PubMed Health⌕ Search

Biomedical subjects

David Bruckman

Publications and source records attributed to David Bruckman.

13 recordsLinked to original sources
PubMed2003

Diagnostic value of single versus dual chamber electrograms recorded from an implantable defibrillator.

INTRODUCTION: The clinical utility of ventricular electrograms in comparison to atrial and ventricular electrograms in diagnosing the type of tachycardias recorded by an implantable defibrillator has not been addressed from the standpoint of a clinician's diagnostic accuracy and confidence in that diagnosis. METHODS: Fifty-two tachycardia episodes recorded from dual chamber defibrillators were divided into two tests. The initial test contained only information from the ventricular electrogram and the second test contained information from both the atrial and ventricular electrograms. For each test, the reviewers were asked to provide the specific diagnosis, the originating chamber of origin of the tachycardia, and the confidence of their responses for each question. McNemar's test for matched pairs was used to determine accuracy and an analysis of variance to determine reviewer confidence. RESULTS: The overall accuracy for both the specific diagnosis (61% vs. 79%; p < 0.001) and the chamber of origin (76% vs. 90%; p < 0.001) improved when both the atrial and ventricular electrograms were available for review. Reviewer confidence appeared to correlate with diagnostic accuracy. CONCLUSIONS: The data clearly show the favorable impact of dual chamber defibrillators on the diagnostic accuracy and confidence of clinicians faced with a clinical tachycardia recorded from an implantable defibrillator. Such improvements may translate into more focused and appropriate therapeutic interventions.

Aged↗
PubMed2003

Use patterns of low-molecular weight heparin and the impact on length of stay in patients hospitalized for atrial fibrillation.

BACKGROUND: Low-molecular weight heparin, although unproven as a protective anticoagulant in atrial fibrillation, is not uncommonly used in this clinical setting. This investigation sought to assess the prevalence of its use for atrial fibrillation and its impact on length of hospital stay. METHODS: A retrospective analysis of patients admitted to the cardiology service at a university hospital with the primary diagnosis of atrial fibrillation was conducted for a 6-month interval in 3 consecutive years. Baseline demographic and clinical information, anticoagulation status, and length of hospital stay were compared. RESULTS: A total of 213 patients were identified and divided into 2 groups (before and after low-molecular weight heparin availability). Low-molecular weight heparin use increased with time (0% in 1997, 16.9% in 1998, 24.1% in 1999) and was associated with a significant reduction in length of hospital stay, from 3.3 +/- 2.8 days to 2.4 +/- 2.1 days (P =.03), and a trend toward a decreased international normalized ratio. CONCLUSIONS: This investigation noted the increasing trend toward the use of low-molecular weight heparin as a protective anticoagulant for atrial fibrillation, despite the lack of controlled data about its efficacy. The observed reduction in length of hospital stay is implicated as a potential reason for the use of low-molecular weight heparin.

Aged↗
PubMed2003

Documentation of asthma severity in pediatric outpatient clinics.

National asthma guidelines recommend assessment and documentation of asthma severity at each clinic visit. A cross-sectional medical record review was conducted, which found that only 34% of records had any documentation of severity in the previous 2 years. However, severity documentation is associated with other indicators of quality care such as receipt of an action plan, spacer device, peak flow meter, asthma education, and influenza vaccination. These results suggest that use of a system for classifying asthma severity compels the physician to consider the long-term management of asthma, rather than just acute treatment of the disease. Interventions to improve physician practice should continue to emphasize severity assessment.

Age Factors↗
PubMed2002

Primary care referral of children with psychosocial problems.

OBJECTIVES: To examine primary care provider referral patterns for patients with psychosocial problems and to understand the factors that influence whether a mental health referral is made. DESIGN: Secondary analysis of the Child Behavior Study data collected during 1994-1997 from background survey of providers, visit survey of providers and parents, and follow-up survey of parents. SETTING: Two hundred six primary care offices in the United States, Canada, and Puerto Rico. PATIENTS: Four thousand twelve of 21 150 patients aged 4 to 15 years in the Child Behavior Study with a clinician-identified psychosocial problem. MAIN OUTCOME MEASURES: Referral for psychosocial problem at index visit and reported follow-up with mental health care provider within 6 months. RESULTS: Six hundred fifty (16%) of 4012 patients with psychosocial problems were referred at the initial visit. In multivariate analysis, significant factors associated with likelihood of referral included patient factors (severity, type of problem, academic difficulties, prior mental health service use) and family factors (mental health referral of parent); however, none of the provider factors were significant. Clinicians reported frequent barriers to referral and mental health services in the general background survey; however, these factors were rarely reported as influences on individual management decisions. Only 61% of referred families reported that their child saw a mental health care provider in the 6-month period after the initial primary care referral. CONCLUSIONS: Most psychosocial problems are initially managed in primary care without referral. However, referral is an important component of care for patients with severe problems, and many families are not effectively engaged in mental health services, even after a referral is made.

Adolescent↗
PubMed2002

Effects of end-of-month admission on length of stay and quality of care among inpatients with myocardial infarction.

PURPOSE: We studied whether transfer of care when house staff and faculty switch services affects length of stay or quality of care among hospitalized patients. SUBJECTS AND METHODS: We performed a retrospective analysis in 976 consecutive patients admitted with myocardial infarction from 1995 to 1998. Patients who were admitted within 3 days of change in staff were denoted end-of-month patients. RESULTS: Of 782 eligible patients, 690 (88%) were admitted midmonth and 92 (12%) at the end of the month. The median length of stay was 7 days for midmonth and 8 days for end-of-month patients (P = 0.06). End-of-month admission was an independent predictor of length of stay in multivariate models. In addition, a significant difference in length of stay was noted between patients admitted at the beginning and end of the academic year. There were no statistically significant differences in the use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, or lipid-lowering agents at discharge between midmonth and end-of-month patients. Mortality and in-hospital adverse events did not differ between the two groups, with the possible exception of a greater incidence of acute renal failure in the end-of-month patients. CONCLUSIONS: Although admission during the last 3 days of the month is an independent predictor of length of stay, it does not have a large effect on quality of care among patients with myocardial infarction.

Cardiology Service, Hospital↗
PubMed2002

Atrial fibrillation after coronary surgery: comparison between different health care systems.

AIMS: No studies have evaluated the influence of management strategies in different health insurance environments on atrial fibrillation (AF). This observational study compared the incidence of and treatment strategies for postoperative AF after primary coronary bypass surgery. METHODS AND RESULTS: One insurance and one public funded location was compared: University of Michigan Health Center (USA, n=272) and Tampere University Hospital (Finland, n=314). USA patients had more co-morbidities and were treated more aggressively after acute myocardial infarction. More Finns were on beta-blockers both preoperatively (93 vs. 68%, P<0.001) and postoperatively (97 vs. 66%, P<0.001). However, AF was more frequent among Finns (38 vs. 29%, P=0.037) and present on 4.6% of cases when transferred postoperatively. No USA patients had AF at time of discharge. Mean length of stay was 8.6 days at USA, and not affected by AF. The incidence of in-hospital death, strokes and multiorgan failures was similar. Multivariable analysis, adjusted for site and selection biases (propensity analysis) revealed increasing age [OR=1.063 (1.042, 1.084), P<0.0001] and use of radial arteries [OR=2.175 (1.071, 4.417), P=0.032) to be independent predictors to the incidence of postoperative AF. CONCLUSIONS: We found several major differences in patient selection and treatment strategies among primary coronary bypass patients managed in the two institutions. Despite the marked practice variation, the incidence of postoperative AF was rather similar. Despite routine use of beta-blockers, AF occurred in 29-38% of patients. However, the length of stay was not particularly affected by postoperative AF.

Adrenergic beta-Antagonists↗
PubMed2002

A prospective, randomized, controlled trial of an emergency department-based atrial fibrillation treatment strategy with low-molecular-weight heparin.

STUDY OBJECTIVE: We assess an alternative accelerated clinical pathway approach to the management of patients with newly diagnosed or new-onset atrial fibrillation (AF). METHODS: A prospective, randomized pilot study of 2 AF disease-management strategies was conducted at a single university hospital. A traditional approach of hospital admission versus an accelerated emergency department-based strategy with low-molecular-weight heparin and early cardioversion to sinus rhythm was assessed in a cohort of patients with uncomplicated AF. The primary end points were length of stay and total actual direct costs. RESULTS: Eighteen patients were randomized over a 15-month period. The accelerated treatment strategy in the ED resulted in a substantial decrease in length of stay (2.1+/-2.3 versus <1 day) and a favorable trend toward mean cost reduction ($1,706+/-$1,512 versus $879+/-$394; P =.15). The clinical outcomes (rate of sinus rhythm at discharge and follow-up and complications caused by AF) related to AF were similar in the 2 groups. CONCLUSION: A disease-management strategy for new, uncomplicated AF that uses an ED-outpatient treatment pathway results in a shorter length of stay at potentially lower cost. The results of this pilot study warrant further investigation.

Adolescent↗
PubMed2002

Acute myocardial infarction in the young--The University of Michigan experience.

BACKGROUND: The purpose of this study was to assess frequency, risk factors, treatment, and complications of very young patients with acute myocardial infarction (MI) at the University of Michigan Medical Center (UMMC). METHODS: From a database of 976 consecutive patients admitted to the UMMC with acute MI between 1995 and 1998, we compared care and outcomes of patients divided into 3 age categories: <46 years, 46-54 years, and >54 years. Risk factors, presenting symptoms, type of MI, management, complications, and hospital outcomes of the 3 groups were evaluated. RESULTS: Young patients represented >10% of all patients with acute MI, and >25% of these individuals were women, a number considerably higher than seen in previous studies. This group of young patients was more likely to have Q-wave MI and risk factors such as family history and tobacco use and less likely to have a history of angina. Although all 3 groups received similar inpatient treatment, there was more attention paid to risk factor modification such as smoking cessation and referral to cardiac rehabilitation in younger individuals. Young patients had fewer in-hospital complications and a lower mortality rate. CONCLUSIONS: At the University of Michigan, >1 in 10 with acute MI is <46 years old. Data suggest that current management and aggressive risk factor modification are quite good in this particular group, and overall the mortality rate is very low.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

Receipt of asthma subspecialty care by children in a managed care organization.

BACKGROUND: Although proper outpatient asthma management sometimes requires care from subspecialists, there is little information on factors affecting receipt of subspecialty care in a managed care setting. OBJECTIVE: To determine factors associated with receipt of subspecialty care for children with asthma in a managed care organization. METHODS: We conducted an analysis of the claims from 3163 children with asthma enrolled in a university-based managed care organization from January 1998 to October 2000. We used logistic regression analysis to determine factors associated with an outpatient asthma visit with an allergist or pulmonologist. RESULTS: Of the 3163 patients, 443 (14%) had at least 1 subspecialist visit for asthma; 354 (80%) were seen by an allergist, 63 (14%) were seen by a pulmonologist, and 26 (6%) were seen by both. In multivariate analysis, patients with more severe asthma (odds ratio [OR], 3.81; 95% confidence interval [CI], 2.99-4.86) and older patients (OR, 1.04; 95% CI, 1.02-1.07) were more likely to receive care from a subspecialist. Compared with Medicaid patients, both non-Medicaid patients with copayment (OR, 2.52; 95% CI, 1.85-4.43) and non-Medicaid patients without any copayment (OR, 3.40; 95% CI, 2.35-4.93) were more likely to receive care from an asthma subspecialist. CONCLUSIONS: Children insured by Medicaid are less likely to receive care from subspecialists for asthma. Reasons may be due to health care system-related factors, such as accessibility of subspecialists, to physician referral decisions, and/or to patient factors, such as adherence to recommendations to see a subspecialist. Our findings suggest a need to further investigate health care system barriers, physician referral, and patient acceptance and completion of subspecialty referral.

Adolescent↗
PubMedDate not supplied

Receipt of specialty eye care by children.

BACKGROUND: No nationally representative data are available regarding use of eye care services by children. OBJECTIVES: To determine the proportion of children who receive specialty eye care and to evaluate the association of such care with age and other factors associated with health care utilization. METHODS: We used the 2000 National Health Interview Survey to estimate the proportion of nonblind children who received eye care in the preceding 12 months. The association between eye care and the factors of interest among children aged 6-17 years was measured through adjusted bivariate comparisons and logistic regression modeling. RESULTS: Eye care was received in the preceding 12 months by an estimated 7.3% (95% confidence interval [CI] 6.0-8.6) of the 22.8 million children aged 0-5 years and 24.8% (95% CI 23.5-26.2) of the 48.5 million children aged 6-17 years. Among children aged 6-17 years, girls had 29% greater odds than boys to have received eye care (P=.001). Among children <200% of the federal poverty level, those with public health insurance had greater odds of receiving eye care than did uninsured children or those with private health insurance (P<.001). Among children >200% of the federal poverty level, uninsured children had lower odds than did children with public or private health insurance (P<.004) to receive eye care. Well-child care was associated with increased eye care utilization among children aged 12-14 years (P<.001). CONCLUSIONS: Receipt of specialty eye care is common and increases with age. However, there are marked variations among school-aged children. Future studies should address the causes and effects of these findings.

Adolescent↗