PubMed Health⌕ Search

Biomedical subjects

J E Hux

Publications and source records attributed to J E Hux.

15 recordsLinked to original sources
PubMed2001

Problems for clinical judgement: 1. Eliciting an insightful history of present illness.

This article presents the results of a review of studies of psychology that describe how ordinary human reasoning may lead patients to provide an unreliable history of present illness. Patients make errors because of mistakes in comprehension, recall, evaluation and expression. Comprehension of a question changes depending on ambiguities in the language used and conversational norms. Recall fails through the forgetting of relevant information and through automatic shortcuts to memory. Evaluation can be mistaken because of shifting social comparisons and faulty personal beliefs. Expression is influenced by moods and ignoble failures. We suggest that an awareness of how people report current symptoms and events is an important clinical skill that can be enhanced by knowledge of selected studies in psychology. These insights might help clinicians avoid mistakes when eliciting a patient's history of present illness.

Humans↗
PubMed2000

Increasing rates of ischemic heart disease in the native population of Ontario, Canada.

BACKGROUND: The prevalence of ischemic heart disease (IHD) has been declining in North America since the 1960s. Over this time, Native populations, which have traditionally had low rates of IHD, have undergone striking lifestyle changes that may have had health consequences. In this context, IHD trends in the Native communities of Ontario, Canada, were evaluated. OBJECTIVE: To assess trends in admission rates for IHD in the Native population of Ontario compared with the general population of Ontario. METHODS: A comprehensive administrative database of all hospital admissions in Ontario 1981 to 1997, was used. Age- and sex-adjusted rates of hospital admissions with IHD-related diagnostic or procedure codes were determined in all residents of Ontario communities that had regular census participation and at least 95% of their population claiming Native origins (N=16,874 in 1991). Comparison was made with all residents of the surrounding northern Ontario region (N=822,450) and of the whole province (N = 10,084,885). RESULTS: In 1981, the rate of IHD admissions was similar in all groups, at 99 to 124 per 10,000 persons. By 1997, it decreased to 82 per 10,000 in the province (slope, -1.09; 95% confidence interval, -1.26 to -0.91), with a similar trend in northern Ontario. However, in the Native communities, it increased to 155 per 10,000 (slope, 5.6; 95% confidence interval, 3.8-7.5). A similar trend was seen for acute myocardial infarction admissions, a more precisely coded subset of IHD. Spurious causes of increasing rates were ruled out. CONCLUSIONS: Hospitalizations for IHD have doubled in the Native population despite declining rates in the general population. These findings document an alarming trend in Native health and support the need for further research and targeted intervention.

Hospitalization↗
PubMed1999

Confidential prescriber feedback and education to improve antibiotic use in primary care: a controlled trial.

BACKGROUND: Antibiotics are a medication class for which inappropriate prescribing is frequently described. We sought to assess the effectiveness of a mailed intervention combining confidential prescribing feedback with targeted educational bulletins in increasing the use of less expensive, first-line antibiotics by practising physicians. METHODS: The participants were 251 randomly selected primary care physicians from southern Ontario who consented to participate (135 in the feedback group and 116 in the control group). Prescribing data were obtained from the claims database of the Ontario Drug Benefit program, which covers all Ontarians over age 65 years for drugs selected from a minimally restrictive formulary. Confidentially prepared profiles of antibiotic prescriptions coupled with guidelines-based educational bulletins were mailed to the intervention group every 2 months for 6 months. The control group received no intervention until after completion of the study. The main outcome measures were change from baseline in physician's median antibiotic cost and proportion of episodes of care in which a prespecified first-line antibiotic was used first. RESULTS: The median prescription cost of about $11 remained constant in the feedback group but rose in the control group (change of $0.05 v. $3.37, p < 0.002). First-line drug use increased in the feedback group but decreased in the control group (change of 2.6% v. -1.7%, p < 0.01). In a mailed survey of 100 feedback recipients (response rate 76%), 82% indicated that they would participate readily in another, similar program. INTERPRETATION: A simple program of confidential feedback and educational materials blunted cost increases, increased the use of first-line antibiotics and was highly acceptable to Ontario primary care physicians.

Adult↗
PubMed1999

Monetary and nonmonetary costs to patients attending an ambulatory dermatology clinic.

BACKGROUND: Despite universal coverage under a provincial health plan, the residents of Ontario, Canada, still bear some costs for outpatient care, particularly for prescription drugs. OBJECTIVE: To determine the financial and nonmonetary costs borne by patients presenting at a dermatology clinic in an academic centre, and to assess the extent to which these costs were problematic. METHODS: Consecutive new patients in a 6-week period completed a self-administered questionnaire. RESULTS: Eighty-six of 140 questionnaires (61%) were returned for analysis. The mean total cost to patients was C$28.92 (range $0 to $177.00). Medications were the largest expense (mean $35.66 for those receiving medication). Despite relatively prompt referrals (mean 12.4 days) and short in-office waiting time (mean 26.5 minutes), there was a trend for subjects to rate time costs as more problematic than monetary costs. CONCLUSION: Patients attending a dermatology clinic bear variable monetary and nonmonetary costs. For some patients these costs may have the potential to impair access to care.

Academic Medical Centers↗
PubMed1997

Case selection and appropriateness of coronary angiography and coronary artery bypass graft surgery in British Columbia and Ontario.

OBJECTIVES: To compare the types of patients selected for coronary angiography (CA) and coronary artery bypass graft (CABG) surgery, and the appropriateness of the procedures performed on these patients in a random sample of cases in British Columbia and Ontario. DESIGN: Retrospective randomized medical record review. SETTING: All hospitals performing CA and/or CABG in British Columbia and Ontario in fiscal year 1989/90. PATIENTS: For CA, 395 randomly selected patients in Ontario and 139 randomly selected patients in British Columbia; for CABG, 431 randomly selected patients in Ontario and 125 randomly selected patients in British Columbia. MAIN OUTCOME MEASURES: Case selection was measured in terms of the demographic and clinical characteristics of patients undergoing the procedures. Appropriateness was measured by comparing the clinical characteristics of patients undergoing the procedures with explicit criteria established by a panel of Canadian physicians. The yield from CA was measured as the proportion of patients who were found to have insignificant anatomical disease. RESULTS: Analysis of patients selected for CA showed that sample patients from Ontario were less likely than those from British Columbia to be female (25% versus 37%, respectively, P = 0.012) and less likely to have undergone a previous revascularization (12% versus 24%, respectively, P = 0.005). The distribution of main indications for CA differed between the two provinces (P = 0.002), with Ontario patients more likely to have chronic stable angina (45% versus 24%) and less likely to have unstable angina (16% versus 26%). For CABG, sample patients from Ontario were less likely to be 65 years of age or older (32% versus 45%, P = 0.016) and more likely to have an ejection fraction less than 35% (14% versus 5%, P = 0.006). The distribution of the main indications for CABG differed (P < 0.001), with Ontario patients more likely to have chronic stable angina (68% versus 38%) and less likely to have unstable angina (20% versus 43%). There was no statistically significant difference in CA cases rated as inappropriate (8.4% in Ontario versus 10.8% in British Columbia, P = 0.396) or CABG cases rated as inappropriate (3.9% in Ontario versus 2.4% in British Columbia, P = 0.393). There were no statistically significant differences in the proportion of CA that yielded insignificant anatomical disease (17.5% in Ontario versus 18.4% in British Columbia, P = 0.355). CONCLUSIONS: There were differences between Ontario and British Columbia in the demographic and clinical characteristics of patients selected for CA and CABG. This may indicate differences in the referral process in the two provinces. Despite these differences the rates of inappropriate procedures and the yield from CA were similar.

Aged↗
PubMed1996

Are the marginal returns of coronary artery surgery smaller in high-rate areas? The Steering Committee of the Provincial Adult Cardiac Care Network of Ontario.

BACKGROUND: Population-based rates of surgery vary within and between health-care systems, causing concern that case selection is less appropriate in high-rate areas. This inverse relationship has not been shown with appropriateness criteria generated by expert panels. We applied a trials-based measure of the potential survival benefit of coronary artery bypass graft surgery (CABG) to patients in a provincial registry, to determine the relationship between survival gains and rates of CABG. METHODS: We did a population-based retrospective review of linked registry and administrative datasets. 5058 patients in the linked datasets underwent isolated CABG in Ontario between April 1, 1992, and March 31, 1993. Potential survival benefit of surgery was scored with an algorithm derived from a published overview of trials comparing CABG to medical treatment, analysed by county and by referral regions. FINDINGS: Overall, case selection was appropriate whether assessed clinically (96.3% had either severe disease as judged on the coronary arteries affected or moderate to severe angina) or on the basis of survival benefit scores (94.0% predicted to obtain moderate or high benefit). There was significant variation in benefit scores across referral regions (p < 0.001). Benefit scores correlated inversely with county surgical rate (r = -0.49, p < 0.005) and the proportion of low-benefit cases increased with rates (r = 0.50, p < 0.005). Referral regions served by high-rate surgical centres had lower mean benefit scores. INTERPRETATION: Most patients undergoing CABG in Ontario are in the high-survival benefit category. Surgery is defensible for patients with low survival benefit on the grounds of symptom relief, but the proportion of cases with low benefit rises with higher local rates of surgery. The inverse relationship between surgery rates and appropriateness of case selection may be better understood as diminishing marginal returns for specific outcomes with rising local use of procedures.

Aged↗
PubMed1996

Noninvasive assessment of cardiac function during exercise in patients with CHF or COPD: measurement of aortic bloodflow indices by continuous wave Doppler.

OBJECTIVE: To test whether continuous-wave Doppler measurements of aortic bloodflow indices would reliably distinguish patients with congestive heart failure (CHF) from those with chronic obstructive pulmonary disease (COPD) and a similar degree of exertional dyspnea. DESIGN. Parallel group comparison. SETTING: University teaching hospital. PARTICIPANTS: Eighteen out-patients with clinically distinct syndromes of CHF or COPD but of similar age and functional limitation. INTERVENTION: Participants were observed during graded treadmill exercise. The following indices were obtained: heart rate, systolic blood pressure (SBP), earlobe oxygen saturation, and continuous-wave Doppler measurements of aortic bloodflow from the suprasternal notch. MAIN RESULTS: Exercise duration (mean +/- SE): COPD 14.2 +/- 1.2 mins, CHF 14.0 +/- 1.2 mins, not significant. Maximum results during exercise: heart rate, CHF 143 +/- 7 beats/min, COPD 149 +/- 5 beats/min, not significant; peak velocity, CHF 0.60 +/- 0.04 m/s, COPD 0.92 +/- 0.07 m/s, P < 0.005; peak acceleration, CHF 17 +/- 1 m/s2, COPD 37 +/- 3 m/s2, P < 0.001; SBP: CHF 152 +/- 8 mmHg, COPD 207 +/- 5 mmHg, P < 0.001; minimum oxygen saturation: CHF 92 +/- 1%, COPD 88 +/- 2%, not significant. CONCLUSIONS: Aortic bloodflow indices can be measured during exercise in patients with exertional dyspnea due to CHF or COPD and, in CHF, these indices are significantly reduced compared with individuals with COPD measured at similar levels of exercise. These data suggest that measurement of aortic bloodflow indices may have a role as an adjunct to routine tests in the diagnosis of patients with dyspnea. Further studies are indicated in patients with clinical features of both COPD and CHF in whom the etiology of dyspnea is uncertain.

Aged↗
PubMed1994

Prescribing propensity: influence of life-expectancy gains and drug costs.

OBJECTIVE: To determine whether physician willingness to prescribe drugs for primary prevention of cardiovascular disease is influenced by information about the resultant life-expectancy gains (presented in one of two formats) and about drug costs. MATERIALS AND METHODS: Mailed survey (four versions randomly allocated) asking physicians to assess hypothetical preventive interventions with outcomes expressed either as averaged or as stratified gains in life expectancy (e.g., average gain of 15 weeks, versus 5% of treated patients gain 2 to 6 years, 10% gain up to 2 years, and 85% remain unchanged). Both costs and gains were varied to high and low values. The subjects rated their willingness to prescribe treatments on an 11-point scale from "strongly oppose" to "strongly favor." PARTICIPANTS: Internists randomly selected from two Canadian academic centers (n = 330). RESULTS: 231 usable responses were received (76% of the deliverable questionnaires). For low-yield scenarios typical of very effective primary prevention strategies, the physicians gave significantly higher ratings in response to stratified life-expectancy data than to equivalent averaged data (p < 0.0001). The same trend was not observed for high-yield scenarios (p = NS). The ratings were strongly influenced by cost: 34% of the physicians reversed their treatment decisions in response to a tenfold price increase. Despite this, the rankings of the treatments differed from those expected on the basis of cost-effectiveness criteria (p < 0.0001). CONCLUSIONS: Physician enthusiasm for a therapy designed to prolong life expectancy may be influenced by the format in which that life-expectancy gain is presented. Knowledge of drug cost also affects physicians' choices, but their greater focus on treatment effects causes their rankings to depart from those expected with cost-effectiveness criteria.

Attitude of Health Personnel↗
PubMed1994

Drug prices and third party payment: do they influence medication selection?

The growing burden of prescription drug costs has focused attention on factors which influence physicians' prescribing decisions. We hypothesised that third party coverage of prescription costs would elicit selection of expensive drugs, but that this tendency could be moderated by price reminders. In a mailed survey, primary care physicians throughout Ontario (n = 1072) were provided with the clinical scenario of a patient with an infectious exacerbation of chronic obstructive pulmonary disease, and asked to select diagnostic tests as well as 1 of 6 antibiotics. Two antibiotics were expensive (ciprofloxacin and cefaclor; average price $Can52.23), and 4 inexpensive {amoxicillin, cotrimoxazole (trimethoprim/sulfamethoxazole), erythromycin and tetracycline; average price $Can2.80}. Neither expensive drug is considered first line therapy for the condition described. Questionnaires differed in the presence or absence of drug benefit coverage and price information. The response rate was 71%. With third party cost coverage and prices shown, 18% of respondents selected an expensive antibiotic. This increased to 38% when the prices were omitted {odds ratio 2.72; 95% confidence interval (CI) 1.61, 4.60; p less than 0.001}, and decreased to 8% when the patient was said to have no drug benefits coverage (odds ratio 0.40; 95% CI 0.19, 0.84; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Bacterial Agents↗
PubMedDate not supplied

Communicating the benefits of chronic preventive therapy: does the format of efficacy data determine patients' acceptance of treatment?

Patients' informed acceptance of chronic medical therapy hinges on communicating the potential benefits of drugs in quantitative terms. In a hypothetical scenario of treatment initiation, the authors assessed how three different formats of the same data affected the willingness of 100 outpatients to take what were implied to be three different lipid-lowering drugs. Side-effects were declared negligible and costs insured. Subjects make a "yes-no" decision about taking such a medication, and graded the decision on a certainty scale. Advised of a relative risk reduction--"34% reduction in heart attacks"--88% of the patients assented to therapy. All other formats elicited significantly more refusals (p < 0.0001): for absolute risk difference--"1.4% fewer patients had heart attacks"--42% assented; for inverted absolute risk--"treat 71 persons for 5 years to prevent one heart attack"--only 31% accepted treatment. When the data were extrapolated to disease-free survival--"average gain of 15 weeks"--40% consented. Similar responses were obtained for descriptions of an antihypertensive drug: 89% assented to therapy when given relative risk reduction but only 46% when given absolute risk reduction. The subjects were confident in both acceptance and refusal: 93% of the decisions were rated "somewhat certain" to "completely certain." The authors conclude that patients' views of medical therapy are shaped by the formats in which potential benefits are presented. Multiple complementary formats may be most appropriate. The results imply that many patients may decline treatment if briefed on the likelihood or extent of benefit.

Adult↗