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Biomedical subjects

Gerald W Smetana

Publications and source records attributed to Gerald W Smetana.

12 recordsLinked to original sources
PubMed2007

A comparison of outcomes resulting from generalist vs specialist care for a single discrete medical condition: a systematic review and methodologic critique.

BACKGROUND: Studies of clinical outcomes for generalist vs specialist care for diagnoses within a specialist's narrow domain have tended to favor specialty care. METHODS: A MEDLINE search from January 1, 1980, through April 1, 2005, and a hand search of retrieved bibliographies of English-language studies that compared generalist vs specialist care for individual patients with a single discrete medical condition were performed. Two reviewers determined eligibility for each study and abstracted data onto a standardized instrument. RESULTS: A total of 49 articles met our inclusion criteria: 24 studies favored specialty care, 13 found no difference in outcomes, 7 varied by individual outcome, 1 depended on physician experience, and 4 favored generalist care. Only 8 studies reported integration into health delivery systems, 4 considered physician experience, 3 documented information technology support, and 2 considered the impact of care management programs. Selection bias was adequately addressed in 58% of studies that favored specialty care and in 71% of studies that found no difference or favored generalist care (P = .52). Studies that favored specialty care were less likely to consider 4 key, potentially confounding physician or practice characteristics compared with studies that found no difference or favored generalist care (3% vs 15% of potential instances, respectively; P = .009). CONCLUSIONS: The literature regarding the influence of generalist vs specialist care on outcomes for patients with a single discrete condition suffers from important methodologic shortcomings. Further research is needed to inform health care policy as it pertains to the optimal role of generalists and specialists in the physician marketplace.

Clinical Competence↗
PubMed2006

Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians.

Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.

Adult↗
PubMed2006

Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians.

BACKGROUND: The importance of clinical risk factors for postoperative pulmonary complications and the value of preoperative testing to stratify risk are the subject of debate. PURPOSE: To systematically review the literature on preoperative pulmonary risk stratification before noncardiothoracic surgery. DATA SOURCES: MEDLINE search from 1 January 1980 through 30 June 2005 and hand search of the bibliographies of retrieved articles. STUDY SELECTION: English-language studies that reported the effect of patient- and procedure-related risk factors and laboratory predictors on postoperative pulmonary complication rates after noncardiothoracic surgery and that met predefined inclusion criteria. DATA EXTRACTION: The authors used standardized abstraction instruments to extract data on study characteristics, hierarchy of research design, study quality, risk factors, and laboratory predictors. DATA SYNTHESIS: The authors determined random-effects pooled estimate odds ratios and, when appropriate, trim-and-fill estimates for patient- and procedure-related risk factors from studies that used multivariable analyses. They assigned summary strength of evidence scores for each factor. Good evidence supports patient-related risk factors for postoperative pulmonary complications, including advanced age, American Society of Anesthesiologists class 2 or higher, functional dependence, chronic obstructive pulmonary disease, and congestive heart failure. Good evidence supports procedure-related risk factors for postoperative pulmonary complications, including aortic aneurysm repair, nonresective thoracic surgery, abdominal surgery, neurosurgery, emergency surgery, general anesthesia, head and neck surgery, vascular surgery, and prolonged surgery. Among laboratory predictors, good evidence exists only for serum albumin level less than 30 g/L. Insufficient evidence supports preoperative spirometry as a tool to stratify risk. LIMITATIONS: For certain risk factors and laboratory predictors, the literature provides only unadjusted estimates of risk. Prescreening, variable selection algorithms, and publication bias limited reporting of risk factors among studies using multivariable analysis. CONCLUSIONS: Selected clinical and laboratory factors allow risk stratification for postoperative pulmonary complications after noncardiothoracic surgery.

Clinical Laboratory Techniques↗
PubMed2006

Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians.

BACKGROUND: Postoperative pulmonary complications are as frequent and clinically important as cardiac complications in terms of morbidity, mortality, and length of stay. However, there has been much less research and no previous systematic reviews of the evidence of interventions to prevent pulmonary complications. PURPOSE: To systematically review the literature on interventions to prevent postoperative pulmonary complications after noncardiothoracic surgery. DATA SOURCES: MEDLINE English-language literature search, 1 January 1980 through 30 June 2005, plus bibliographies of retrieved publications. STUDY SELECTION: Randomized, controlled trials (RCTs); systematic reviews; or meta-analyses that met predefined inclusion criteria. DATA EXTRACTION: Using standardized forms, the authors abstracted data on study methods, quality, intervention and control groups, patient characteristics, surgery, postoperative pulmonary complications, and adverse events. DATA SYNTHESIS: The authors qualitatively synthesized, without meta-analysis, evidence from eligible studies. Good evidence (2 systematic reviews, 5 additional RCTs) indicates that lung expansion interventions (for example, incentive spirometry, deep breathing exercises, and continuous positive airway pressure) reduce pulmonary risk. Fair evidence suggests that selective, rather than routine, use of nasogastric tubes after abdominal surgery (2 meta-analyses) and short-acting rather than long-acting intraoperative neuromuscular blocking agents (1 RCT) reduce risk. The evidence is conflicting or insufficient for preoperative smoking cessation (1 RCT), epidural anesthesia (2 meta-analyses), epidural analgesia (6 RCTs, 1 meta-analysis), and laparoscopic (vs. open) operations (1 systematic review, 1 meta-analysis, 2 additional RCTs), although laparoscopic operations reduce pain and pulmonary compromise as measured by spirometry. While malnutrition is associated with increased pulmonary risk, routine total enteral or parenteral nutrition does not reduce risk (1 meta-analysis, 3 additional RCTs). Enteral formulations designed to improve immune status (immunonutrition) may prevent postoperative pneumonia (1 meta-analysis, 1 additional RCT). LIMITATIONS: The overall quality of the literature was fair: Ten of 20 RCTs and 6 of 11 systematic reviews were good quality. CONCLUSIONS: Few interventions have been shown to clearly or possibly reduce postoperative pulmonary complications.

Analgesia↗
PubMed2006

Preoperative pulmonary evaluation: identifying and reducing risks for pulmonary complications.

Postoperative pulmonary complications are among the most common sources of morbidity in patients undergoing major surgery. For this reason, the preoperative patient evaluation should emphasize risk factors for pulmonary complications as well as for traditional cardiac complications, as the former are comparably frequent and associated with longer hospital stays. Procedure-related risk factors are more important than patient-related risk factors for predicting pulmonary events, but clinicians should assess both types of factors. Pulmonary function testing has a limited role and should not be the basis for denying surgery if the surgical indication is compelling. Strategies to reduce the risk of postoperative pulmonary complications include optimizing management of chronic lung disease before surgery, lung expansion maneuvers, pain control, and selective placement of nasogastric tubes.

Humans↗
PubMed2004

Factors that influence patient response to requests to change to a unified restrictive formulary.

OBJECTIVE: To determine factors that influence patient willingness to accept a medication change to a unified, restrictive formulary. DESIGN: Prospective cohort study. SETTING: University-affiliated hospital-based primary care internal medicine practice. PATIENTS/PARTICIPANTS: Two hundred ninety-seven members of a managed care plan who had received a prescription for a nonformulary medication in the previous 4 months and whose primary care physician approved a conversion to a formulary medication. INTERVENTIONS: Clinical nurses invited patients to change to a formulary medication at the time of a telephone refill request based on a standard script. MEASUREMENTS AND MAIN RESULTS: The overall conversion rate to the formulary medication was 59.8%. Seventy-four percent of patients who requested a refill by telephone converted to the formulary (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.02 to 4.72). Patient age (OR, 1.03; CI, 1.01 to 1.05) and male gender (OR, 2.00; CI, 1.09 to 3.67) were each significant correlates of conversion. After adjustment in a multivariable model, only telephone refill request (adjusted OR, 2.31; CI, 1.07 to 4.97) and age (adjusted OR, 1.03; CI, 1.01 to 1.06) remained significant. Among the patients who made a telephone refill request, those who converted were more likely to completely trust their physician's judgment (P=.04) and to trust their physician to put their health over cost concerns (P=.05). Formulary conversion reduced costs beginning 3 months after the conversion date. CONCLUSIONS: A protocol for encouraging conversion to a unified formulary at the point of a telephone refill request increases formulary compliance rates and reduces medication costs. Patients who decline to convert medications are less likely to trust their physician.

Adult↗
PubMed2003

The case against routine preoperative laboratory testing.

In this article, we have shown that almost all "routine" laboratory tests before surgery have limited clinical value. Clinicians should order only a small number of routine tests based on age as noted in Table 13. Selective use of other preoperative tests should be based on history and physical examination findings that identify subgroups of patients who are more likely to have abnormal results. In general, clinicians should order tests only if the outcome of an abnormal test will influence management. When an abnormal test results from such testing, it is critical that physicians document their thinking about the result. Most routine preoperative tests are neither expensive nor risky. For this reason, clinicians can have a low threshold for ordering these tests in patients for whom the frequency of abnormalities is increased compared with a healthy population. We believe that physicians should not be criticized for selective test ordering before surgery. Physicians and institutions recommending routine preoperative testing for all patients provide no clinical value to their patients at considerable cost.

Diagnostic Tests, Routine↗
PubMed2003

Preoperative pulmonary assessment of the older adult.

Postoperative pulmonary complications in the elderly are common and are a significant source of morbidity, mortality, and prolonged length of stay. Risk factors differ from the well-known risk factors for cardiac complications and can be divided into patient- and procedure-related factors. Patient-related factors include COPD, recent cigarette use, poor general health status as defined by Goldman or ASA class, dependent functional status, and laboratory parameters including abnormal chest radiograph, renal insufficiency, and low serum albumin. Age is a minor risk factor when adjusted for comorbidities and confers approximately a two-fold increase in risk. Elderly patients who are otherwise acceptable surgical candidates should not be denied surgery based solely on age and concern for postoperative pulmonary complications. The surgical site is the single most important predictor of pulmonary complications. High-risk surgeries include thoracic, upper abdominal, aortic, neurosurgery, and peripheral vascular. Other procedure-related risk factors include surgery lasting longer than 3 hours, the use of general anesthesia, pancuronium use, and emergency surgery. Clinicians should not recommend routine preoperative spirometry before high-risk surgery because it is no more accurate in predicting risk than clinical evaluation. Patients who might benefit from preoperative spirometry include those who have unexplained dyspnea or exercise intolerance and those who have COPD or asthma in whom uncertainty exists as to the status of airflow obstruction when compared with baseline. After identifying patients at risk for postoperative pulmonary complications, clinicians can recommend strategies to reduce risk throughout the operative period. In addition to minimizing or avoiding the above risk factors, optimization of COPD or asthma, deep breathing exercises, incentive spirometry, and epidural local anesthetics reduce the risk of postoperative pulmonary complications in elderly surgical patients.

Age Factors↗
PubMed2002

Does this patient have temporal arteritis?

CONTEXT: Clinicians must be able to confidently diagnose temporal arteritis (TA), since failure to make a correct diagnosis may lead to irreversible visual loss as well as inappropriate evaluation and treatment of headache, fatigue, and other potential presenting symptoms. The diagnostic value of particular signs and symptoms among patients with suspected TA is unknown. OBJECTIVE: To determine the accuracy of historical features, physical examination, and erythrocyte sedimentation rate (ESR) in diagnosis of TA. DATA SOURCES: We performed a MEDLINE search of English-language articles published between January 1966 and July 2000 and a hand search of bibliographies of retrieved articles, previous reviews, monographs, and textbooks. STUDY SELECTION: Studies that provided detailed clinical information on patients who had been referred for temporal artery biopsy. Of 114 studies retrieved, 41 met our inclusion criteria; 21 included both biopsy-positive and biopsy-negative patients and formed the core of our review. DATA EXTRACTION: Both authors independently reviewed each study to determine eligibility, abstracted data using a standardized instrument, and classified study quality using predetermined criteria. DATA SYNTHESIS: The prevalence of TA in the general population is less than 1%. However, in our 21 core studies, 39% of patients referred for temporal artery biopsy had positive results. The only 2 historical features that substantially increased the likelihood of TA among patients referred for biopsy were jaw claudication (positive likelihood ratio [LR], 4.2; 95% confidence interval [CI], 2.8-6.2) and diplopia (positive LR, 3.4; 95% CI, 1.3-8.6). The absence of any temporal artery abnormality was the only clinical factor that modestly reduced the likelihood of disease (negative LR, 0.53; 95% CI, 0.38-0.75). Predictive physical findings included temporal artery beading (positive LR, 4.6; 95% CI, 1.1-18.4), prominence (positive LR, 4.3; 95% CI, 2.1-8.9), and tenderness (positive LR, 2.6; 95% CI, 1.9-3.7). Normal ESR values indicated much less likelihood of disease (negative LR for abnormal ESR, 0.2; 95% CI, 0.08-0.51). CONCLUSIONS: A small number of clinical features are helpful in predicting the likelihood of a positive temporal artery biopsy among patients with a clinical suspicion of disease; the most useful finding is a normal ESR, which makes TA unlikely.

Aged↗
PubMed2002

Clinicians, educators, and investigators in general internal medicine: bridging the gaps.

Financial and time pressures, disparate promotional pathways, geographic separation, and difficulty acknowledging personal fallibility can contribute to polarization of clinician-educators and investigators in general internal medicine (GIM). As a consequence, clinician-educators and investigators may fail to use their joint expertise, may encounter friction in their relationships, and may present a troubled image to trainees considering careers in GIM. We suggest specific strategies that clinician-educators, investigators, administrative leaders, and medical schools might use to foster collaboration.

Academic Medical Centers↗