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Donald A Redelmeier

Publications and source records attributed to Donald A Redelmeier.

47 records · Page 3Linked to original sources
PubMed2003

Memories of colonoscopy: a randomized trial.

Patients' memories of the past may influence their decisions about the future, yet memories are imperfect and susceptible to bias. We tested whether a memory failure observed in psychology experiments could be applied in a clinical setting to lessen patients' memories of the pain of an unpleasant medical procedure. We studied consecutive outpatients undergoing colonoscopy who were medically stable, mentally competent, and able to speak English (n=682). By random assignment, half the patients had a short interval added to the end of their procedure during which the tip of the colonoscope remained in the rectum. Pain during the procedure was measured with a ten point intensity scale. Memory following the procedure was measured using both a rating scale and a ranking task. Randomization resulted in two similar groups. As theorized, patients who underwent the extended procedure experienced the final moments as less painful (1.7 vs. 2.5 on a ten point intensity scale, P<0.001), rated the entire experience as less unpleasant (4.4 vs. 4.9 on a 10 cm visual analogue scale, P=0.006), and ranked the procedure as less aversive compared to seven other unpleasant experiences (4.1 vs. 4.6 with eight as the worst, P=0.002). Rates of returning for a repeat colonoscopy (median duration of follow-up 5.3 years) averaged 50.4% and were slightly higher (odds ratio=1.41, P=0.038) for those who underwent the longer procedure controlling for prior colonoscopy, procedure indications, and abnormal findings. Memory failures observed in experimental conditions can be found in clinical settings involving awake patients and may offer opportunities for improving patients' willingness to undergo future unpleasant medical procedures.

Adult↗
PubMed2003

A comparison of risk perception and psychological morbidity in women with ductal carcinoma in situ and early invasive breast cancer.

PURPOSE: To assess how women with ductal carcinoma in situ (DCIS) perceive their risks of recurrence, dying from breast cancer, and psychological distress compared to women with early stage invasive breast cancer (EIBC). PATIENTS AND METHODS: Eligible patients included those with DCIS or EIBC (T1 or T2, N0) referred to one cancer center between November 1998 and June 1999. Participants completed a self-administered survey regarding their views of their risks of developing recurrent cancer, of dying of breast cancer and the presence of psychological symptoms of distress. Responses were scored and compared between the two groups. RESULTS: In total, 495 patients were screened, 240 found ineligible, 228 patients who agreed to participate. No significant difference between the two groups was observed in perceptions of risk related to the likelihood of developing local recurrence (DCIS: 53%, EIBC 45%, P = 0.14), distant recurrence (DCIS: 36%; EIBC: 39%, P = 0.35) or dying of breast cancer (DCIS: 27%, EIBC 27%, P = 0.5). Both groups expressed similar levels of psychological distress (anxiety, DCIS: 56%, EIBC 54%, P = 0.38; depression, DCIS: 41%, EIBC, 48%, P = 0.17). CONCLUSIONS: Despite the excellent prognosis, women with DCIS express serious concerns and report similar psychological morbidity as women with invasive cancer.

Adult↗
PubMed2003

The quality of life and cost utility of home nocturnal and conventional in-center hemodialysis.

BACKGROUND: Home nocturnal hemodialysis is an intensive form of hemodialysis, where patients perform their treatments at home for about 7 hours approximately 6 nights a week. Compared with in-center conventional hemodialysis, home nocturnal hemodialysis has been shown to improve physiologic parameters and reduce health care costs; however, the effects on quality of life and cost utility are less clear. We hypothesized that individuals performing home nocturnal hemodialysis would have a higher quality of life and superior cost utility than in-center hemodialysis patients. METHODS: Home nocturnal hemodialysis patients and a demographically similar group of in-center hemodialysis patients from a hospital without a home hemodialysis program underwent computer-assisted interviews to assess their utility score for current health by the standard gamble method. RESULTS: Nineteen in-center hemodialysis and 24 home nocturnal hemodialysis patients were interviewed. Mean annual costs for home nocturnal hemodialysis were about 10,000 dollars lower for home nocturnal hemodialysis (55,139 dollars +/- 7651 dollars for home nocturnal hemodialysis vs. 66,367 dollars +/- 17,502 dollars for in-center hemodialysis, P = 0.03). Home nocturnal hemodialysis was associated with a higher utility score than in-center hemodialysis (0.77 +/- 0.23 vs. 0.53 +/- 0.35, P = 0.03). The cost utility for home nocturnal hemodialysis was 71,443 dollars/quality-adjusted life-year (QALY), while for in-center hemodialysis it was 125,845 dollars/QALY. Home nocturnal hemodialysis was the dominant strategy, with an incremental cost-effectiveness ratio (ICER) of -45,932 dollars. The 95% CI for the ICER, and 2500 bootstrap iterations of the ICER all fell below the cost-effectiveness ceiling of 50,000 dollars. The net monetary benefit of home nocturnal hemodialysis ranged from 11,227 dollars to 35,669 dollars. CONCLUSION: Home nocturnal hemodialysis is associated with a higher quality of life and a superior cost utility when compared to in-center hemodialysis.

Adult↗
PubMed2003

Kidney transplantation in the elderly: a decision analysis.

Transplantation offers superior life expectancy and quality of life compared with dialysis in young patients with end-stage renal failure. However, the initial risks of mortality and morbidity are high. This study used a decision analysis model to evaluate the costs and benefits of kidney transplantation versus continued dialysis for older patients with renal failure. A decision analytic model comparing cadaveric renal transplantation to continued hemodialysis treatment was developed. The base case considered a theoretical cohort of patients aged 65 yr without known comorbidity or contraindications to transplantation who would have to wait 2 yr for a cadaveric transplant. Separate models were constructed for patients with diabetes or cardiovascular disease and for patients receiving an organ after a variety of wait-list times. Probability, utility, and survival data were obtained from published reports and renal registries. For 65-yr-old patients, quality-adjusted life expectancy increased by 1.1 quality-adjusted life years (QALY) at an incremental cost of $67,778 per QALY. Assuming a 2-yr wait-listed time, transplantation remained economically attractive for 70-yr-old patients (incremental cost effectiveness [ICE], $79,359 per QALY) but was less economically attractive for those over 75 yr of age (ICE, $99,553) or for 70-yr-olds with either cardiovascular disease or diabetes (ICE, $126,751 and $161,090 per QALY, respectively). The analytic results were sensitive only to the time spent waiting for the graft. The cost-effectiveness reduced such that the costs associated with one QALY were in excess of $100,000/yr when the probability of a complication was > or = 50% per 3-mo cycle and when the utility of transplantation fell below 0.62. If available within a timely period, transplantation may offer substantial clinical benefits to older patients at a reasonable financial cost. Prolonged waiting times dramatically decrease the clinical benefits and economic attractiveness of transplantation, suggesting that living donor transplantation may be of particular benefit in this population.

Aged↗
PubMed2003

Evaluating paramedic comfort with field pronouncement: development and validation of an outcome measure.

OBJECTIVES: Interventions designed to improve cardiac resuscitation and the quality of field pronouncement need to consider outcomes on paramedic providers. The authors developed and evaluated the reliability and validity of a survey instrument measuring paramedic comfort with field pronouncement. METHODS: A mail survey of 120 paramedics (EMT-Ps) was performed using the Modified Dillman survey methodology. Questions were sorted for analysis into subgroups assessing psychological comfort and technical skills. Sixty-five respondents were retested within two weeks. RESULTS: The overall response rate was 96% (115). Respondents had an average age of 36 years (SD +/- 5), with 5.2 years (SD +/- 3.8) of out-of-hospital experience as an EMT-P, and were involved in a median of ten field pronouncements annually (range = 2-60). The face and content validity of the survey instrument was consistent with a content matrix derived by a focus group. The Cronbach's alpha for the survey instrument was 0.91. The retest response rate was 76% (46). The test-retest reliability coefficient was 0.84. CONCLUSIONS: This survey is a valid and reliable instrument for measuring the paramedic psychological comfort with field pronouncement. The high response rate and intrareliability support its generalizability. This outcome measure may be helpful in evaluating the psychological impact of changes to emergency medical services (EMS) policy with respect to termination of resuscitation promoted by the National Association of EMS Physicians.

Adult↗
PubMed2003

Emergency department gridlock and out-of-hospital delays for cardiac patients.

OBJECTIVES: To determine the effect of simultaneous ambulance diversion at multiple emergency departments (EDs) (gridlock) on transport delays for patients with chest pain. METHODS: Retrospective data on consecutive ambulance patients with chest pain and the diversion status of EDs in Toronto were obtained from January 1998 to December 1999. Gridlock was calculated separately for the four city quadrants as the daily duration of episodes where all EDs in the quadrant were simultaneously diverting ambulances. The primary outcome was 90th percentile ambulance transport interval (scene departure to hospital arrival). RESULTS: Eleven thousand four hundred patients were included (mean age 67 years; female 51%; severity of illness: moderate to life-threatening 89%). Gridlock occurred an average of 1.1 hour/day, and 3,060 patients were transported on days when it occurred. Ninetieth percentile transport interval was 15.5 minutes (95% CI = 15.3 to 15.9) for patients not exposed to gridlock vs. 17.4 minutes (95% CI = 16.8 to 17.8) for patients who were exposed to gridlock. In multivariate analyses, gridlock was associated with both transport and total out-of-hospital interval delays (0.2 min/hour, 95% CI = 0.1 to 0.4 and 0.2 min/hour, 95% CI = 0.04 to 0.4, respectively). Delays were similar regardless of patient severity of illness (p = 0.5). Age (0.8 min/10 years, 95% CI = 0.5 to 1), female gender (1.9 min, 95% CI = 1.3 to 2.6), advanced care paramedics (5.3 min, 95% CI = 4.4 to 6.3), and snowfall (0.8 min/cm, 95% CI = 0.2 to 1.5) were also independently associated with delays. CONCLUSIONS: Ambulance diversion was associated with delays in out-of-hospital ambulance transport for chest pain patients, but only when it resulted in gridlock. The magnitude of the out-of-hospital delay was the same regardless of the patient's severity of illness.

Ambulances↗
PubMed2002

Problems for clinical judgement: 5. Principles of influence in medical practice.

The basic science of psychology has identified specific ingrained responses that are fundamental elements of human nature, underpin common influence strategies and may apply in medical settings. People feel a sense of obligation to repay a perceived debt. A request becomes more attractive when preceded by a marginally worse request. The drive to act consistently will persist even if demands escalate. Peer pressure is intense when people face uncertainty. The image of the requester influences the attractiveness of a request. Authorities have power beyond their expertise. Opportunities appear more valuable when they appear less available. These 7 responses were discovered decades ago in psychology research and seem intuitively understood in the business world, but they are rarely discussed in medical texts. An awareness of these principles can provide a framework for physicians to help patients change their behaviour and to understand how others in society sometime alter patients' choices.

Humans↗
PubMed2002

Cost savings of home nocturnal versus conventional in-center hemodialysis.

BACKGROUND: Home nocturnal hemodialysis (HNHD) can improve clinical and biochemical factors in people with renal failure, but its cost-effectiveness relative to conventional in-center hemodialysis (IHD) is uncertain. We hypothesized that HNHD would provide more dialysis treatments at a lower total cost than IHD. METHODS: A prospective one-year descriptive costing study was performed at two centers in Toronto, Canada, involving patients enrolled from a HNHD program (N = 33), and a matched cohort from an IHD program (N = 23). All costs are expressed as mean weekly amount in Canadian year 2000 dollars. A projected mean annual cost (PMA) was calculated also. RESULTS: The mean number of treatments per week was much higher with HNHD (5.7 vs. 3.0, P = 0.004). Cost categories found to be less expensive for HNHD were staffing (weekly $210 vs. $423, P < 0.001, PMA $10,932 vs. $22,056) and overhead and support (weekly $80 vs. $238, P < 0.001, PMA $4179 vs. $12,393). There was a trend toward lower costs for hospital admissions and procedures (weekly $23 vs. $134, P = 0.355, PMA $1173 vs. $6997) and for medications ($172 vs. $231, P = 0.082, PMA $8989 vs. $12,029). Costs found to be more expensive for HNHD were the cost of direct hemodialysis materials (weekly $318 vs. $126, P < 0.001, PMA $16,587 vs. $6575) and capital costs (weekly $118 vs. $17, P < 0.001, PMA $6139 vs. $871), with a trend toward higher cost for laboratory tests (weekly $33 vs. $26, P = 0.094, PMA $1744 vs. $1364). Physician costs were the same at $128 per week (PMA $6650). The weekly mean total cost for health care delivery was 20% less for HNHD ($1082 vs. $1322, P = 0.006), with projected mean annual costs more than $10,000 lower ($56,394 vs. $68,935). CONCLUSIONS: HNHD provides about three times as many treatment hours at nearly a one-fifth lower cost, with savings evident even when only program and funding-specific costs are considered.

Adult↗
PubMed2002

Diabetes care in the U.S. and Canada.

OBJECTIVE: To compare the glycemic control of patients with type 1 diabetes treated in the U.S. and Canada. RESEARCH DESIGN AND METHODS: A large multicenter randomized clinical trial conducted in the U.S. and Canada was analyzed. Patients with type 1 diabetes, screened from 1983 to 1989 for enrollment in the Diabetes Control and Complications Trial (DCCT), were categorized as treated in the U.S. (n = 2,604) or Canada (n = 245). HbA(1c) levels were compared between U.S. and Canadian patients, both before and after adjustment for predictors of HbA(1c). RESULTS: In general, volunteers screened for the DCCT were highly educated and following healthy lifestyles. Canadians were somewhat younger (25 vs. 27 years of age, P = 0.002), less likely to be college educated (62 vs. 71%, P = 0.002), more likely to receive care through a family doctor (41 vs. 28%, P = 0.001), and had a higher frequency of out-patient visits (4 vs. 3 per year, P = 0.004). Despite these differences in health care delivery, the mean HbA(1c) at baseline was identical in the two countries (8.9 vs. 9.0, P = 0.40). Adjustment for demographic, lifestyle, and clinical predictors of HbA(1c) yielded similar findings (9.0 vs. 9.2, P = 0.15). Equal percentages of American and Canadian patients who were screened ultimately entered the trial (21 vs. 19%, P = 0.20), and those randomized to conventional care achieved similar mean HbA(1c) levels (9.1 vs. 9.2, P = 0.50). CONCLUSIONS: Differences in care delivery patterns do not yield large differences in glycemic control for patients with type 1 diabetes who were recruited in the U.S. and Canada for a large randomized trial.

Adolescent↗
PubMed1996

Patients' memories of painful medical treatments: real-time and retrospective evaluations of two minimally invasive procedures.

Patients' memories of painful medical procedures may influence their decisions about future treatments, yet memories are imperfect and susceptible to bias. We recorded in real-time the intensity of pain experienced by patients undergoing colonoscopy (n = 154) and lithotripsy (n = 133). We subsequently examined patients' retrospective evaluations of the total pain of the procedure, and related these evaluations to the real-time recording obtained during the experience. We found that individuals varied substantially in the total amount of pain they remembered. Patients' judgments of total pain were strongly correlated with the peak intensity of pain (P < 0.005) and with the intensity of pain recorded during the last 3 min of the procedure (P < 0.005). Despite substantial variation in the duration of the experience, lengthy procedures were not remembered as particularly aversive. We suggest that patients' memories of painful medical procedures largely reflect the intensity of pain at the worst part and at the final part of the experience.

Adult↗