Biomedical subjects

J Feinglass

Publications and source records attributed to J Feinglass.

At least 37 records · Page 2Linked to original sources

PubMed1997

Treatment of proximal vein thrombosis with subcutaneous low-molecular-weight heparin vs intravenous heparin. An economic perspective.

BACKGROUND: Subcutaneous low-molecular-weight heparin is at least as effective and safe as classic intravenous heparin therapy for the treatment of proximal vein thrombosis. Anticoagulant monitoring is not required with low-molecular-weight heparin. OBJECTIVE: To perform an economic evaluation of these therapeutic approaches by comparing cost and effectiveness. PATIENTS AND METHODS: A randomized trial in 432 patients with proximal vein thrombosis that compared intravenous heparin and low-molecular-weight heparin with objective documentation of clinical outcomes provided the opportunity to perform an analysis of cost-effectiveness to rank these alternative therapies in terms of both their cost and effectiveness. The economic viewpoint of this analysis was that of a third-party payer (ie, a ministry of health in Canada or an insurance company in the United States). RESULTS: In the intravenous heparin-treated group, the cost incurred for 100 patients was $414,655 (Canadian dollars) or $375,836 (US dollars), with a frequency of objectively documented venous thromboembolism of 6.9%. In the low-molecular-weight heparin-treated group, the cost incurred for 100 patients was $399,403 (Canadian dollars) or $335,687 (US dollars), with a frequency of objectively documented venous thromboembolism of 2.8%, thus providing a cost saving of $15,252 (Canadian dollars) or $40,149 (US dollars). Multiple sensitivity analyses were performed, and these procedures did not alter the findings of the study. CONCLUSIONS: The findings indicate that low-molecular-weight heparin therapy is at least as effective and safe but less costly than intravenous heparin treatment. The potential for outpatient therapy in up to 37% of patients who are receiving low-molecular-weight heparin would substantially augment the cost saving.

Anticoagulants↗

PubMed1997

Subcutaneous low-molecular-weight heparin vs warfarin for prophylaxis of deep vein thrombosis after hip or knee implantation. An economic perspective.

BACKGROUND: Postoperative venous thrombosis and pulmonary embolism present a major clinical threat to patients undergoing total hip or knee arthroplasty. We performed an economic evaluation of warfarin sodium and subcutaneous low-molecular-weight heparin sodium prophylaxis comparing cost and effectiveness. METHODS: A consecutive series of 1436 patients who underwent hip or knee arthroplasty comparing these 2 regimens in a randomized trial with objective documentation of outcomes provided the opportunity to perform economic evaluations for Canada and the United States. RESULTS: Deep vein thrombosis was documented in 231 (37.4%) of 617 patients given warfarin and in 185 (31.4%) of 590 patients given low-molecular-weight heparin (P = .03). In Canada, warfarin and low-molecular-weight heparin (tinzaparin sodium) incurred costs per 100 patients of $11,598 and $9,197, respectively, providing a cost savings of $2,401 for the low-molecular-weight heparin group. The drug cost of low-molecular-weight heparin (tinzaparin) was $6 per day and for warfarin was $0.32 per day. Sensitivity analysis showed that low-molecular-weight heparin is more costly if drug costs are increased by 1.5-fold (ie, the cost of tinzaparin is increased from $6 per day to $8.82 per day or more). In the United States, the analysis was also not definitive; low-molecular-weight heparin was more costly than warfarin at drug costs of $15 and $2.01 per day, respectively. CONCLUSIONS: Our findings indicate that the decision to use low-molecular-weight heparin or warfarin prophylaxis in patients undergoing major joint replacement surgery is a finely tuned trade-off. Prophylaxis with low-molecular-weight heparin is equally or more effective than the more complex prophylaxis with warfarin. Major bleeding is uncommon but less frequent with warfarin use. The most significant parameters that influence the comparative cost-effectiveness are the cost of the drug, the cost of international normalized ratio monitoring, and the costs associated with major bleeding. The analysis also demonstrates that the results are health care system dependent (Canada vs US). In Canada, low-molecular-weight heparin (tinzaparin) is less costly because it avoids the need for international normalized ratio monitoring. In the United States, the drug cost for low-molecular-weight heparin will likely be the principal determinant of relative cost-effectiveness.

Adult↗

PubMed1997

Systolic function, readmission rates, and survival among consecutively hospitalized patients with congestive heart failure.

We sought to describe the relation between left ventricular systolic function and rates of hospital readmission and survival among consecutively hospitalized patients with congestive heart failure. Medical records were reviewed for these patients at an academic medical center between Jan. 1, 1992, and Dec. 31, 1993. Left ventricular systolic function assessments performed within 6 months before discharge were used to classify left ventricular systolic function. Hospital readmission rates and survival through Dec. 31, 1994, were compared between patients with systolic dysfunction and those with preserved systolic function. Among 412 patients hospitalized with a primary diagnosis of congestive heart failure, 224 had undergone a left ventricular function assessment during the 6 months before hospital discharge. In-hospital mortality and readmission rates were higher among patients without a recent assessment of left ventricular systolic function. Of patients with systolic dysfunction, 55% versus 41% of patients with preserved systolic function were either readmitted or had an emergency room visit within 6 months after discharge (p = 0.06). At 27 months' follow-up, cumulative survival probabilities were 65% for patients with preserved systolic function, 65% for patients with systolic dysfunction, and 60% for patients without a left ventricular systolic function assessment (p = 0.24). Patients without a recent left ventricular systolic function assessment have significantly higher hospital readmission rates than patients with a recent systolic function assessment. Among hospitalized patients, mortality rates are comparable between patients with systolic dysfunction and those with preserved systolic function. However, patients with heart failure with systolic dysfunction may have higher readmission rates.

Aged↗

PubMed1997

Heart failure between 1986 and 1994: temporal trends in drug-prescribing practices, hospital readmissions, and survival at an academic medical center.

Since 1987, publications in widely circulated medical journals have reported improved survival and lower hospital readmission rates when patients with heart failure and systolic dysfunction are treated with angiotensin-converting enzyme (ACE) inhibitors. We describe changes in ACE inhibitor use among patients hospitalized with heart failure between 1986 and 1993. Simultaneous trends in readmissions and survival rates are reported. Subjects were 612 consecutive patients hospitalized with a principal diagnosis of heart failure at an academic medical center during the period of Sept. 1, 1986, to Dec. 31, 1987 (interval I) or during the period Aug. 1, 1992, to Nov. 30, 1993 (interval II). Medical records were reviewed for 434 patients, consisting of all patients hospitalized with heart failure during interval II and a randomly selected 50% subset of patients hospitalized during interval I. Among 145 patients with systolic dysfunction whose medical records were reviewed, ACE inhibitor prescriptions significantly increased between interval I and interval II (43% vs 71%, p < 0.01, odds ratio 3.22, 95% confidence interval 1.62 to 6.42). Prescriptions of ACE inhibitors combined with digoxin and a diuretic also increased (37% vs 56%, p = 0.02, odds ratio 2.22, 95% confidence interval 1.14 to 4.32). Among all 612 patients, 6-month heart failure readmission rates increased from 13% to 21% (p = 0.02, odds ratio 1.79, 95% confidence interval 1.10 to 2.82). There was no significant change in survival rate between interval I and interval II, however, survival rate was marginally significantly improved among patients with systolic dysfunction. Our results suggest that drug-prescribing practices have significantly changed between 1986 and 1993. The absence of observed improvement in outcomes may result from changes in hospital admission criteria for heart failure.

Aged↗

PubMed1996

Effect of lower extremity blood pressure on physical functioning in patients who have intermittent claudication. The Chicago Claudication Outcomes Research Group.

PURPOSE: Claudication patients' perceptions of walking impairment often influence recommendations for peripheral bypass and angioplasty. The actual relationship between lower extremity blood flow and physical functioning, however, has rarely been explicitly studied. METHODS: Patients were enrolled at a visit to one of 16 vascular surgery offices and clinics that participated in a prospective outcomes study. A total of 555 patients (445 men and 110 women) with an abnormal ankle-brachial index (ABI), none of whom had had previous leg revascularization or symptoms of rest pain, skin ulcers, or gangrene, completed the SF36 Health Survey and the Peripheral Arterial Disease Walking Impairment Questionnaire (WIQ). Stepwise multiple regression analysis was used to test the statistical significance and strength of association between patients' ABI level and SF36 physical functioning (PF) and WIQ community walking distance scores, controlled for sociodemographic characteristics and the presence and severity of comorbid conditions. RESULTS: Univariate correlations with ABI were modest but significant (PF score, r = 0.12, p = 0.004; WIQ distance score, r = 0.18, p < 0.001). ABI was a very significant predictor of both PF (b = 18.8; p = 0.001) and WIQ scores (b = 0.33; p < 0.0001) in the multiple regression analysis. Other positive predictors of PF scores were high-school graduation and male sex. Negative predictors of PF scores were heart, lung, and cerebrovascular disease; knee arthritis and chronic back pain; and enrollment at a Veterans Administration clinic rather than a private community or academic office. CONCLUSION: Cross-sectional findings indicate that a 0.3 improvement in ABI is associated with an average improvement of 5.6% in PF or 10.3% in WIQ distance score. However, proper selection of individual candidates for interventional therapy, that is, those patients who have lower ABIs, lower initial functioning, and fewer disabling comorbidities would be predicted to produce a much greater functional benefit. Surgeons should make a rigorous functional evaluation when recommending interventional management of claudication.

Aged↗

PubMed1996

The Intermittent Claudication Research Study: vascular outcomes research using home health nurses.

This article describes an ongoing, multicenter outcomes research study on intermittent claudication being conducted at 16 Chicago-area vascular surgery offices and clinics. The study relies on gathering data through a series of home health follow-up visits by visiting nurses who use portable Doppler equipment. A total of 624 patients (506 men and 118 women) have been enrolled to date. Data on study patients' baseline demographic characteristics, leg symptoms, peripheral blood flow, comorbidities, and walking impairments are presented. Initial physical functioning and walking-distance scores from patient self-report questionnaires are also presented, along with attrition and lower-extremity revascularization rates. The contribution of nursing to this type of patient outcomes research is discussed. The changing climate in health care delivery provides nursing with a great opportunity to influence the U.S. health care system. In particular, the participation of nurses can make a major contribution to research on patient outcomes and medical effectiveness, and especially to new methods of comparing treatment effects on patients' functional status. Interpretation and measurement of patient self-reported health status and quality of life are particularly relevant to nursing, which is based on interventions related to compromised function. Improvement of patients' physical functioning is the heart of nursing practice, and the focus of much of what is done in vascular medicine and surgery. This article describes the contribution of nursing skills and knowledge to an ongoing, government-funded, multicenter research study on intermittent claudication. The ability of nurses to make a unique contribution to outcomes research is demonstrated.

Activities of Daily Living↗

PubMed1996

Use of hematopoietic colony-stimulating factors: the American Society of Clinical Oncology survey. The Health Services Research Committee of the American Society of Clinical Oncology.

PURPOSE: Dissemination of use of the hematopoietic colony-stimulating factors (CSFs) is unprecedented in oncology, with almost all physicians having experience with granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) shortly after the drugs received Food and Drug Administration (FDA) approval in 1991. The American Society of Clinical Oncology (ASCO) Health Services Research Committee sought to assess patterns of use of CSFs before dissemination of its first-ever publication of ASCO guidelines. METHODS: A questionnaire describing clinical scenarios was mailed to American oncologists and hematologists who practice medical oncology. In each scenario, the physician was asked whether he would prefer to use a CSF to prevent or treat neutropenia. RESULTS: The response rate to the mailed survey was 49% (N = 475). Most physicians preferred to use CSFs for secondary prophylaxis in patients receiving chemotherapy at rates of 44% to 85%, rather than reduce doses. Patterns of use did not differ for palliative, curative, or adjuvant chemotherapy. While the majority of CSF patterns of care were similar to those recommended in the ASCO guidelines, more than half of the physicians chose to use CSFs in the treatment of febrile neutropenia, an area not supported in the subsequent guidelines. In general, physicians at academic medical centers and in Health Maintenance Organization (HMO) practices were more likely to prefer dose-reduction strategies over addition of CSFs, while fee-for-service physicians preferred the opposite strategies. CONCLUSION: Variations in CSF preferences for use were related to differences in clinical characteristics (history of afebrile v febrile neutropenia), drug characteristics (G-CSF or GM-CSF), and physician practice characteristics (HMO or fee-for-service setting). However, before dissemination of the guidelines, the majority of American oncologists preferred strategies that were subsequently included in the ASCO CSF guidelines. CSF guidelines would be most likely to reduce CSF use for treatment of afebrile and uncomplicated febrile neutropenia.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1995

Changes in study design, gender issues, and other characteristics of clinical research published in three major medical journals from 1971 to 1991.

OBJECTIVE: To examine trends in study design and other characteristics of original research published in JAMA, Lancet, and the New England Journal of Medicine (NEJM) between 1971 and 1991. DESIGN: A retrospective cross-sectional study of original clinical research published in JAMA, Lancet, and NEJM during 1971, 1981, and 1991. MEASUREMENTS: Four hundred forty-four articles were independently reviewed by at least two investigators and classified according to study design and other preselected study characteristics. Changes over time were analyzed by chi-square tests for categorical variables and analysis of variance for continuous variables. MAIN RESULTS: Clinical results doubled, from 17% of all articles in 1971 to 35% in 1991 (p < 0.004), while case series decreased from 30% to 4% (p < 0.0001). Of 118 clinical trials, randomized controlled trials increased from 31% to 76% (p < 0.003) and nonrandomized controlled trials decreased from 42% to 8% (p < 0.002). Multicenter studies increased from 10% to 39% (p < 0.0001) and the prevalence of health services research increased from none in 1971 to 12% in 1991 (p < 0.001). The proportion of the studies explicitly excluding women from the subject population decreased from 11% in 1971 to 3% in 1991 (p < 0.03). In 1991 7% of the studies were composed entirely of men subjects, while only 0.7% of the studies were specific to men's health. Twelve percent of the studies in 1991 were specific to women's health. Between 1971 and 1991 there was no change in the prevalence of women first authors or studies addressing women's or minorities' health issues. CONCLUSIONS: Several important changes in clinical research studies published in JAMA, Lancet, and NEJM have taken place between 1971 and 1991. Clinical trials have increased in frequency, largely replacing studies containing ten or fewer subjects. Health services research has increased in prevalence, reflecting growing interest in studies addressing the delivery of health care. Our data support the hypothesis that exclusion of women from clinical research studies is an important contributor to the paucity of data concerning women's health.

Clinical Trials as Topic↗

PubMed1995

Hospitalized congestive heart failure patients with preserved versus abnormal left ventricular systolic function: clinical characteristics and drug therapy.

PURPOSE: To compare clinical characteristics of and pharmacologic therapy for hospitalized patients with congestive heart failure (CHF) and left ventricular systolic dysfunction or normal left ventricular systolic function. PATIENTS AND METHODS: Medical records were reviewed for all patients discharged with a principal diagnosis of CHF from a university hospital and a community hospital between September 1, 1991 and August 31, 1992. Pertinent medical history items and prescribed drug therapies at discharge were recorded for each patient's first calendar year admission. Patients were categorized as having either normal left ventricular systolic function or systolic dysfunction based on the results of echocardiography and radionuclide angiography or contrast ventriculogram. RESULTS: Of 298 patients with CHF, 92 (31%) had normal left ventricular systolic function. Patients with normal systolic function were older, were more often women, were less likely to have a history of coronary artery disease, and were more likely to have a history of hypothyroidism than patients with systolic dysfunction. However, the prevalence of clinical characteristics overlapped considerably between the two groups. Among patients with systolic dysfunction, 79% were discharged on a therapeutic regimen of digoxin, 65% on an angiotensin-converting enzyme inhibitor, and 26% on either a beta-blocker or a calcium channel blocker. Among patients with normal systolic function, 50% were discharged on a regimen of a beta-blocker or a calcium channel blocker and 38% were discharged on digoxin. Twenty-six percent of patients with normal systolic function and without a history of atrial fibrillation were discharged on a digoxin regimen. CONCLUSION: Hospitalized CHF patients with normal left ventricular systolic function and those with diminished left ventricular systolic function share many clinical features. Since recommended drug therapy and prognosis differ, our data underscore the importance of diagnostic testing to assess left ventricular systolic function. Drug therapy for CHF patients provides a major challenge for quality-of-care improvement.

Aged↗

PubMed1995

Patient age as a determinant of housestaff time allocation.

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Adult↗

PubMed1995

Late survival risk factors for abdominal aortic aneurysm repair: experience from fourteen Department of Veterans Affairs hospitals.

BACKGROUND: This study evaluates late survival risk factors for patients who underwent elective abdominal aortic aneurysm surgical procedures performed at 14 Department of Veterans Affairs hospitals across the United States between 1985 and 1987. METHODS: Preoperative risk factors for a representative sample of 280 male veterans were obtained from an extensive Department of Veterans Affairs Office of Quality Management study and subsequent chart review. The National Death Index was used to determine survival through December 1991. RESULTS: Mortality at 30 days was 2.9%. Kaplan-Meier survival probabilities were 89% (+/- 2%) at 1 year and 64% (+/- 3%) at 5 years. Multivariate hazards models indicated significantly poorer survival for patients with age greater than 69 years, chronic obstructive pulmonary disease, cerebrovascular disease, and left ventricular hypertrophy. A history of coronary artery disease including previous myocardial infarction or bypass operation did not predict late survival for this cohort. CONCLUSIONS: Given the substantial burden of comorbidity of veterans who use Department of Veterans Affairs facilities, the overall survival experience of this all male cohort compares well with previously published series and with overall U.S. male life expectancy. The fact that a history of coronary artery disease did not predict survival for this cohort may be related to selection bias; however, a more likely explanation is the presence of unsuspected coronary disease among patients without a documented history of angina or myocardial infarction.

Age Factors↗

PubMed1995

Surgical management of atheroembolization.

PURPOSE: Atheroembolization may cause limb loss or organ failure. Surgical outcome data are limited. We report the largest series of atheroembolization focusing on patterns of disease, surgical treatment and outcome. METHODS: One hundred patients (70 men), mean age 62 +/- 11 years, operated on for lower extremity, visceral, or nonthoracic outlet upper extremity atheroemboli were identified prospectively and monitored over a 12-year period. The atheroembolic source was localized by use of a combination of computed tomography scanning (n = 55), arteriography (n = 93), duplex scanning (n = 25), transesophageal echocardiography (n = 6), and magnetic resonance imaging (n = 4). Occlusive aortoiliac disease (47 patients) and small aortic aneurysms (20 patients; mean aneurysm size 3.5 +/- 0.8 cm) were the most common source of atheroemboli. Imaging studies revealed 12 patients with extensive suprarenal aortic thrombus. Correction of the embolic source was achieved with aortic bypass (n = 52), aortoiliac endarterectomy and patch (n = 11), femoral or popliteal endarterectomy and patch (n = 11), infrainguinal bypass (n = 3), extraanatomic reconstruction (n = 6), graft revision (n = 3), upper extremity bypass (n = 11), or upper extremity endarterectomy and patch (n = 3). RESULTS: All four deaths within 30 days and all seven deaths within the first 6 months after operation were among the 12 patients with suprarenal aortic thrombus. The cumulative survival probabilities for all patients at 1, 3, and 5 years were 89%, 83%, and 73%, respectively. After operation, nine patients required major leg amputations and 10 required toe amputations. Renal atheroemboli led to hemodialysis in 10 patients. Recurrent embolic events occurred in five of 97 patients monitored for a mean of 32 months. All five recurrences occurred in the first 8 months after operation. Three patients with recurrent emboli had suprarenal aortic disease, one of whom had undergone axillofemorofemoral bypass. Four of 15 patients receiving postoperative warfarin anticoagulation had development of recurrent embolism. Only one patient not receiving postoperative warfarin had a recurrent event (p < 0.05 by Fisher exact test). CONCLUSION: The atheroembolic source is the aorta or iliac arteries in two thirds of patients who underwent operation. Computed tomography scanning of the aorta is a useful diagnostic technique. The source of the emboli can be eliminated surgically with low mortality or limb loss rates except when the suprarenal aorta is involved.

Adult↗

PubMed1994

Gender differences in interventional management of peripheral vascular disease: evidence from a blood flow laboratory population.

Recent studies of gender differences in the treatment of coronary artery disease have concluded that female patients often receive less aggressive care than male patients. This study compares rates of lower extremity surgical and endovascular procedures by gender for peripheral vascular disease patients seen in the blood flow laboratory at our institution in 1987. Revascularization rates were compared for 192 female and 218 male patients with abnormal blood flow examinations and no prior lower extremity procedures. Female patients were older (3.3 years; p < 0.02), had a lower prevalence of ankle/brachial indices greater than 0.5 (64.2% of males vs. 51.8% of females; p < 0.01), a higher prevalence of hypertension (p < 0.03), and a lower prevalence of smoking (p < 0.02). No significant baseline differences were found for the prevalence of limb salvage indications or other comorbid conditions. A total of 41 women (21.4%) and 64 men (29.4%) underwent subsequent lower extremity surgical or endovascular procedures in 1987 (p = 0.08). Men had a significantly higher procedure rate among the 311 patients without limb salvage indications (p = 0.03). When statistically significant covariates such as limb salvage, age, ankle/brachial index, comorbidity, and smoking are controlled for in logistic regression analysis, men were found to have more than twice the chance of being selected for procedures (p = 0.009). Although limited to practice patterns at one institution, these results suggest that other centers should examine criteria for interventional therapy in mild-to-moderate peripheral vascular disease.

Aged↗

PubMed1994

The ankle-brachial index as a predictor of survival in patients with peripheral vascular disease.

OBJECTIVE: To determine whether the ankle-brachial index (ABI) predicts survival rates among patients with peripheral vascular disease. DESIGN: A retrospective survival analysis of patients with abnormal ABIs who visited the authors' blood-flow laboratory during 1987. The National Death Index was used to ascertain survival status for all patients up to January 1, 1992. Kaplan-Meier and Cox proportional hazards analyses were used to determine the relationship between increasing lower-extremity ischemia, measured by ABI, and survival time. Clinical characteristics controlled for included age, smoking history, gender, and comorbidities, as well as the presence of lower-extremity rest pain, ulcer, or gangrene. SETTING: A university hospital blood-flow laboratory. PATIENTS/PARTICIPANTS: Four hundred twenty-two patients who had no prior history of lower-extremity vascular procedures and who had ABIs < 0.92 in 1987. RESULTS: Cumulative survival probabilities at 52 months' (4.3 years') follow-up were 69% for patients who had ABIs = 0.5-0.91, 62% for patients who had ABIs = 0.31-0.49, and 47% for patients who had ABIs < or = 0.3. In multivariate Cox proportional hazard analysis, the relative hazard of death was 1.8 (95% confidence interval = 1.2-2.9, p < 0.01) for the patients who had ABIs < or = 0.3 compared with the patients who had ABIs 0.5-0.91. Other independent predictors of poorer survival included age > 65 years (p < 0.001); a diagnosis of cancer, renal failure, or chronic lung disease (p < 0.001); and congestive heart failure (p < 0.04). CONCLUSION: The ABI is a powerful tool for predicting survival in patients with peripheral vascular disease. Patients with ABIs < or = 0.3 have significantly poorer survival than do patients with ABIs 0.31-0.91. Further study is needed to determine whether aggressive coronary risk-factor modification, a work-up for undiagnosed coronary or cerebrovascular atherosclerotic disease, or aggressive therapy for known atherosclerosis can improve survival of patients with ABIs < or = 0.3.

Aged↗

PubMed1994

First-year residents' caring, medical knowledge, and clinical judgment in relation to laboratory utilization.

PURPOSE: To investigate first-year residents' levels of caring (concern for others' well-being), medical knowledge, and clinical judgment in relation to their levels of laboratory utilization. METHOD: Self-report questionnaires about caring, knowledge, and judgment were given in 1986-87 to 36 first-year residents in a three-year internal medicine residency program of the McGaw Medical Center of Northwestern University. Inpatient laboratory utilization data obtained from structured chart audits over a one-year period were used to construct comparable diagnosis- and severity-specific physician practice profiles, from which the residents received overall utilization scores for laboratory test charges. Statistical methods included Cronbach's alpha reliability coefficient and multiple regression analysis. RESULTS: The multiple regression analysis showed that medical knowledge was an independent predictor of increased laboratory utilization (standardized beta = .54, p < .04, partial R2 = .07); clinical judgment was an independent predictor of decreased utilization (standardized beta = -.53, p < .05, partial R2 = .06); and caring was unrelated to utilization (standardized beta = .15, ns, partial R2 = .01). CONCLUSION: The finding that clinical judgment was related to less laboratory utilization suggests that future research should investigate the decision-making concomitants of judgment to better understand its translation into resource utilization. It is possible that the relationship between medical knowledge and laboratory utilization is developmentally specific, and thus the knowledge of more experienced physicians, who would likely be more precise decision makers than first-year residents, may be related to decreased rather than increased utilization.

Chicago↗

PubMed1994

Reducing hospital costs for the geriatric patient admitted from the emergency department: a randomized trial.

OBJECTIVE: To test the impact of a geriatric evaluation and management model on the costs of acute hospital management of emergently admitted older adults. DESIGN: Randomized controlled trial. Patients were followed in the acute hospital from admission through discharge. Results based on both univariate and multiple regression analyses. SETTING: Private, nonprofit, academic medical center in a densely populated urban area. PATIENTS: Adults 70 years of age and older admitted from the Emergency Department to the medicine service (non-ICU admission) who did not have an internist on staff at the admitting hospital. Of 141 randomized patients, 111 (78.7%) met eligibility criteria. INTERVENTION: Assignment of a geriatrician and a social worker as the primary managing team during the hospital stay. MAIN OUTCOME MEASURES: Length of stay, total cost of acute hospital care, cost of laboratory, pharmacy, and rehabilitation services. RESULTS: Patients in the intervention group had 2.1 fewer days of hospitalization, but this shorter length of stay was not statistically significant (P = 0.108). There were no differences in mortality or discharge disposition. In risk-adjusted, multiple regression analysis the intervention group had a statistically significant lower predicted total cost per patient than the usual care group (-$2,544, P = 0.029); assignment to the intervention group was associated with a lower predicted cost per patient for laboratory (including cardiology graphics) services (P = 0.007) and pharmacy costs (P = 0.047). CONCLUSIONS: When controlled for important predictors of expected resource use, care provided by a geriatric management team resulted in a significant reduction in the cost of hospitalization. A reduction in the cost of laboratory, cardiographic, and pharmacy services is consistent with the team's philosophy of defining the services needed based on goals related to functional outcomes.

Academic Medical Centers↗

PubMed1994

Hospital cost incentives in a fragmented health care system.

During the mid-1980s, hospital prospective payment regulation was associated with major changes in medical practice, resulting in initially significant reductions in the rate of growth of inpatient costs. More recently, the rate of growth of hospital costs has returned to historic levels, yet most hospitals have been reluctant to intensify their economic monitoring of physicians. Using data from a large teaching hospital in the Midwest, this article presents a model of marginal profitability by payor and by relative physician costliness. The results illustrate the mixed incentives for hospitals to reduce costly medical practice variations.

Accounting↗

PubMed1993

A quality-of-care analysis of cascade iatrogenesis in frail elderly hospital patients.

Cascade iatrogenesis is defined as a related sequence of adverse events that are triggered by an initial medical intervention. In an attempt to determine whether such a phenomenon is be associated with the quality of care provided, physician reviewers identified iatrogenic cascades and the rated quality of care given to a sample of long-stay teaching hospital patients. The care was rated with a structured implicit review instrument. Cascade iatrogenesis was found to occur most frequently among the oldest patients, the most functionally impaired, and those with a high severity of illness on admission. Closer examination of these findings suggests that there is significant potential for improving physicians' initial functional and diagnostic assessment skills when treating frail elderly patients.

Aged↗