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Biomedical subjects

J E Till

Publications and source records attributed to J E Till.

At least 19 recordsLinked to original sources
PubMed1992

Effect of nonmedical factors on family physicians' decisions about referral for consultation.

OBJECTIVES: To identify nonmedical factors perceived by family physicians (FPs) and consultants as important influences on decisions about referral for consultation, to determine the relative frequency with which such factors are cited and to identify those factors ranked as most important by the FPs and consultants. DESIGN: Survey with semistructured interview between July 1989 and April 1990. PARTICIPANTS: A total of 41 FPs and 20 consultants who were practising or had practised previously in Nova Scotia. INTERVENTIONS: The questionnaire comprised 10 questions: 4 were nondirective "probes" designed to elicit responses without suggesting possible answers, 2 asked the participants to rank such responses in order of importance, and 4 were "prompts" that asked for comments about a list of factors based on a review of the literature. RESULTS: A total of 4845 discrete items were mentioned as being capable of influencing FPs' decisions about referral for consultation. Aggregation of related items resulted in a list of 35 nonmedical factors, of which 11 were identified by at least half the respondents and 14 by less than half but more than 10. These 25 factors fell into three categories: patient and family factors (e.g., patient's wishes), FP and consultant factors (e.g., FP's capabilities), and other influences (e.g., style of practice). On the basis of both frequency of identification and priority scores "patient's wishes" emerged as the most important factor. Two medical factors that were consistently cited--type of problem and age of patient--were thought to interact with the other factors. CONCLUSION: Certain nonmedical considerations may substantially affect physicians' referral practices.

Data Collection↗
PubMed1992

Is there a role for preference assessments in research on quality of life in oncology?

The development of ways to evaluate interventions that may have an impact on quality of life is a rapidly-developing area of research in clinical oncology, especially within the context of randomized controlled trials. We propose a role for assessments of preferences in such evaluations, including preference studies designed to assess attitudes toward the clinical acceptability of interventions, and preference trials designed to assess choice behaviour in relation to interventions. We suggest that such preference assessments represent a specific case of a more general issue: the need to develop an 'ethics of evidence', that is, standards for the creation, assessment and communication of evidence. We then outline a framework within which an 'ethics of evidence' might be developed, and suggest that the framework also may provide a useful model for the processes involved in the transfer of research results into clinical practice. As an illustration, we consider the problem of decision making in circumstances where the choice of therapy depends primarily on the patient's own preferences, as, for example, in the choice of mastectomy or breast-conserving treatment in early-stage breast cancer. The long-term goal is to develop criteria which might be used to foster shared rational decision making in such circumstances.

Beneficence↗
PubMed1991

Comparison of search strategies on CD Plus/MEDLINE.

OBJECTIVE: To compare two strategies for searching MEDLINE using the CD Plus/MEDLINE program on compact disc. DESIGN: Comparison study. INTERVENTIONS: Two search strategies were designed and executed for each of two topics (patient recruitment to clinical trials and attitudes of patients, the public and health care professionals toward clinical trials). Strategy A: searches based on key words selected from the medical subject heading (MeSH) tree structure. Strategy B: searches based on MeSH terms most frequently used to index a known set of relevant articles. Defined search restrictions were then applied. The effects of the restrictions on the absolute number of citations retrieved and on the proportion of relevant citations were assessed. OUTCOME MEASURES: Number of articles retrieved, number of relevant articles, precision and recall of each search strategy and overlap between strategies. MAIN RESULTS: Strategy A produced more citations than strategy B (recruitment 147 v. 38, attitude 366 v. 57) but had more inappropriate citations (recruitment 75 v. 17, attitude 265 v. 25). Both strategies produced 73 relevant recruitment citations and 101 relevant attitude citations. In the recruitment search although the precision did not differ significantly between strategies A and B the difference in recall was significant (98.6% v. 28.8% respectively, p less than 0.0001). In the attitude search strategy A had a lower precision than strategy B (27.6% v. 56.1%, p less than 0.0001) but a much higher recall (100% v. 31.7%, p less than 0.0001). CONCLUSIONS: Strategy A would be more valuable to researchers doing extensive reviews, whereas strategy B would be useful for the busy clinician who simply wants a few appropriate references quickly and is willing to sacrifice comprehensive retrieval in the interest of efficiency.

Algorithms↗
PubMed1991

Communicating probabilistic information to cancer patients: is there 'noise' on the line?

The objective was to examine the way that cancer patients translate verbal descriptors of probability into numerical estimates. A list of words commonly used on consent forms to describe the likelihood for benefits or risks of therapies was provided to 100 cancer patients. Two formats, paper/pencil or computer, were used to provide the list of words. Two methods, magnitude estimation and linear analogue scaling, were used to obtain probability estimates for each word. In addition, two scenarios were developed to study 'context effects' on numerical interpretations of verbal descriptions of probability. All patients provided numerical values for the words on two occasions, separated by one week, and two interviewers collected the data. Regardless of method or format, each word elicited widely variable numerical interpretations. An ANOVA model, including patient, word, interviewer, time, method and format, indicated that patient and interviewer produced major effects on probability estimates. Agreement between methods and across time was good. Paper/pencil and computer formats yielded similar results. Context effects did not appear to influence the numerical probabilities elicited by the 2 scenarios. It was concluded that, within this group of patients, there was no consensus about numerical meaning of a given word, and that interviewers can systematically influence numerical interpretations. There appears to be a great deal of 'noise' in this particular line of communication between patients and health professionals.

Aged↗
PubMed1991

Use of written cases to study factors associated with regional variations in referral rates.

The major purpose was to explore the use of written case scenarios to investigate factors associated with regional variations in referral for consultation. Data were collected in Nova Scotia, where extensive computer-based records of utilization of health services are kept, and the nine health care regions are in sufficient proximity to make visits and interviews feasible. Interviews with 9 x 25 = 225 randomly-selected family physicians, using scenarios analogous to ICD-9 codes, permitted testing of hypotheses about the effects of selected variables on referral rates for hypothetical cases. The family physicians' self-reported referral behavior for the written case scenarios was compared, region by region, with the actual referral of analogous cases by physicians in the same region, as determined from Nova Scotia Health Services and Insurance Commission records. The results indicated that written scenarios provide a useful tool for studies of such variables. Generally, the family physicians responded appropriately to the information that described the hypothetical patients ("case cues"). However, comparisons of hypothetical and actual referral rates indicated that appropriate information about the environment within which referral decisions take place ("environmental cues") may be needed to explain actual regional variations in referral rates.

Attitude of Health Personnel↗
PubMed1991

Heterogeneity in responses to cancer. Part I: Psychiatric symptoms.

Heterogeneity in psychiatric responses to disease specific diagnosis is demonstrated for two groups of cancer patients who are comparable in prognosis and treatment intensity. Implications of this heterogeneity are drawn for etiological study and for planning psychiatric interventions.

Adaptation, Psychological↗
PubMed1991

Heterogeneity in responses to cancer. Part II: Sexual responses.

Heterogeneity in psychosexual responses to disease-specific diagnosis is demonstrated for two groups of cancer patients with testis cancer and Hodgkin's disease who are comparable in prognosis and treatment intensity. The two groups of patients and their partners are shown to differ in their ability to recover from psychiatric problems associated with the diagnosis and/or treatment of cancer.

Adaptation, Psychological↗
PubMed1990

Leukemia in Utah and radioactive fallout from the Nevada test site. A case-control study.

Previous studies reported an association between leukemia rates and amounts of fallout in southwestern Utah from nuclear tests (1952 to 1958), but individual radiation exposures were unavailable. Therefore, a case-control study with 1177 individuals who died of leukemia and 5330 other deaths (controls) was conducted using estimates of dose to bone marrow computed from fallout deposition rates and subjects' residence locations. A weak association between bone marrow dose and all types of leukemia, all ages, and all time periods after exposure was found. This overall trend was not statistically significant, but significant trends in excess risk were found in subgroups defined by cell type, age, and time after exposure. The greatest excess risk was found in those individuals in the high-dose group with acute leukemia who were younger than 20 years at exposure and who died before 1964. These results are consistent with previous studies and with risk estimates for other populations exposed to radiation.

Acute Disease↗
PubMed1990

Development of a method to estimate thyroid dose from fallout radioiodine in a cohort study.

A cohort of 4831 persons aged 11-18 y in 1965 was identified among students in the schools of Washington County, UT; Lincoln County, NV; and Graham County, AZ. These children who had potentially been exposed to radioiodine from atomic weapons test fallout from the Nevada Test Site during 1951-1962 were selected for participation in a study of thyroid disease. The entire cohort was first examined during 1965-1968 for thyroid abnormalities. A total of 3,085 of these people were again reexamined during 1985-1986 to determine any subsequent occurrence of thyroid disease. In order to determine the relationship of the radiation dose to the thyroid with incidence of thyroid disease, we have developed a suite of models to calculate estimates of the internal dose received by the thyroid from fallout radioiodines. For completeness, the exposure to the thyroid from external radiation is also estimated. Dose estimates are made specific to each individual in the study using individual residential histories, the locality-specific exposure rate and radionuclide deposition, descriptions of dairy management for identified milk producers, and the subjects' sources of foods and intake rates of milk and leafy vegetables determined by interview. Other data such as the relationship of radioiodine deposition to measured exposure rate, environmental transfer parameters, and age-dependent factors for the conversion of radioiodine intake to thyroid dose were taken from work of other investigators. Dairy management information, milk distribution practices, the milk source for each study subject, as well as age-specific intake rates of milk and leafy vegetables, were determined by interview.

Adolescent↗
PubMed1990

Individual external exposures from Nevada Test Site fallout for Utah leukemia cases and controls.

External gamma-ray exposures from fallout originating at the Nevada Test Site (NTS) have been assigned to 6,507 individual subjects (1,177 leukemia cases and 5,330 control subjects) who died as Utah residents between 1952 and 1981. Leukemia cases were identified, confirmed, and classified by cell type from the Utah Cancer Registry, Utah State vital records, and medical records. Residential histories were obtained from the Deceased Membership File (DMF) of the Church of Jesus Christ of Latter-day Saints (LDS), supplemented by information from the LDS Church Census Records that were taken in 1950, 1955, and 1960-62. Control subjects were selected randomly within age strata from the DMF and were frequency-matched to the cases by age at death and for sex. Individual radiation exposures were assigned as a function of residence location and time interval for each residence during the fallout period (1951-1958) using geographic exposure data taken from the literature. Temporal distribution of exposure for subjects who resided in more than one locality or who were born or died during the fallout period was determined from data of other investigators. Calculated gamma-ray exposures for each place of residence were summed for each subject to yield the exposure to fallout from the NTS.

Case-Control Studies↗
PubMed1990

Are we getting informed consent from patients with cancer?

We developed a consent form for a hypothetical trial and asked patients to underline information that was pertinent to their decision to accept or refuse to participate in the proposed trial. We also investigated whether patients correctly interpreted statements describing the probability of certain events occurring. Of the 50 patients, 74% did not indicate that both risks and benefits were pertinent. Of the 20 patients who would not enter the trial, 70% focused on risks of therapy only. In contrast, of the 30 who agreed to enter, only 33% focused entirely on risks, while 10% did not note potential for either benefit or risk. For each of four probability statements, patients chose one of four possible interpretations, only one of which was correct. Depending on the statement, between 26 and 54% of the interpretations were incorrect. It appears that many decisions regarding trial entry may be based upon incomplete or incorrect information.

Adult↗
PubMed1989

Exemplary family physicians and consultants: empirical definition of contemporary medical practice.

To identify the characteristics of exemplary family physicians and consultants, we interviewed 25 family physicians and 25 consultants (5 each in the specialties of internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery) selected by their peers as being exemplary in their own practice setting. The results indicated that the participants had well-formulated concepts of exemplary practitioners, defining five main categories of performance: clinical competence, relationship with patients, availability, family physician-consultant relationship and a fifth category that included organizational ability and personality attributes. The family physicians and the consultants placed different values on these categories and indicated that these values might change under different clinical circumstances. Their concepts appear to be compatible with, but not restricted to, a model of contemporary medical practice based on an ethic specific to medicine.

Attitude of Health Personnel↗
PubMed1989

Measuring satisfaction with health care: a comparison of single with paired rating strategies.

One of the central problems in studies of patient satisfaction with health care is the development of reliable and valid methods to determine the relative importance of different aspects of health care. Two techniques, paired comparisons and rating on a visual analogue scale, were compared in terms of their consistency with logical assumptions, test-retest reliability, and convergent validity. Thirty women with breast cancer were asked to assess brief hypothetical scenarios describing out-patient clinic visits to a tertiary cancer care centre. Each scenario incorporated three variables related to satisfaction with care: staff attitude, control over treatment decisions, and continuity of medical supervision. The paired choice method showed marginally better reliability and logical consistency than the rating method. Of the three variables assessed, continuity of medical supervision was consistently ranked highest in importance, and control over treatment decisions lowest. These preference assessment techniques appear to be suitable for use in the development of patient satisfaction indices, and for studies designed to examine variations in the priority given to different aspects of satisfaction with care.

Attitude of Health Personnel↗
PubMed1989

Cancer patients: their desire for information and participation in treatment decisions.

The relationship between cancer patients' desire for information and their preference for participation in decision making has been examined. Approximately 77% of the 52 patients reported that they had participated in decision making to the extent that they wished, while most of the remaining 23% would have preferred an opportunity to have greater input. Although many of the patients actively sought information, a majority preferred the physician to assume the role of the primary decision maker. Ethically, the disclosure of information has been assumed to be necessary for autonomous decision making. Nevertheless, the results of this study indicate that patients may actively seek information to satisfy an as yet unidentified aspect of psychological autonomy that does not necessarily include participation in decision making.

Canada↗