PubMed Health⌕ Search

Biomedical subjects

D A Revicki

Publications and source records attributed to D A Revicki.

At least 19 recordsLinked to original sources
PubMed1995

Evaluating the quality of life associated with rifabutin prophylaxis for Mycobacterium avium complex in persons with AIDS: combining Q-TWiST and multiattribute utility techniques.

Our objective was to evaluate the effect of rifabutin prophylaxis in patients with AIDS and CD4 counts of less than 200 per cubic millimetre using a combination of Q-TWiST (quality-adjusted time without symptoms and toxicity) and multiattribute health utility assessment. The design consisted of a secondary analysis of two previously reported multicentre, randomized, placebo-controlled clinical trials conducted in 78 academic, community and Department of Veterans Affairs HIV centres and private practices. 542 patients with AIDS and CD4 counts of less than 200 per cubic millimetre were assigned to rifabutin 300 mg/day and 562 were assigned to a placebo. A modified Q-TWiST approach was used for comparing treatments based on the occurrence and duration of time with and without severe symptoms and clinical endpoints. Health states were constructed to represent combinations of clinical events experienced by study patients. Five physicians assigned utilities for health states using a six-attribute health classification system. These utilities were used to adjust survival for QOL. The rifabutin and placebo groups were compared using estimated quality-of-life-adjusted days. The incidence of MAC was 9% for the rifabutin group and 18% for the placebo group (p < 0.001). Differences, although not statistically significant, were observed for rates of survival and hospitalization. The rifabutin group experienced less anaemia (p < 0.02), and fever and night sweats (p < 0.02) than the placebo group. Average Q-TWiST days were 325 for the rifabutin group and 309 for the placebo group (p < 0.05). Q-TWiST days were significantly lower for patients with MAC bacteraemia (p < 0.04) and hospitalizations (p < (0.003). Rifabutin prophylaxis resulted in fewer MAC infections and greater quality-of-life-adjusted days of survival compared to no rifabutin. Quality-of-life-adjusted survival, based on a combination of the Q-TWiST and multiattribute health utility index, is a feasible approach for evaluating the outcomes of medical treatment. Future studies should, however, use patient-assigned utility weights to compute Q-TWiST scores, since physician generated utilities may differ significantly from those of patients.

AIDS-Related Opportunistic Infections↗
PubMed1995

Health-related quality of life associated with recombinant human erythropoietin therapy for predialysis chronic renal disease patients.

The investigators evaluated the impact of recombinant human erythropoietin (r-HuEPO) therapy on health-related quality of life (HRQL) in predialysis chronic renal disease patients with anemia. Eighty-three patients were entered into a randomized, parallel-group, open-label clinical trial with follow-up evaluations over 48 weeks. Forty-three patients were assigned to r-HuEPO treatment, and 40 patients were assigned to an untreated control group. Hematocrit levels were measured at baseline and monthly. HRQL was assessed at baseline and at weeks 16, 32, and 48. The HRQL assessment included measures of physical function, energy, role function, health distress, cognitive function, social function, home management, sexual dysfunction, depression, and life satisfaction. Significant improvements in hematocrit levels were observed in the r-HuEPO-treated group (P < 0.0001), and no changes were seen in the untreated group. Correction of anemia (hematocrit > or = 36) occurred in 79% of r-HuEPO-treated patients and 0% of control patients. Significant improvements in assessments of energy (P < 0.05), physical function (P < 0.05), home management (P < 0.05), social activity (P < 0.05), and cognitive function (P < 0.05) were found for the r-HuEPO-treated group. No changes were observed in the control group, except for a decrease in physical function (P < 0.05). Between-group differences favoring the r-HuEPO-treated group were found for energy (P < 0.05) and physical functioning (P < 0.05). In patients receiving r-HuEPO, significant improvements were seen in hemotocrit levels, and these increases resulted in improvements in HRQL.

Adolescent↗
PubMed1995

The use of decision analysis in the pharmacoeconomic evaluation of an antidepressant: a cost-effectiveness study of nefazodone.

A decision model can be a useful tool for evaluating the cost-effectiveness of a drug during research and development, before the drug is marketed. Decision analysis provides a structured process for comparing the costs and consequences of a new drug with those of standard drug therapy. This article introduces the use of a decision model and discusses the advantages and disadvantages of such a model. A cost-utility study of nefazodone, a new antidepressant, illustrates the application and interpretation of decision models. Decision analyses using data from clinical trials are a great potential source of information on the economic impact of new drugs. However, the development and use of such models require tolerance of uncertainty, the ability to represent complex relationships accurately, awareness of all factors that might influence the results, and a willingness to validate the model to the extent that validation is possible. The disadvantage of clinical decision models is that the findings are only as reliable as the information on which the model is based. Nevertheless, sensitivity analyses can be used to vary any information in question and assess the impact of that variation on the findings of the analyses. The advantage of clinical decision models is that they encourage the consideration and explicit representation of all pertinent inputs and outcomes. They clearly differentiate knowledge supported by data from assumptions, and compel assessment of the effect of those assumptions on the findings. The cost-effectiveness of nefazodone relative to standard treatment for major depression was evaluated using a decision model that simulated the lifetime direct medical costs and health outcomes associated with nefazodone and two comparators, imipramine and fluoxetine. The model included the possible clinical management pathways and the use of medical resources in treating major depression from early adulthood until death. Sensitivity analyses were performed to determine the impact of variation in model parameters on the results of the model. Using the base case assumptions of the model, which included parity of pricing with fluoxetine, nefazodone was found to be a cost-effective treatment for major depression.

Antidepressive Agents↗
PubMed1995

Abdominal pain in an HMO.

BACKGROUND: Previous surveys have found that 14%-25% of the population report abdominal pain. Only one study examined the age-gender specific prevalence of abdominal pain in the population, and no study has examined the self-reported causes of abdominal pain. METHODS: To describe the epidemiology of abdominal pain in a large health maintenance organization population, 6,199 randomly selected members were contacted and interviewed by telephone about the occurrence of abdominal pain and related health care in the past year. RESULTS: Of those interviewed, 27% reported abdominal pain in the past year, while 38% of those individuals saw a physician for their pain. Women were more likely than men to have had pain and to have seen a physician for their pain. Fewer older individuals reported abdominal pain, but when pain occurred, they sought medical care more often than younger individuals. CONCLUSIONS: Women and younger individuals report abdominal pain more frequently. Women and older individuals are more likely to seek care for their pain.

Abdominal Pain↗
PubMed1995

Quality of care in cataract surgery cases experiencing post-operative complications with co-managed care.

BACKGROUND: The quality of co-managed services and the ability of community optometrists to diagnose complications following cataract surgery were investigated in a previous study of 2,458 cases. Questions were raised about the quality of co-managed care in 50 of the cases; this study evaluates the care received by these patients. METHODS: Medical records for 44 cases (6 cases could not located) were reviewed to determine whether community optometrists diagnosed post-surgical complications and whether cases were effectively managed. All reviews were performed by two optometrists and an ophthalmologist. Six cases were excluded because of no complication or attribution to underlying disease. RESULTS: In 34 of the 38 remaining cases (89.5%), co-management was successful in diagnosing complications and in managing the patient to maximize vision function. 99.8% (2,454 of 2,458) of co-managed cases contained evidence that the optometrists provided high quality post-operative care and were able to diagnose complications. Using physician evaluations as the standard, the sensitivity of detection of complications by optometrists was 95.9% and the specificity was 99.5%. CONCLUSIONS: Co-managing optometrists provide quality care and can diagnose post-operative complications.

Aged↗
PubMed1995

Methods of pharmacoeconomic evaluation of new medical treatments in psychiatry.

There is concern in developed countries about the increasing cost of health care. Developers of new psychopharmacologic agents are asked to demonstrate cost-effectiveness as well as safety and efficacy before widespread use is encouraged. Pharmacoeconomic studies are designed to evaluate the health outcomes and cost-effectiveness of new medical treatments relative to existing treatments. Retrospective and prospective research designs have been used in pharmacoeconomic studies. New approaches such as medical effectiveness studies and modeling studies based on clinical decision analysis are increasingly used to evaluate cost-effectiveness. This article introduces important concepts of pharmacoeconomic evaluation and discusses the methods and their strengths and weaknesses. Safety and efficacy studies and pharmacoeconomic studies provide useful and complementary evidence on how a new treatment affects clinical, health-related quality-of-life, and economic outcomes.

Drug Evaluation↗
PubMed1995

Change in clinical status, health status, and health utility outcomes in HIV-infected patients.

Psychometric health status scales and health utility scales were compared to measure the impact of changes in clinical status in patients infected with the human immunodeficiency virus (HIV). The data used included the first two waves of a longitudinal study of 160 HIV-infected patients, a population that was 34% women and 65% African American. The Medical Outcome Study-HIV Health Survey (MOS-HIV); sleep, cognitive function, and depression scales; the Sickness Impact Profile Home Management Scale; and questions on HIV-related clinical symptoms were administered. Standard gamble utilities and categorical rating scale preferences were assessed for current health state. The MOS-HIV scale scores of asymptomatic patients were significantly higher than those of symptomatic patients and patients with acquired immune deficiency syndrome. No differences were observed for utilities. Increases in clinical symptoms over 4 months were associated with changes in health perception, pain, physical role function, social function, mental health, depression, energy, cognitive function, and categorical rating scale preferences. The MOS-HIV and other health status measures discriminated between HIV disease stages and were associated with clinical status. Standard gamble utilities did not discriminate among the three groups and were not correlated with clinical status.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Responsiveness and calibration of the General Well-Being Adjustment Scale in patients with hypertension.

We examined the discriminant ability and responsiveness of the General Well-Being Adjustment Scale in patients enrolled in a randomized clinical trial of antihypertensive therapy. We also tried to translate the effects of physical symptoms on general well-being. This secondary analysis used demographic, clinical, physical symptom, and general well-being data for 545 white, male hypertensive patients. General well-being was measured by the General Well-Being Adjustment Scale (GWB) collected on 2 occasions over 8 weeks of treatment. Patients with any one of 14 physical symptoms or problems, compared to those without symptoms, had lower GWB scores (p < 0.003 to p < 0.0001). Decreases of 2.83-8.76 points in GWB scores were observed in patients developing physical symptoms over the 8 week study period (p < 0.05 to p < 0.0001). These effects were demonstrated in patients developing cold sensitivity, sexual problems, chest pain, shortness of breath, loss of taste, nausea, hot or cold spells, numbness and tingling, dry mouth, blurred vision, and dizziness. We conclude that the GWB is responsive to clinically meaningful changes in symptoms and may provide a more complete evaluation of the effects of medical treatment. The GWB is a valid and responsive measure of health status outcomes in the evaluation of antihypertensive treatment.

Adult↗
PubMed1992

Reliability and validity of a health-related quality of life battery for evaluating outpatient antidepressant treatment.

This study was designed to evaluate the reproducibility, validity and responsiveness of a health-related quality of life (HRQOL) battery that was assembled for the evaluation of antidepressant therapy. The Montgomery-Asberg Depression Rating Scale was used to measure severity of depression. The HRQOL battery contained measures of energy and fatigue, social behaviour, cognitive function, home and work role function, and general well-being (i.e., health perceptions, life satisfaction) selected from previously developed and validated instruments. The clinical investigators and research nurses reported on difficulty in using the HRQOL battery. Most patients were able to complete the questionnaire without problems within 10 min. Reproducibility was very good with intraclass correlation coefficients ranging from 0.74 to 0.97. The HRQOL scales showed evidence of good concurrent validity. The scales were moderately correlated with MADRS scores (r = 0.30-0.62). The magnitude of these correlations indicate that HRQOL scales are related to depression measures, but they are not alternative measures of depression. Changes in MADRS scores were associated with changes in all scales, except for work behaviour, indicating that improvements in depression ratings also resulted in improvements in health status and well-being. The HRQOL scales included in this study were found to be reliable, reproducible, and valid and no appreciable burden was placed on patients or investigators participating in the study. With the exception of the Work Behaviour scale, the HRQOL scales were very responsive to changes in depression severity. This brief HRQOL instrument can provide a comprehensive assessment of the outcomes of antidepressant treatment.

Adult↗
PubMed1992

A study of occupational stress and depression among emergency physicians.

OBJECTIVE: To determine the level of stress and depression among emergency physicians and whether these variables were related to the emergency physician's decision to leave the specialty. STUDY DESIGN AND TYPE OF PARTICIPANTS: The study involved a random sample of 1,350 emergency physicians who received a questionnaire containing scales on depression and occupational stress as well as questions about their future plans for remaining in the specialty. RESULTS: Seven hundred sixty-three usable surveys (56.5%) were returned. Mean scores for the locus of control, Work-Related Strain Inventory, and the Center for Epidemiologic Studies--Depression Scale (CES-D) were within normal ranges. However, a disproportionate number, ie, more than 2.5% of the sample, scored more than two standard deviations from the mean. With the exception of the work satisfaction scale, there were no significant differences between the scores of fellows and nonfellows on measures of locus of control, stress, or depression. Of the population, 12.4% indicated that they were somewhat likely to very likely to leave the clinical practice of emergency medicine within the next year; 26.7% planned on leaving in the next five years, and less than half (42.9%) planned on seeing patients ten years from now. Older men, women, and those with high levels of stress and low job satisfaction were more likely to leave the specialty over the next ten years. CONCLUSION: While the vast majority of emergency physicians reported normal levels of stress, a disproportionate number reported high levels of stress and depression and plan on leaving the specialty of emergency medicine. The number of individuals planning to leave appeared to be greater than the number that will be replaced through residency training.

Career Mobility↗
PubMed1992

Relationship between health utility and psychometric health status measures.

This study examined the relationship between health utility and psychometric health status measures. Utility scores derived by standard gamble and categorical rating methods were also compared to determine if they produce equivalent preference scales. Health status and utility was assessed in 73 chronic renal disease patients with anemia (hematocrit less than or equal to 30) participating in a 48-week clinical study. Patient preferences for current health and three hypothetical states were assessed using standard gamble and categorical rating procedures. Standard gamble utility was related to home management (P less than .05); categorical rating utility was related to home management (P less than .05), energy (P less than .05), alertness behavior (P less than .05), social interaction (P less than .05), and life satisfaction scale scores (P less than .05). Only 25-27% of the variance in utility scores was explained by the health status measures. Standard gamble utilities were consistently higher than categorical rating values for end-stage renal disease with hemodialysis (P less than .0001) and severe anemia requiring blood transfusions (P less than .0001). Patient preferences for current health may be influenced in part by their functional status and well-being, risk aversion or risk-taking attitudes, and the cognitive evaluation processes involved in making judgments necessary for the measurement task, as well as their actual preferences.

Choice Behavior↗
PubMed1992

Medical care and cost outcomes after pentoxifylline treatment for peripheral arterial disease.

We assessed the medical outcomes and costs associated with the pharmacologic treatment of patients with peripheral arterial disease (PAD) in a population-based historical cohort study of patients enrolled in a health maintenance organization. For up to 2 years, we compared 58 patients who used therapeutic amounts of pentoxifylline with a comparison group of 112 patients who received a minimal subefficacious trial of pentoxifylline. Medical records data were used to assess and control for the severity of PAD and other potentially confounding factors. Continuous use of a therapeutic amount of pentoxifylline during an initial 120-day period significantly reduced the incidence of PAD-related invasive therapeutic and diagnostic procedures in the first year of follow-up (adjusted relative risk, 0.35; 95% confidence interval, 0.12 to 0.99). However, there were no significant differences in the risk of a PAD-related hospitalization or cost of PAD-related care between continuous pentoxifylline users and the comparison group. Pentoxifylline therapy may reduce the risk of vascular surgery while not increasing the total cost of PAD care.

Aged↗
PubMed1991

Work-related stress and depression among physicians pursuing postgraduate training in emergency medicine: an international study.

STUDY OBJECTIVE: To compare the levels of work-related stress and depression reported by physicians-in-training in emergency medicine in three survey sites and to determine the effects of gender and marital status on stress and depression among these physicians. DESIGN: Cross-sectional mail surveys. SETTING AND TYPE OF PARTICIPANTS: Physicians-in-training in the United States, United Kingdom, and Australasia. INTERVENTION: Questionnaires requesting demographic information and including scales assessing work-related stress and depression were administered. MEASUREMENTS AND RESULTS: A 3 x 2 x 2 multivariate analysis of variance in which survey site, gender, and marital status were independent variables and stress and depression scale scores were dependent variables revealed significant differences when stress and depression were analyzed simultaneously. Univariate analyses of variance revealed significant differences in stress by survey site and gender and in depression for all three independent variables. Comparison of adjusted means revealed that respondents from the United Kingdom reported significantly higher levels of stress than did respondents from the United States and that women reported significantly higher levels than men. Respondents from the United States reported significantly higher levels of depression than did respondents from the other countries, women reported higher levels than men, and unmarried respondents reported higher levels than married respondents. CONCLUSION: Despite limitations resulting from self-report bias, cross-sectional survey methodology, sampling error, and differences in training among the three survey sites, the respondents experienced similar levels of stress and depression attributable to anticipated sources.

Australia↗
PubMed1991

Reliability and validity of the Work-Related Strain Inventory among health professionals.

This article provides evidence from five samples of different health professionals (family physicians, emergency medical technicians, hospital nurses, flight nurses, and emergency medicine residents) for the reliability and validity of the Work-Related Strain Inventory (WRSI). The inventory consists of 18 items and was designed to measure perceptions of strain in occupational settings. Internal consistency reliability ranged from .85 to .90 and, as predicted, was correlated with the Maslach Burnout Inventory and measures of depression, role ambiguity, job satisfaction, and work-group functioning. When compared with different measures of depression symptoms (eg, Zung Self-Rating of Depression Scale, Center for Epidemiologic Studies Depression Scale), the Work-Related Strain Inventory was found to measure a different and independent construct. This inventory, a short, easily administered measure with good reliability, may be useful for appraising levels of work-related strain in behavioral and organizational models of the consequences of stress in different work environments.

Adult↗
PubMed1990

Reliability of ratings of anesthesia's contribution to adverse surgical outcomes.

The interrater reliability of physician ratings of anesthesia contribution to adverse outcomes was evaluated. A physician panel reviewed hospital records, anesthesia records, standard data collection forms, and, when available, autopsy reports for 28 patients experiencing severe morbidity or death within 48 hours following anesthesia for surgery. Consensus among reviewers about the contribution of anesthesia to adverse outcomes ranged from 82.1% to 92.9%. Kappa coefficients indicated excellent interrater reliability for the Edwards Scale and rating scale, and good interrater reliability for the percent scale.

Anesthesia↗
PubMed1990

Strain, social support, and mental health in rural elderly individuals.

This study examined the relationships among social support, life strain, and mental health in a sample of 210 rural elderly individuals. Life strain was operationalized as economic deprivation, illness disability, and ADL impairment. Demographic characteristics had little effect on mental health. Physical health status was highly predictive of life satisfaction and psychological distress among rural elderly individuals. Disability associated with chronic illness and ADL impairment was related to increased reports of symptoms of emotional and psychosomatic distress. Measures of social contacts and instrumental support exerted small to moderate effects on life satisfaction, psychosomatic distress, and emotional distress. Affective support moderated the effects of health-related strain on mental health.

Activities of Daily Living↗
PubMed1990

Physician payment reform: anesthesiology as a case study.

We examined the effects of Resource-based Relative Value Scale (RBRVS)- and physician diagnosis-related groups (MDDRG)-based payment for anesthesiology services related to surgery by simulating these physician payment reform options. We merged Medicare Part A (hospital) and Part B (anesthesiology) payment data for 7,770 patients for the MDDRG analysis and examined 10,431 surgical procedures for the RBRVS analysis within 27 diagnosis-related groups (DRGs) during the second half of 1986 in 16 hospitals representing different geographic regions, bed size, and teaching status. Assuming budget neutrality (i.e., constant total expenditure for anesthesiology services) and using the proposed methodologies, we simulated RBRVS and MDDRG payments and compared them to current payments for anesthesiology services. Individual surgical procedures demonstrated a two- to more than four-fold variation in duration, accompanied by a similar variation in anesthesiology payments. Within DRGs, there was a three- to ten-fold variation in duration, and a two- to seven-fold variation in anesthesiology payments. Anesthesiology time was highly correlated with surgical time (r = 0.86-0.96). Compared to the current system, RBRVS and MDDRG systems were associated with systematic variations in payments, such that on average, on each case, anesthesiologists practicing in rural and nonteaching hospitals would gain, whereas those in urban or suburban and teaching facilities would lose. After adjusting for complexity of procedure, the distribution of payment gains and losses was a function of duration of surgery, which is not influenced by the anethesiologist. Longer cases of a given surgical procedure result in payment decreases. The results document the importance of retaining a time factor in the payment methodology for anesthesiology services to maintain equitable payment across practice settings--an objective of physician payment reform.

Anesthesia Department, Hospital↗