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Biomedical subjects

D Blumenthal

Publications and source records attributed to D Blumenthal.

At least 37 records · Page 2Linked to original sources
PubMed2000

Improving preventive care by prompting physicians.

OBJECTIVES: To assess the impact of prompting physicians on health maintenance, answer questions regarding the mode of delivery, and identify opportunities and limitations of this information intervention. METHODS: Systematic electronic and manual searches (January 1, 1966, to December 31, 1996) were conducted to identify clinical trial reports on prompting clinicians. Three eligibility criteria were applied: (1) randomized controlled clinical trial, (2) clinician prompt, alert, or reminder in the study group and no similar intervention in the control group, and (3) measurement of the intervention effect on the frequency of preventive care procedures. Data were abstracted by independent reviewers using a standardized abstraction form, and quality of methodology was scored. A series of meta-analyses on triggering clinical actions was performed using the random-effects method. The statistical analyses included 33 eligible studies, which involved 1547 clinicians and 54 693 patients. RESULTS: Overall, prompting can significantly increase preventive care performance by 13.1% (95% confidence interval [CI], 10.5%-15.6%). However, the effect ranges from 5.8% (95% CI, 1.5%-10.1%) for Papanicolaou smear to 18.3% (95% CI, 11.6%-25.1%) for influenza vaccination. The effect is not cumulative, and the length of intervention period did not show correlation with effect size (R = -0.015, P = .47). Academic affiliation, ratio of residents, and technique of delivery did not have a significant impact on the clinical effect of prompting. CONCLUSIONS: Dependable performance improvement in preventive care can be accomplished through prompting physicians. Vigorous application of this simple and effective information intervention could save thousands of lives annually. Health care organizations could effectively use prompts, alerts, or reminders to provide information to clinicians when patient care decisions are made.

Humans↗
PubMed2000

Academic industry relationships in biotechnology: a primer on policy and practice.

Academic industry relationships (AIRs) in biotechnology are part of the modern life science economy. They cannot and should not be prevented. But their benefits should not be exaggerated, nor their risks minimized or ignored. It is essential that these relationships be understood, monitored, and managed in a manner that protects the investments and the integrity of involved individuals, institutions, and science in general. Failure to do so could result in loss of public confidence and support for research enterprise--a priceless resource whose integrity and independence are critical to the future of the scientific endeavor.

Animals↗
PubMed1999

Changes in the scope of care provided by primary care physicians.

BACKGROUND: Strategies to control medical costs and improve the quality of care often translate into decisions affecting the range of services primary care physicians provide to patients, which patients are referred for specialty care, and the points in disease processes at which referrals are made. This study focused on physicians' assessments of changes in the scope of care provided by primary care physicians and their assessments of the appropriateness of the scope of the care that primary care physicians are expected to provide. METHODS: We analyzed data from the 1996-1997 Community Tracking Study Physician Survey. Telephone interviews were conducted with 12,385 physicians (reflecting a response rate of 65 percent) who were drawn from a representative random sample of physicians providing direct patient care in the continental United States and not employed by the federal government. The analysis was based on responses from the 7015 primary care physicians and 5092 specialists who had been in practice for at least two years. RESULTS: Thirty percent of the primary care physicians and 50 percent of the specialists reported that the scope of care provided by primary care physicians had increased during the previous two years. Twenty-four percent of the primary care physicians and 38 percent of the specialists reported that the scope of care expected to be provided by primary care physicians was greater than it should be. According to multivariate analysis, primary care physicians other than general or family practitioners (i.e., pediatricians and general internists), those who were in one- or two-physician practices, those who received revenues from capitation, and those who served as gatekeepers for their patients' care were significantly more likely to report that the scope of care they were expected to provide was greater than it should be. CONCLUSIONS: The finding that nearly one in four primary care physicians reported that the scope of care they were expected to provide was greater than it should be arouses concern about the potential impact of changes in the delivery of health care. The associations we found between financial and administrative aspects of managed care and physicians' concern about the scope of care they provide to their patients deserve careful consideration.

Data Collection↗
PubMed1999

Mosaicism with a normal cell line and an unbalanced structural rearrangement.

Mosaicism with a normal cell line (N) and an unbalanced autosomal structural rearrangement (UASR) is rare. This report describes a case of a newborn female with a karyotype of 46,XX,der(4)t(4;15)(q35;q22)/46,XX. Molecular cytogenetic analysis confirmed the origin of the derivative chromosome 4. Here we discuss this case as well as other cases of mosaic karyotypes involving N/UASR.

Chromosome Aberrations↗
PubMed1999

A common breakpoint on 11q23 in carriers of the constitutional t(11;22) translocation.

Structural chromosomal rearrangements occur commonly in the general population. Individuals that carry a balanced translocation are at risk of having unbalanced offspring; therefore, the frequency of translocations in couples with recurrent spontaneous abortions is higher than that in the general population. The constitutional t(11;22) translocation is the most common recurrent non-Robertsonian translocation in humans and may serve as a model to determine the mechanism that causes recurrent meiotic translocations. We previously localized the t(11;22) translocation breakpoint to a region on 22q11 within a low-copy repeat, termed "LCR22." To define the breakpoint on 11q23 and to ascertain whether this region shares homology with LCR22 sequences, we performed haplotype analysis on patients with der(22) syndrome. We found that the breakpoint on 11q23 occurred between two genetic markers, D11S1340 and APOC3-tetra, both being present within a single bacterial-artificial-chromosome clone. To determine whether the breakpoint occurred within the same region among a larger set of carriers, we performed FISH mapping studies. The breakpoints were all within the same clone, suggesting that this region may harbor sequences that are prone to breakage. We narrowed the breakpoint interval, in both derivative chromosomes from two unrelated carriers, to a 190-bp, AT-rich repeat, which indicates that this repeat may mediate recombination events on chromosome 11. Interestingly, the LCR22s harbor AT-rich repeats, suggesting that this sequence motif may mediate recombination events in nonhomologous chromosomes during meiosis.

Animals↗
PubMed1999

Academic health centers on the front lines: survival strategies in highly competitive markets.

The authors describe approaches that five academic health centers (AHCs) have taken to reduce costs, enhance quality, or improve their market positions since the onset of price competition and managed care. The five AHCs, all on the West Coast, were selected for study because they (1) are located in markets that had been highly competitive for the longest time; (2) are committed to all the major missions of AHCs; and (3) own or substantially control their major clinical teaching facilities. The study findings reflect the status of the five AHCs during the fall of 1998. Although some findings may no longer be current (especially in light of ongoing implementation of the Balanced Budget Act of 1997), they still provide insights into the options and opportunities available to many AHCs in highly competitive markets. The authors report on the institutions' financial viability (positive), levels of government support (advantageous), and competition from other AHCs (modest). They outline the study AHCs' survival strategies in three broad areas: increasing revenues via exploiting market niches, reducing costs, and reorganizing to improve internal governance and decision making. They also report how marketplace competition and the strategies the AHCs used to confront it have affected the AHCs' missions. The authors summarize the outstanding lessons that all AHCs can learn from the experiences of the AHCs studied, although adding that AHCs in other parts of the country should use caution in looking to the West Coast AHCs for answers.

Academic Medical Centers↗
PubMed1999

The duration of ambulatory visits to physicians.

BACKGROUND: The objective of our study was to determine the typical length of ambulatory visits to a nationally representative sample of primary care physicians, and the patient, physician, practice, and visit characteristics affecting duration of visit. METHODS: We used an analysis of cross-sectional survey data to determine duration of visit and the characteristics associated with it. The data sources were a random sample of the 19,192 visits by adults to 686 primary care physicians contained in the 1991-1992 National Ambulatory Medical Care Survey, and the results of the Physician Induction Interview conducted by the National Center for Health Statistics. Duration of visit was defined as the total time spent in face-to-face contact with the physician. RESULTS: Mean duration of visit was 16.3 minutes (standard deviation = 9.7). Multivariate analysis allowed the calculation of the independent effect on visit length of a variety of characteristics of patients, physicians, organizational/practice setting, geographic location, and visit content. Certain patient characteristics (increasing age and the presence of psychosocial problems) were associated with increased duration of visit. Visit content was also associated with increased duration, including ordering or performing 4 or more diagnostic tests (71% increase), Papanicolaou smears (34%), ambulatory surgical procedures (34%), patient admission to the hospital (32%), and 3 preventive screening tests (25%). Reduced duration of visit was associated with availability of non-physician support personnel and health maintenance organization and Medicaid insurance. CONCLUSIONS: Multiple factors affect duration of visit. Clinicians, policymakers, and health system managers should take these considerations into account in managing physician resources during daily ambulatory practice.

Adult↗
PubMed1999

The scope of care expected of primary care physicians: is it greater than it should be?

The United States has long relied on specialist physicians more heavily than other countries, and some policy experts have repeatedly recommended that the share and role of primary care physicians (PCPs) be increased as a way of providing cost-effective care. The growth of managed care, changing practice arrangements and new medical technology are forces that may be increasing the role of PCPs. This Issue Brief reports findings published in the New England Journal of Medicine showing that many physicians believe the scope of care provided by PCPs without referral to specialists is increasing. Moreover, almost a quarter of PCPs report that the scope of care they are expected to provide is greater than it should be. The likelihood of PCPs' concern is related to specific managed care techniques, practice size and specialty, among other factors.

Forecasting↗
PubMed1998

Carve outs: definition, experience, and choice among candidate conditions.

Despite increasing discussion of carve outs as a device for controlling costs and improving quality of care, little systematic information exists on the effects of carve outs on cost, quality, and access to healthcare services. In the absence of such information, a conceptual framework is useful for deciding which conditions and populations may benefit from carve-out strategies, and how such arrangements should be designed. After carefully defining carve outs, and distinguishing them from other similar arrangements, this paper identifies five characteristics of a healthcare condition that increase the likelihood that a carve out's benefits will outweigh its drawbacks. The paper also examines the advantages and disadvantages of alternative approaches to structuring and administering carve-out arrangements, including how to pay for services, how to integrate them with mainstream care, provisions for consumer choice and provisions for carve-out accountability. The piece concludes that population carve outs, in which all the healthcare problems of a group of patients are managed by the carve-out organization, have inherent advantages, and identifies candidate conditions for population carve outs.

Chronic Disease↗
PubMed1998

Looking a gift horse in the mouth: corporate gifts supporting life sciences research.

CONTEXT: Throughout the last decade a number of studies have been conducted to examine academic-industry research relationships. However, to our knowledge, no studies to date have empirically examined academic scientists' experience with research-related gifts from companies. OBJECTIVE: To examine the frequency, importance, and potential implications of research-related gifts from companies to academic life scientists. DESIGN: A mailed survey conducted in 1994 and 1995 of 3394 faculty who conduct life science research at the 50 universities that received the most research funding from the National Institutes of Health in 1993. SETTING: Research-intensive universities. PARTICIPANTS: A total of 2167 of the 3394 faculty responded to the survey (response rate, 64%). MAIN OUTCOME MEASURES: The percentage of faculty who received a research-related gift from a company in the last 3 years, the perceived importance of gifts to respondents' research, and what, if anything, the recipient thought the donor(s) expected in return for the gift. RESULTS: Forty-three percent of respondents received a research-related gift in the last 3 years independent of a grant or contract. The most frequently received gifts were biomaterials (24%), discretionary funds (15%), research equipment and trips to meetings (11% each), support for students (9%), and other research-related gifts (3%). Of those who received a gift, 66% reported the gift was important to their research. More than half of the recipients reported that donors expected the following in return for the gift: acknowledgment in publications (63%), that the gift not be passed on to a third party (60%), and that the gift be used only for the agreed-on purposes (59%). A total of 32% of recipients reported that the donor wanted prepublication review of any articles or reports stemming from the use of the gift, 30% indicated the company expected testing of their products, and 19% indicated that a donor expected ownership of all patentable results from the research in which a gift was used. However, what recipients thought donors expected differed by the type of gift received. CONCLUSIONS: Research-related gifts are a common and important form of research support for academic life scientists. However, recipients frequently think that donors place restrictions and expect returns that may be problematic for recipients as well as institutions.

Academic Medical Centers↗
PubMed1998

Changes in the daily practice of primary care for children.

BACKGROUND: The environment in which medicine is practiced has changed in the past 2 decades, but little information has been available on how the day-to-day practice of primary care for children has changed during this period. OBJECTIVE: To identify aspects of primary care practices for children that are undergoing substantial changes. DESIGN: Analysis of National Ambulatory Medical Care Surveys from 1979 to 1981, 1985, and 1989 to 1994. PARTICIPANTS: Primary care practitioners recorded data on 58,488 child visits. MAIN OUT COME MEASURES: Characteristics and insurance status of children, physician activities during visits, and disposition after visit. RESULTS: Child visits to primary care physicians increased by 22% between 1979 and 1994. The mean age of children visiting primary care physicians decreased from 6.7 years in 1979 to 5.7 years in 1994 (P for trend, < .001). The ethnic diversity of child visits increased primarily as a result of an increasing proportion of visits by Hispanic (6.0% in 1979 to 12.6% in 1994, P for trend, < .001) and Asian patients (1.6% in 1979 to 4.1% in 1994, P for trend, < .001). Medicaid and managed care increased dramatically as sources of payment. Changes in physician activities included an increase in some preventive services, changes in the most commonly encountered medications, and an increased mean duration of patient visits (11.8 minutes in 1979 to 14.2 minutes in 1994, P for trend, < .001). CONCLUSIONS: These data may assist in the development of educational and research initiatives for physicians caring for children. The declining proportion of adolescent visits may present physicians with challenges in the care of adolescents. Physician prescribing practices showed changes without evidence of a benefit to child health. The increased ethnic diversity and provision of preventive services were associated with an increased mean duration of primary care visits. The increased duration of child visits may conflict with the managed care emphasis on physician productivity.

Asian↗
PubMed1998

Specialty differences in cardiovascular disease prevention practices.

OBJECTIVES: The aim of this study was to examine physician specialty differences in cardiovascular disease prevention practices. BACKGROUND: Despite the importance of cardiovascular disease prevention, little is known about current national practices, particularly physician specialty differences. METHODS: Using a national survey of office visits, we evaluated differences in the propensity of physicians of different specialties to provide prevention services. We analyzed 30,929 adult visits to 1,521 physicians selected by stratified random sampling in the 1995 National Ambulatory Medical Care Survey. Standard and ordinal multiple logistic regression models were employed to estimate the independent effects of physician and patient characteristics. RESULTS: A variety of cardiovascular disease prevention services were provided during an estimated 547 million adult office visits to US physicians in 1995, including blood pressure measurement (50% of visits), cholesterol testing (5%) and counseling for exercise (12%), weight (6%), cholesterol (4%) and smoking (3%). In addition, medication management was reflected by the report of antihypertensives in 12% of visits and lipid-lowering medications in 2%. Across these eight services, propensity to provide services varied consistently with specialty. Controlling for patient and visit characteristics and compared to general internists, the likelihood of providing services was higher for cardiologists (adjusted odds ratio 1.65, 95% confidence interval 1.44 to 1.89) but lower for obstetrician/gynecologists (0.75, 0.68 to 0.82), family physicians (0.69, 0.64 to 0.74), general practitioners (0.58, 0.53 to 0.63), other medical specialists (0.65, 0.59 to 0.72) and surgeons (0.06, 0.05 to 0.06). CONCLUSIONS: Cardiologists have the greatest propensity to provide cardiovascular disease prevention services, while primary care physicians vary substantially in their practices. These findings suggest a need to address variations in cardiovascular disease prevention.

Adult↗
PubMed1998

New bottles for vintage wines: the changing management of the medical school faculty.

Medical schools are being challenged to develop innovative mechanisms of faculty governance and management that enlist faculty in meeting the demands of a competitive marketplace. The authors describe some of these mechanisms in this article, which is the result of case studies made in 1997 of ten schools. Measures to increase the accountability of faculty to the strategic directions of the school include having appointment letters that specify explicitly the roles and responsibilities of the faculty member, conducting annual performance reviews based upon more objective criteria, tying salary to performance, lengthening the pre-tenure probation period, instituting post-tenure review, and redefining the salary guarantees of tenured faculty. Equally important is balancing these policies with initiatives to strengthen the accountability of schools to their faculty. Improved methods of communication between administrators and faculty and more efficient processes to enable faculty to participate in decision making are appearing. Formal approaches to mentoring and faculty development are being implemented. Recognition and reward programs are being strengthened. Alternatives to tenure are being developed in recognition of the need for increasingly diverse roles of faculty and to ensure job security. The reengineering of the processes that will lead to shared vision and accountability will require massive cultural change. The realization of these goals is likely to depend on the skill of medical school managers and the ability and willingness of faculty members to work collaboratively and creatively in designing new methods to accomplish old missions. Next month's AAMC Paper will explore changes in the structure and management of medical schools and their owned or closely affiliated facilities to improve the efficiency of achieving their core missions.

Faculty, Medical↗
PubMed1998

Reforming the structure and management of academic medical centers: case studies of ten institutions.

The authors describe a variety of strategies that academic medical centers (AMCs) are using to preserve their missions in the face of changing demands and declining resources. The report is based on comparative studies of ten centers conducted by the authors in 1997 and 1998. (AMCs are defined as medical schools and their owned or closely affiliated clinical facilities.) The studies show that the kinds of reforms that AMCs are making in the conduct of their missions and the results they are aiming for are often characteristic of successful organizations described by experts in organizational change and management. The major reforms found included balancing planning and opportunism; developing new approaches for faculty participation in governance; experimenting with the organization of core functions; listening to the customer; aligning incentives; creating a sense of urgency for change; and reducing the emphasis on paper credentials when recruiting for management positions. While these findings are encouraging, it seems clear that AMCs will need to change and adapt at an ever-increasing rate. Competitive pressures will require them to continuously improve the ways they achieve all their missions. New technologies such as informatics will threaten AMCs' near-monopoly in teaching and research. The new environment will require rapid decision making, the setting aside of traditional professional or departmental structures when they inhibit efficiency or quality, and more effective communication with external publics. How well AMCs can maintain their commitment to core values while adopting new methods in pursuit of those values will determine their futures.

Academic Medical Centers↗
PubMed1998

A report card on continuous quality improvement.

Efforts to incorporate the principles of continuous quality improvement (CQI) into health care have been underway for about ten years. In order to understand the lessons of this decade of experience, senior organizational leaders and experts in the field of health care were interviewed. This select group agreed that there have been concrete accomplishments: the tactic of assigning blame for mistakes to individuals is gradually giving way to an emphasis on detecting problems with process; there is a new focus on the health care customer; and many valuable projects have been inaugurated. Nevertheless, the interviews underlined the reality that the movement has not yet made a sizable impact on the U.S. health care system. Until there is a profound, organization-wide recognition of the need for change, universal commitment to CQI principles will not be achieved.

Attitude of Health Personnel↗