett's esophagus: a national study of practice patterns and their cost implications.

OBJECTIVE: The optimal management of Barrett's esophagus (BE) is controversial. Little is known about current practice patterns or associated direct medical costs. METHODS: In a national cross-sectional survey, we asked a random sample of gastroenterologists how they would manage patients with BE and various degrees of dysplasia. We used logistic regression to identify factors associated with so-called "frequent" (at least every 12 months) surveillance. We calculated direct medical costs using Medicare payments and population-based estimates of the number of BE patients under surveillance. RESULTS: Approximately 50% of 555 gastroenterologists responded. More than 96% of respondents recommended endoscopic surveillance for BE. For BE without dysplasia, 30% would perform frequent surveillance; this was the case particularly gastroenterologists older than age 45 yr (odds ratio = 1.91, p = 0.038) or those receiving primarily fee-for-service reimbursement (odds ratio = 2.57, p = 0.004). For BE with low-grade dysplasia, the frequency of endoscopy was highly variable (range, 1-24 months). For BE with high-grade dysplasia, 73% of gastroenterologists recommended esophagectomy and the remainder recommended endoscopic surveillance. Approximately 95% of the gastroenterologists who recommended surveillance for high-grade dysplasia, however, were not in agreement with recommended protocols. We estimated the national annual expenditure for surveillance endoscopy every 24 months for BE without dysplasia to be at least $22 million. Increase in surveillance intensity from low frequency (every 36 months) to high frequency (every 12 months) strategies would escalate costs by $29 million annually. CONCLUSIONS: Physician age and reimbursement influence BE surveillance practice, suggesting the influence of nonclinical factors on clinical decision making. The majority of clinicians who would recommend surveillance for high-grade dysplasia may not be using an appropriately aggressive strategy. Variations in surveillance strategies can have large cost implications.

Adenocarcinoma↗
PubMed1998

The physician as ambivalent Samaritan: will internists resuscitate victims of out-of-hospital emergencies?

To determine how internists would respond to out-of-hospital emergency medical situations, we surveyed internal medicine residents and attending physicians at urban academic medical centers regarding their willingness to help in five such scenarios. For those scenarios in which they were reluctant to help, they were asked why. Knowledge of Good Samaritan statutes was also assessed. Respondents were most likely to give aid, including mouth-to-mouth resuscitation if necessary, in scenarios involving a man complaining of chest pain in a restaurant (69%) and a call for help on an airplane (54%), and least likely to help a disheveled man lying on the sidewalk (2%). The most common reasons for not helping were a reluctance to perform mouth-to-mouth resuscitation, feeling that it was not one's responsibility to help, and concern about infectious disease. Knowledge of New York's Good Samaritan law was not associated with willingness to help.

Adult↗
PubMedDate not supplied

The myth of the medical breakthrough: smallpox, vaccination, and Jenner reconsidered.

A discussion of the particulars leading to the eradication of smallpox is pertinent to both investigators and the public as the clamor for more "breakthroughs" intensifies. The rational allocation of biomedical research funds is increasingly threatened by disease-advocacy groups and congressional earmarking. An overly simplistic view of how advances truly occur promises only to stunt the growth of researchers and research areas not capable of immediate great breakthroughs. The authors review the contributions of Jenner and his countless predecessors to give a more accurate account of how "overnight medical breakthroughs" truly occur-through years of work conducted by many people, often across several continents. In the public eye, few achievements are regarded with such excitement and awe as the medical breakthrough. Developments such as the discovery of penicillin and the eradication of polio and smallpox have each become a great story built around a singular hero. Edward Jenner, for example, is credited with discovering a means of safely conferring immunity to smallpox. The success of vaccination and subsequent eradication of this disease elevated Jenner to a status in medical history that is rivaled by few. However, the story of the eradication of smallpox does not start or end with the work of Jenner. Men such as Benjamin Jesty and Reverend Cotton Mather as well as unnamed physicians from tenth century China to eighteenth century Turkey also made critical contributions to the crowning achievement. Inoculation to prevent smallpox was commonplace in Europe for generations prior to Jenner's work. Jenner himself was inoculated as a child. In fact, vaccination with cowpox matter was documented in England over 20 years prior to Jenner's work. The authors' review of primary and secondary sources indicates that although Jenner's contribution was significant, it was only one of many. It is extremely rare that a single individual or experiment generates a quantum leap in understanding; this "lone genius" paradigm is potentially injurious to the research process. Wildly unrealistic expectations can only yield unsuccessful scientific investigation, but small steps by investigators supported by an informed public can build toward a giant leap, as the story of smallpox eradication clearly demonstrates.

History, 16th Century↗