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Biomedical subjects

H G Welch

Publications and source records attributed to H G Welch.

At least 55 records · Page 3Linked to original sources
PubMed1996

Trends in diagnostic testing following a national guideline for evaluation of dyspepsia.

BACKGROUND: The extent to which national guidelines affect actual clinical practice is largely unknown. OBJECTIVE: To gauge the impact of a national guideline about dyspepsia on subsequent clinical practice. DESIGN: We compared trends in the rates of the two principal diagnostic tests used to evaluate dyspepsia: upper gastrointestinal tract series (UGI) and endoscopy. METHODS: We used the Health Care Financing Administration's (Baltimore, Md) 100% National Medicare part B file to determine annual counts for the two procedures in each of 10 years (1984 through 1993). To calculate procedure rates, we divided the number of procedures in each year by the total population enrolled in Medicare part B in that year. RESULTS: In 1984, before publication of the guideline, the UGI rate was more than triple the rate of endoscopy (UGI rate, 59 per 1000 beneficiaries; endoscopy rate, 17 per 1000). Subsequent to publication of the guideline in 1985, UGI use slowly decreased while endoscopy utilization slowly increased. The rate of change for both procedures was steady over the 10-year period. Endoscopy rates finally exceeded UGI in 1993 (endoscopy, 37 per 1000; UGI, 36 per 1000). CONCLUSIONS: Despite a prominent national guideline, UGI utilization remains high and is slowly decreasing. Because utilization data before 1984 are incomplete, we cannot isolate the precise impact of the guideline. However, the slow decline in UGI utilization suggests that, at best, the guideline had limited impact on clinical practice. If this response is representative of other guidelines, alternative approaches to change clinical practice will need to be found.

Barium Sulfate↗
PubMed1996

The impact of diagnostic testing on therapeutic interventions.

OBJECTIVE: To gain insight into the usefulness of managing the earlier phase of decision making, we examined the relationship between selected diagnostic tests and the therapeutic interventions they might trigger. DESIGN: Medicare's National Claims History and Part B files were used to obtain summary information on 100% of all physician claims submitted from 1987 through 1993. We regressed the annual rates of selected therapeutic interventions on selected diagnostic tests, which had been previously paired based on the clinical expectation that the test might drive subsequent intervention. POPULATION AND SETTING: These data represent the physician services received by approximately 30 million elderly Americans in each of 7 years. MAIN OUTCOME MEASURE: Coefficient of determination (R2). RESULTS: The annual rate for the diagnostic tests increased rapidly during the period (range, 1.4- to 3.0-fold increase) and accounted for the bulk of the variance in therapeutic intervention rates (R2>0.80, P<.01) for five diagnostic-therapeutic pairs: cardiac catheterization with cardiac revascularization procedures, imaging of the spine with back surgery, swallowing studies with percutaneous gastrostomy, mammography with breast biopsy and excision, and prostate biopsy with prostatectomy. Although the rate of abdominal ultrasound increased during the period, it was not related with either cholecystectomy or abdominal aortic aneurysm repair. CONCLUSION: There has been a substantial increase in diagnostic testing in the United States that closely tracked the increase of clinically relevant downstream procedures. Managing diagnostic testing could be an important strategy for controlling the increase of therapeutic interventions.

Diagnostic Tests, Routine↗
PubMed1996

Estimating treatment benefits for the elderly: the effect of competing risks.

To fully involve patients in treatment decisions, physicians need to communicate future health prospects that patients will have both with and without newly diagnosed disease. These prospects depend not only on the risks patients face from the new disease but also on the risks they face from other causes. Nowhere is an understanding of these competing risks more relevant than in the care of the elderly. In this study, we use the declining exponential approximation for life expectancy (DEALE) to provide a framework to help clinicians gauge the effect of competing risks as a function of age. Because older patients have many competing risks for death, the absolute effect of a new diagnosis on life expectancy is often relatively small. Consequently, the potential gain in survival even from perfect therapy may also be small. Moreover, no therapy is perfect, and the risks of therapy often increase with age. In the elderly, the combination of a high burden of competing risks and high rates of treatment-related complications conspires to reduce the net benefit of numerous interventions. We conclude that, compared with younger patients, the elderly should request only the more clearly effective treatments and should be willing to tolerate fewer associated complications before they agree to initiate therapy.

Aged↗
PubMed1996

Meeting walk-in patients' expectations for testing. Effects on satisfaction.

OBJECTIVE: To examine the relation between meeting expectations for tests and visit satisfaction in walk-in patients. DESIGN: Survey of patients before and after the visit. SETTING: Walk-in medical clinic at a Veterans Affairs Medical Center. PATIENTS: 143 male veterans were eligible for this study: 128 agreed to participate; 109 completed both questionnaires. MEASUREMENTS: Before the visit, we measured health status, baseline satisfaction with care, and expectations for common tests. After the visit, we measured visit-specific satisfaction, patient perception of provider interpersonal behavior (provider humanism), and patient report of whether specific tests were received. Logistic regression was used to determine the effect of meeting expectations for tests while controlling for other factors. RESULTS: Of all patients, 62% expected one or more tests, nearly as many as expected a medication or a diagnosis. In multivariate analysis restricted to those expecting tests, provider humanism was the sole significant predictor of visit-specific satisfaction (odds ration [OR] 6.4; 95% confidence interval [CI] 1.6, 26.1). The proportion of expectations for testing that were met was not significantly associated with satisfaction (OR 1.05; 95% CI 0.92, 1.21). CONCLUSIONS: Meeting patient expectations for tests does not have an important effect on satisfaction. Even in the walk-in setting, patient perception of the providers' interpersonal behavior was a more important factor in satisfaction with the visit. Physicians who order tests solely to improve patient satisfaction may be able to reduce unnecessary testing without decreasing patient satisfaction.

Adult↗
PubMed1996

The impact of practicing in multiple hospitals on physician profiles.

Although physicians are all too familiar with the psychologic impact of having multiple responsibilities, the associated impact on practice styles has not been examined systematically. To provide some data on the effects of "work dispersion," we examined the hypothesis that the inpatient resource use of physicians would rise with the number of hospitals in which they work. Data for 1991 from Medicare's National Claims History File were used to profile a sample of attending physicians (n = 33,756) in seven states. The attending physician "profile" was the case mix-adjusted relative value of all physician services (regardless of who delivered them) that were delivered during each patient's hospital stay. Relative value was measured in relative value units, used by Medicare in determining physician payments. The authors then categorized physicians in terms of the number of hospitals to which they admitted patients. Physician profiles were adjusted further to control for geography, physician specialty, and characteristics of the physician's primary (ie, most used) hospital. One third of the physicians in the sample had admissions to more than one hospital. Physicians working in one hospital had inpatient practice profiles 2.1% below the sample mean. Additional hospital affiliations were associated with progressively higher profiles: two hospitals, 2.3% above the mean; three hospitals, 4.5% above; four hospitals, 8.2% above; and five or more hospitals, 11.5% above (all P < 0.01). The practice of medicine in more than one hospital is associated with higher inpatient profiles and shows a dose-response relationship. Physicians and policy makers will need to consider carefully whether there are any associated benefits to justify the increased cost.

Adult↗
PubMed1995

Autologous bone marrow transplantation versus chemotherapy in relapsed/refractory non-Hodgkin's lymphoma: estimates of long-term survival from the recent literature.

Long-term survival following chemotherapy or autologous bone marrow transplantation in adults with relapsed/refractory non-Hodgkin's lymphoma was evaluated. English language articles published from January 1, 1988 to September 1, 1993 were obtained from a broad-based MEDLINE search retrieving 3,854 citations regarding therapy for lymphomas. Citations were evaluated using both computer-based evaluation and manual review. Articles were included if they addressed the disease of interest (non-Hodgkin's lymphoma, Working Formulation D-H), the population of interest (adults with either relapsed or refractory disease), and the therapies of interest (chemotherapy or autologous bone marrow transplantation). Articles were excluded if they did not provide convincing information on long-term survival (as evidenced by either survival analysis or individual patient data) or if they reported a small number of patients (N < 15). No randomized trials of the two therapies were found. Nine case series were found reporting on 444 eligible patients receiving chemotherapy; eight were found reporting on 256 patients undergoing autologous marrow transplantation. After weighting by sample size, the mean 3-year survival rate was 25% (95% CI, 20-30%) following chemotherapy and 40% (95% CI, 33-47%) following marrow transplantation. The reporting of potentially relevant prognostic factors was inconsistent among articles. Despite our comprehensive synthesis and evaluation of currently available data, the survival advantage of marrow transplantation in relapsed/refractory non-Hodgkin's lymphoma that we report must be viewed as tentative, given the limitations of the case series data. In addition, establishing the comparability of patients treated with these therapies is made more difficult by the inconsistent reporting of potentially relevant prognostic factors. The results of an international randomized trial of these two therapies is forthcoming and may address some of these shortcomings.

Adult↗
PubMed1995

Fee-for-data: a strategy to open the HMO black box.

This paper outlines a simple proposal to maintain utilization data in the face of managed care growth. Health maintenance organizations (HMOs) would be required to submit claims (encounter-level data) and in return would be paid a percentage of what Medicare would pay fee-for-service providers. The capitation payment rate would be lowered to maintain budget-neutrality. This proposal would enable the collection of key data that might not otherwise be captured in a Medicare program dominated by HMOs and other forms of managed care. The data are necessary to drive Medicare policies and to gauge the impact of changes to the program. The program would be well advised to make the small additional investment to make the data system complete. The key issue in implementing such a proposal will be HMOs' ability to generate those data at reasonable cost.

Capitation Fee↗
PubMed1995

Criteria for maximal oxygen uptake: review and commentary.

Historically, the achievement of maximal oxygen uptake (VO2max) has been based on objective criteria such as a leveling off of oxygen uptake with an increase in work rate, high levels of lactic acid in the blood in the minutes following the exercise test, elevated respiratory exchange ratio, and achievement of some percentage of an age-adjusted estimate of maximal heart rate. These criteria are reviewed relative to their history, the degree to which they have been achieved in published research, and how investigators and reviewers follow them in current practice. The majority of the criteria were based on discontinuous protocols, often carried out over several days. Questions are raised about the applicability of these criteria to modern continuous graded exercise test protocols, and our lack of consistency in the terminology we use relative to the measurement of maximal oxygen uptake.

Exercise↗
PubMed1994

Advance directives and the cost of terminal hospitalization.

BACKGROUND: It has been assumed that patients using advance directives would direct terminal care away from the intensive care unit and choose shorter, less costly, less technological terminal hospital stays. METHODS: This retrospective cohort study examined 336 consecutive patients who died in a university tertiary care medical center: 242 without advance directives, 66 with a previously completed advance directive, 13 admitted for the express purpose of terminal care, and 15 who signed an advance directive during their terminal hospitalization. Total charges (hospital and physician) were calculated for all patients and were adjusted using both physician and hospital diagnosis-related group weights. Patient participation in end-of-life decisions was determined by chart review. RESULTS: The group without advance directives had dramatically higher mean total ($49,900 vs $31,200) terminal hospitalization charges than the group with previously completed advance directives, producing a charge ratio of 1.6. After diagnosis-related group adjustment, the charge ratio was 1.35 (95% confidence interval, 1.07 to 1.72) for physician charge, 1.36 (95% confidence interval, 1.06 to 1.74) for hospital charge, and 1.35 (95% confidence interval, 1.08 to 1.73) for total charge. Multiple regression analysis controlling for age, sex, and cancer diagnosis confirmed these findings. Patients with advance directives were significantly more likely to limit treatment and to participate in end-of-life decisions. CONCLUSION: Patients without advance directives have significantly higher terminal hospitalization charges than those with advance directives. Our investigation suggests that the preferences of patients with advance directives are to limit care and these preferences influence the cost of terminal hospitalization.

Advance Directives↗
PubMed1994

A comparison of the educational costs and incomes of physicians and other professionals.

BACKGROUND: Efforts at physician-payment reform in the United States have focused largely on the relative incomes of primary care physicians and specialists, who more often have procedure-based practices. Comparisons of the incomes of physicians and other professional groups have received less attention. METHODS: We used standard financial techniques to determine the return on educational investment over a working lifetime for five groups of professionals: primary care physicians, specialist physicians, dentists, attorneys, and graduates of business schools. RESULTS: In current dollars, the difference in the average future hourly income between a given professional and a high-school graduate of the same age, after educational expenses are subtracted (average hours-adjusted net present value of the educational investment) was greatest for specialist physicians and attorneys; dentists and businesspeople had intermediate values; and primary care physicians had the lowest value. The annual yield on the educational investment over a working life (hours-adjusted internal rate of return) was 15.9 percent for primary care physicians, as compared with 29.0 percent for businesspeople, 25.4 percent for attorneys, 20.9 percent for specialist physicians, and 20.7 percent for dentists. A sensitivity analysis showed that primary care physicians did less well in terms of the return on investment than the other groups even when we varied the assumptions in our model widely and that specialist physicians did less well than attorneys working in law firms and dental specialists. CONCLUSIONS: Students can expect a poorer financial return on their educational investment when they choose a career in primary care medicine than when they choose a procedure-based medical or surgical specialty, business, the law, or dentistry.

Commerce↗
PubMed1994

Physician profiling. An analysis of inpatient practice patterns in Florida and Oregon.

BACKGROUND: Physician profiling is a method of cost control that focuses on patterns of care instead of on specific clinical decisions. It is one cost-control method that takes into account physicians' desire to curb the intrusion of administrative mechanisms into the clinical encounter. To provide a concrete example of profiling, we analyzed the inpatient practice patterns of physicians in Florida and Oregon. METHODS: Data for 1991 from Medicare's National Claims History File were used to profile 12,720 attending physicians in Florida and 2589 in Oregon. For each attending physician, we determined the total relative value of all physicians' services delivered during each patient's hospital stay. Relative value was measured in relative-value units (RVUs), according to the resource-based relative-value scale used by Medicare in determining payments to physicians. The mean number of RVUs per admission was then adjusted for the physician's case mix according to the patients' assigned diagnosis-related groups. The influence of the physician's specialty and of selected types of services (such as imaging and endoscopy) was also examined. RESULTS: Florida physicians used markedly more resources, on average, than their colleagues in Oregon (46 vs. 30 case-mix-adjusted RVUs per admission). The difference was apparent for all specialties and all types of service. To illustrate the profiling data potentially available to the medical staffs of individual hospitals, we examined specific data on individual attending physicians and for various types of service for three hospitals' staffs. Despite similar overall profiles that fell below the national mean, each staff had a different practice pattern and would require different efforts to improve efficiency. CONCLUSIONS: In an effort to encourage further debate, we have described one method of physician profiling. Profiling data help identify and characterize differences in practice style to which individual physicians or hospital staffs can respond. Because profiling is not based on rigid rules, it is a cost-containment strategy that can easily accommodate legitimate exceptions; it is therefore preferable to methods in which the appropriateness of each clinical decision is judged separately.

Cost Control↗