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Biomedical subjects

F J Fowler

Publications and source records attributed to F J Fowler.

At least 37 records · Page 2Linked to original sources
PubMed1997

Diagnosis and treatment of benign prostatic hyperplasia. Practice patterns of primary care physicians.

OBJECTIVE: To define primary care physicians' (PCPs) practices in managing patients with benign prostatic hyperplasia [BPH], and to compare these practices to portions of the Agency for Health Care Policy and Research BPH guideline and urologists' practices. DESIGN: Mail survey. PARTICIPANTS: Nationwide random sample of PCPs and urologists, selected from the American Medical Association Registry. METHODS: Initial mailing, postcard reminder, second mailing, telephone reminder, final mailing. MAIN RESULTS: Primary care physicians (n = 444, response = 51%) reported seeing a median of 35 patients with BPH over the preceding year, in contrast to 240 for urologists (n = 394, response = 68%). Regarding tests recommended by the guideline, two thirds of PCPs reported rarely or never using the American Urological Association (AUA) symptom index, nearly all reported routinely performing digital rectal examinations, and many (66%) reported routinely ordering tests to determine the serum creatinine level. Although considered "optional" by the guideline, more than 90% of PCPs reported routinely ordering a prostate-specific antigen test, while infrequently using other optional tests. Regarding "not recommended" studies, a substantial minority reported selectively or routinely ordering intravenous pyelography (34%) and renal ultrasound (33%), while two thirds reported rarely or never ordering these tests. Eighty-six percent of PCPs reported prescribing medications for BPH over the preceding year; alpha blockers to a median of 12 patients, and finasteride to a median of 2. Variation in urology referral thresholds was suggested in responses to two patient scenarios. CONCLUSIONS: Primary care physicians are actively managing patients with BPH. Some of their diagnostic evaluations vary from the recommendations of a national guideline and urologists' practices. Referral thresholds appear to vary considerably.

Adult↗
PubMed1997

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument.

OBJECTIVES: This study developed a new acquired immunodeficiency syndrome (AIDS) severity system by including diagnostic, physiological, functional, and sociodemographic factors predictive of survival. METHODS: Three-hundred five persons with AIDS in Boston were interviewed; their medical records were reviewed and vital status ascertained. RESULTS: Overall median (+/- SD) survival for the cohort from the first interview until death was 560 +/- 14.4 days. The best model for predicting survival, the Boston AIDS Survival Score, included the Justice score (stage 2 relative hazard [RH] = 1.25, 95% confidence interval [CI] = 0.80, 1.96; stage 3 RH = 1.76, 95% CI = 1.15, 2.70), a newly developed opportunistic disease score (Boston Opportunistic Disease Survival Score; stage 2 RH = 1.35, 95% CI = 0.90, 2.02; stage 3 RH = 2.10, 95% CI = 1.38, 3.18), and measures of activities of daily living (any intermediate limitations, RH = 1.84, 95% CI = 1.05, 3.21; any basic limitations, RH = 2.60, 95% CI = 1.44, 4.69). This model had substantially greater predictive power (R2 = .17, C statistic = .68) than the Justice score alone (R2 = .09, C statistic = .61). CONCLUSIONS: Incorporating data on clinically important events and functional status into a physiologically based system can improve the prediction of survival with AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1997

The natural history of patients with benign prostatic hyperplasia as diagnosed by North American urologists.

PURPOSE: We defined outcomes for men with a clinical diagnosis of benign prostatic hyperplasia. MATERIALS AND METHODS: We followed for 4 years 500 candidates for elective prostatectomy treated nonoperatively in 5 North American urology practices. RESULTS: There were 371 survivors with complete data at 4 years. Of 60 men with mild, 245 with moderate and 66 with severe baseline symptoms 10, 24 and 39%, respectively, had undergone surgery; 27, 31 and 27%, respectively, were on pharmacological therapy, and 63, 45 and 33%, respectively, were off active treatment at 4 years. Mild or moderate symptoms were noted at 4 years in 83, 59 and 23% of the patients, respectively, while 17, 41 and 77%, respectively, had severe symptoms or had undergone surgery. CONCLUSIONS: Outcomes for men with a clinical diagnosis of benign prostatic hyperplasia depend on initial symptom severity. However, the course of symptoms also varies among patients even with the same initial symptom severity.

Cohort Studies↗
PubMed1996

The importance of patient preference in the decision to screen for prostate cancer. Prostate Patient Outcomes Research Team.

OBJECTIVE: Routine screening for prostate cancer is controversial because of frequent false-positive results, the potential for slow, non-life-threatening growth of untreated cancer, the uncertainty regarding whether treatment can extend life, and the potential for treatment complications. This study examines how information about prostate-specific antigen (PSA) testing and the uncertain benefits of treating prostate cancer affects patients' desire for PSA testing. DESIGN: An educational videotape designed to inform men about the uncertainty surrounding PSA screening and the treatment of early-stage prostate cancer was presented to two groups of male patients 50 years of age or older. SETTING: Dartmouth-Hitchcock Medical Center. PATIENTS/PARTICIPANTS: For study 1, men seeking a free prostate cancer screening were preassigned to view the educational videotape (N = 184) or another videotape (N = 185). For study 2, men scheduled to visit a general internal medicine clinic viewed either the educational videotape (N = 103) or no videotape (N = 93). MEASUREMENTS AND MAIN RESULTS: The men's information and preferences about prostate cancer screening and treatment and actual choice of PSA test at the next test opportunity were measured. Men who viewed the educational videotape were: better informed about PSA tests, prostate cancer, and its treatment; preferred no active treatment if cancer were found; and preferred not to be screened (all significant at p < or = .002 in both studies). Men viewing the educational video were less likely to have a PSA test (p = .041, study 2). This tendency was not significant at the free-PSA clinic (p = .079). CONCLUSIONS: Preference regarding cancer screening and treatment is greatly affected by information about medical uncertainties. Because informed patient choices vary. PSA screening decisions should incorporate individual preferences.

Case-Control Studies↗
PubMed1996

Measurement of overall and disease-specific health status: does the order of questionnaires make a difference?

OBJECTIVES: This study was designed to detect any effect of order when modules on disease-specific and overall health status are combined in an outcomes research questionnaire. METHODS: Men with symptomatic benign prostatic hyperplasia (BPH) were prospectively enrolled in a clinical trial of an educational intervention in Group Health Cooperative of Puget Sound, a prepaid group practice. Within the trial, 392 consecutive men were randomized to one of two versions of a baseline questionnaire. One had a 38-item module on BPH-specific health status first, followed by a 30-item module on overall health status; the other had the modules in reverse order. Scores were compared for three BPH-specific scales and eight scales measuring overall health. Data were collected in the form of self-administered questionnaires. RESULTS: Comparing the groups assigned the two versions of the questionnaire, no significant differences in scores on any of the health status scales were found. CONCLUSIONS: In this dataset, we could find no evidence of an order effect when modules on BPH-specific and overall health status were combined in different sequences.

Group Practice, Prepaid↗
PubMed1996

Outcomes of external-beam radiation therapy for prostate cancer: a study of Medicare beneficiaries in three surveillance, epidemiology, and end results areas.

PURPOSE: This study was designed to obtain representative estimates of the quality of life and probabilities of possible adverse effects among Medicare-age patients treated with external-beam radiation therapy for prostate cancer. METHODS: Patients treated for local or regional prostate cancer with high-energy external-beam radiation between 1989 and 1991 were sampled from a claims data base of the Surveillance, Epidemiology, and End Results (SEER) program from three regions. Patients were surveyed primarily by mail, with telephone follow-up evaluation of non-respondents. There were 621 respondents (83% response rate). The results were compared with data from a previously published national survey of Medicare-age men who had undergone radical prostatectomy. RESULTS: Although they were older at the time of treatment, radiation patients were less likely than surgical patients to wear pads for wetness (7% v 32%) and had a lower rate of impotence (23% v 56% for men < 70 years), while they were more likely to report problems with bowel dysfunction (10% v 4%). Both groups reported generally positive feelings about their treatments. Radiation and surgical patients reported similar rates of additional subsequent treatment (24% v 26% at 3 years after primary treatment). However, radiation patients were less likely to say they were cancer-free, and they reported more worry about cancer than did surgical patients. CONCLUSION: The health-related quality of life of radiation and surgical patients, on average, is similar, but the pattern of experience with adverse consequences of treatment differs by treatment.

Aged↗
PubMed1995

The American Urological Association symptom index: does mode of administration affect its psychometric properties?

PURPOSE: We determine whether self-administration and interviewer administration of the American Urological Association (AUA) symptom index are equivalent. MATERIALS AND METHODS: The AUA symptom index was administered twice to 41 visually impaired or illiterate men. Men who were able were randomized to self-administration first and then interviewer administration (43) or the reverse (40). RESULTS: The scores in each group were reliable. However, because we could not reject a differential carryover effect, the nonsignificant test of mode effect in the crossover design may have been invalid. At time 1 there was no significant difference between group mean scores for randomized patients (p = 0.13). CONCLUSIONS: Although the AUA symptom index should be self-administered when possible, interviewer administration appears to be acceptable.

Aged↗
PubMed1995

Effect of radical prostatectomy for prostate cancer on patient quality of life: results from a Medicare survey.

OBJECTIVES: To assess patient responses to radical prostatectomy and its effects. METHODS: A national sample was taken of 1072 Medicare patients who underwent radical prostatectomy for prostate cancer (1988 through 1990) by mail, telephone, and personal interviews. The effects of the surgery and its complications on these patients' lives were studied through: (1) patient ratings of the extent to which sexual and urinary dysfunctions were "problems" in their lives; (2) two general measures of quality of life, the Mental Health Index and the General Health Index; (3) patient reports of how they felt about the results of treatment and whether they would choose surgery again. RESULTS: On average, dripping urine, particularly to the point where subjects were wearing pads, had a more significant effect on patients than loss of sexual function; incontinence had significant adverse effects on the measures of quality of life and self-reported results of surgery. Overall, postsurgical patients scored comparatively high on the quality of life measures (similar to a cohort of patients with benigh prostatic hyperplasia who had undergone transurethral resection of the prostate), reported feeling positive about the results (81%), and would choose surgical treatment again (89%). Nonetheless, there was variability in patient response to the effects of surgery. CONCLUSIONS: The results demonstrate the ability of many Medicare patients to adapt to adverse outcomes, such as loss of sexual function and incontinence. They also provide evidence of the variability of individual patients' responses to surgical results and reinforce the importance of individualized decision making for patients facing a decision about radical prostatectomy for prostate cancer.

Aged↗
PubMed1995

A brief male sexual function inventory for urology.

OBJECTIVES: To develop a brief questionnaire to measure male sexual function. METHODS: An initial set of questions was refined and reduced through cognitive testing and two serial validation studies. In each study, men were recruited from a sexual dysfunction clinic and a general medicine practice to complete the instrument. Test-retest reliabilities, internal consistencies, and construct validities were examined. RESULTS: The final instrument covers sexual drive (two items), erection (three items), ejaculation (two items), perceptions of problems in each area (three items), and overall satisfaction (one item). Psychometric performance was generally very satisfactory, although self-assessments of ejaculate volume are problematic. Translations have been developed and pilot tested in a number of languages. CONCLUSIONS: The Brief Sexual Function Inventory may be useful for measuring male sexual function in practice and research.

Coitus↗
PubMed1995

Patient reactions to a program designed to facilitate patient participation in treatment decisions for benign prostatic hyperplasia.

Patients often want considerable information about their conditions, and enhanced patient participation might reduce unwanted practice variation and improve medical decisions. The authors assessed how men with benign prostatic hyperplasia reacted to an education program designed to facilitate participation in decisionmaking, and how strongly ratings of their symptom state and the prospect of complications predicted their treatment choice. A prospective cohort study was conducted in three hospital-based urology practices: two in prepaid group practices, and one Veterans Administration clinic. Four hundred twenty-one men with symptomatic benign prostatic hyperplasia without prior prostatectomy or benign prostatic hyperplasia complications were enrolled, and 373 provided usable ratings. Subjects participated in an interactive videodisc-based shared decisionmaking program about benign prostatic hyperplasia and its treatment options, prostatectomy, and "watchful waiting." They rated the length, clarity, balance, and value of the program and were followed for 3 months to determine if they underwent surgery. Patients rated the program as generally clear, informative, and balanced. Across all three sites, 77% of patients were very positive and 16% were generally positive about the program's usefulness in making a treatment decision. Logistic models predicting choice of surgical treatment documented the independent importance of negative ratings of the current symptom state (odds ratio 7.0, 95% confidence interval 2.9-16.6), as well as the prospect of postoperative sexual dysfunction (odds ratio 0.20, 95% confidence interval 0.08-0.48) in decisionmaking. Patients rated the Shared Decisionmaking Program very positively and made decisions consistent with their assessed preferences. These results suggest that patients can be helped to participate in treatment decisions, and support a randomized trial of the Shared Decisionmaking Program.

Aged↗
PubMed1995

Measuring disease-specific health status in men with benign prostatic hyperplasia. Measurement Committee of The American Urological Association.

In preparation for an outcomes study of benign prostatic hyperplasia (BPH), two measures of disease-specific health status were developed to supplement a symptom score and overall health status measures. The symptom problem index (SPI) captures how troublesome patients find their urinary symptoms. The BPH impact index (BII) measures how much their urinary problems affect various domains of health. A prospective revalidation of the refined instruments (N = 108 BPH patients and 50 controls) documented that both indices had good internal consistency (Cronbach's alpha = 0.88 and 0.79, respectively) and test-retest (r = 0.88 for both) reliabilities, correlated strongly with symptom scores (r = 0.86 and 0.77), and discriminated between BPH and control subjects (receiver-operating characteristic areas = 0.87 and 0.85, respectively). These indices were nearly as responsive as symptom scores in 50 men actively treated for BPH, and much more responsive than a non-disease-specific General Health Index (GHI), a Mental Health Index (MHI), and an Activity Index (AI). Finally, these measures capture most of the health status significance of BPH symptoms. In linear regression models constructed to predict scores on the GHI, MHI, and AI, symptom scores added little explanatory power to the SPI and, particularly, to the BII. These measures help clarify how BPH affects overall health status and function. Such measures have an important role to play in studies of the outcomes of treatment for BPH, and probably for other conditions that interfere with health status and function.

Adult↗
PubMed1995

Comparing prospective and retrospective measures of treatment outcomes.

This study examines the correspondence between retrospective and prospective assessments of treatment outcomes among female patients treated for gynecologic symptoms (n = 800) and male patients having surgery for benign prostatic hyperplasia (n = 434). The overall health and symptom status of patients in both samples was assessed at enrollment and again 3 months after treatment; at the 3-month follow-up, patients also were asked to compare retrospectively their current health and how they were feeling with their condition before treatment. Findings indicate that prospective and retrospective measures of change do not yield the same results. Retrospective assessments consistently produce higher estimates of the benefits of treatment, although that pattern was clearer for overall health status than for measures of symptoms. Patients' posttreatment health and symptom status contributes as much to retrospective assessments of change as does prospectively measured change, although the retrospective assessments of female patients whose gynecologic symptoms were medically managed were more strongly related to prospective change than those of hysterectomy patients or prostate surgery patients. Overall, we conclude that these alternative measurement strategies yield divergent assessments of change, depending on the type of treatment a patient receives and, to some extent, what is being measured.

Aged↗
PubMed1995

Costs of medical care and out-of-pocket expenditures for persons with AIDS in the Boston Health Study.

We examined the cost of health care and out-of-pocket medical expenditures for 189 persons with AIDS at three sites in Massachusetts: an HMO; a public hospital immunodeficiency clinic; and a group practice at a major teaching hospital. The mean cost of care during a four-month reference period was $9,093 +/- $12,683 (mean +/- standard deviation) per patient. Thirty-six percent of the cost was due to hospital care and 40% was due to home health care. Mean out-of-pocket expenditures were $429 +/- $991 (mean +/- standard deviation). Studies that focus on the cost of hospital care may seriously underestimate the medical costs of AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Measuring public priorities for insurable health care.

The goal of this research was to develop and evaluate a way to measure the value people place on various medical services in their decisions about what health insurance should cover. A vignette approach to measuring consumer values was developed. People were asked to assign priority and desire to have insurance cover 64 different services. A national probability sample of 206 adults was interviewed by telephone. Their ratings were compared with those of a sample of 47 corporate benefits officers of Fortune 500 companies. Priorities were not significantly associated with respondent characteristics. They were positively correlated with independent assessments of the seriousness of the patient's condition and the likely efficacy of the services. Priorities and desire to cover were virtually the same when respondents were asked about insurance for a low-income population as for a general population. Two-thirds of the ratings of the public were the same as those of benefit officers. The public gave higher ratings than benefits officers to long-term care and services to relieve worries, and the public gave lower ratings to the value of treatment of substance abuse and services when the patient could be viewed as at fault. This pilot test indicates this is an efficient, feasible, useful strategy for measuring the extent to which people value various medical services that could contribute to the process of making decisions about health insurance coverage.

Adult↗
PubMed1994

The Maine Women's Health Study: I. Outcomes of hysterectomy.

OBJECTIVE: To assess the effect of hysterectomy for nonmalignant conditions on symptoms and quality of life and to identify adverse effects 1 year after surgery. METHODS: The Maine Women's Health Study was a prospective cohort study of 418 women ages 25-50 years undergoing hysterectomy for any nonmalignant condition. Patients recruited from the practices of 63 physicians performing hysterectomy throughout Maine were interviewed at the time of surgery and 3, 6, and 12 months later. Clinical and hospitalization data were obtained from physician reports and from a statewide hospital discharge data base. The primary outcomes of interest were symptom relief, changes in quality of life, and the development of new symptoms or problems during the year following surgery. RESULTS: The most frequent indications for hysterectomy were leiomyomas (35%), abnormal bleeding (22%), and chronic pelvic pain (18%). For these indications, hysterectomy resulted in marked improvements in a range of symptoms, including pelvic pain, urinary symptoms, fatigue, psychological symptoms, and sexual dysfunction. Significant improvements in scores for indices of mental health, general health, and activity were evident at 6 months and sustained at 1 year. New problems after hysterectomy (measured in those free of the symptom preoperatively) included hot flashes (13%), weight gain (12%), depression (8%), and lack of interest in sex (7%). CONCLUSIONS: Hysterectomy is highly effective for relief of symptoms associated with common nonmalignant gynecologic conditions. Symptom relief following hysterectomy is associated with a marked improvement in quality of life. New problems are reported after hysterectomy by a limited number of women.

Adult↗