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Biomedical subjects

J Lomas

Publications and source records attributed to J Lomas.

At least 73 records · Page 4Linked to original sources
PubMed1990

Placing patients in the queue for coronary revascularization: evidence for practice variations from an expert panel process.

A panel of 16 cardiologists and cardiac surgeons rated 438 case scenarios for the maximum acceptable delay prior to revascularization, using a scale with seven interventional time frames and two nodes for designating dubious or inappropriate cases. If consensus was defined as agreement by 12 or more panelists, only 1.4 percent of the case scenarios showed consensus on a single rating. Dividing the scale into three broad clinical categories (revascularize promptly, place on a waiting list, or no intervention), 11.4 percent of scenarios showed all 16 panelists agreeing on a single category, rising to 59.4 percent of scenarios if agreement by 12 panelists was accepted as a consensus. The mean difference between the panelists' highest and lowest urgency ratings yielded waiting time differences of two weeks for scenarios of very unstable angina, and more than three months for those with stable angina. However, in a regression model, individual panelist factors on average had less effect than clinical features such as severity and stability of angina, or stenosis of major coronary arteries. These findings strongly support the need for consensus criteria to ensure that triage practices are consistent and fair, and also suggest that widespread adoption of a standardized approach to revascularization priorities may be feasible.

Coronary Artery Bypass↗
PubMed1990

Cesarean section in Ontario: practice patterns and responses to hypothetical cases.

A 40% random sample of Ontario's obstetricians were asked to respond to hypothetical scenarios for previous cesarean section, breech presentation and dystocia, and to describe their practice patterns. Their responses confirmed findings from other studies, which reported differences between physicians' responses to hypothetical cases and their actual practice. In this study, 18% chose a cesarean section for the hypothetical case of a patient who had previously undergone cesarean section and 2% chose a cesarean section for the hypothetical case of breech presentation. However, in practice, the obstetricians reported that they do cesarean section on 71% of their previous section patients and on 57% of their breech patients. Physicians in teaching hospitals were less likely than those in community hospitals to choose cesarean section for a woman who had previously undergone cesarean section both hypothetically and in practice. For breech presentation, no difference was found. The discrepancy between responses to the hypothetical cases and practice patterns could not be attributed to the absence of anesthesia services or to restrictive hospital policies.

Anesthesia Department, Hospital↗
PubMed1989

Recent trends in cesarean section rates in Ontario.

After increasing steadily for 15 years the cesarean section rate in Ontario stabilized at 20.2 per 100 deliveries in the fiscal years 1986-87 and 1987-88. An important factor in the stabilization was a decrease in the rate of repeat section. The diagnosis and management of dystocia and fetal distress continue to put upward pressure on the cesarean section rate, which is higher than would be expected if recent practice guidelines had been fully implemented. There is a need for further research into the appropriate management of labour and delivery and into more targeted techniques for bringing practice into line with appropriate standards of care.

Breech Presentation↗
PubMed1989

Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians.

Guidelines for medical practice can contribute to improved care only if they succeed in moving actual practice closer to the behaviors the guidelines recommend. To assess the effect of such guidelines, we surveyed hospitals and obstetricians in Ontario before and after the release of a widely distributed and nationally endorsed consensus statement recommending decreases in the use of cesarean sections. These surveys, along with discharge data from hospitals reflecting actual practice, revealed that most obstetricians (87 to 94 percent) were aware of the guidelines and that most (82.5 to 85 percent) agreed with them. Attitudes toward the use of cesarean section were congruent with the recommendations even before their release. One third of the hospitals and obstetricians reported changing their practice as a consequence of the guidelines, and obstetricians reported rates of cesarean section in women with a previous cesarean section that were significantly reduced, in keeping with the recommendations (from 72.2 percent to 61.1 percent; P less than 0.01). The surveys also showed, however, that knowledge of the content of the recommendations was poor (67 percent correct responses). Furthermore, data on actual practice after the publication of the guidelines showed that the rates of cesarean section were 15 to 49 percent higher than the rates reported by obstetricians, and they showed only a slight change from the previous upward trend. We conclude that guidelines for practice may predispose physicians to consider changing their behavior, but that unless there are other incentives or the removal of disincentives, guidelines may be unlikely to effect rapid change in actual practice. We believe that incentives should operate at the local level, although they may include system-wide economic changes.

Cesarean Section↗
PubMed1989

Trends in use of medical services by the elderly in British Columbia.

We analysed physician fee-for-service use in British Columbia from 1974-75 to 1985-86. Over the study period use increased by 5.3% per year. This can be factored into increases attributable to changes in the age structure of the population (0.4% per year), general population growth (1.8%, for a combined annual "population effect" of 2.2%) and age-specific increases in per-capita use (3% per year). The average annual increase for people aged 75 years or more was 5.5% per capita. The area with the fastest growth in use by the elderly was specialist care, particularly diagnostic services. The average number of specialists seen by people aged 75 years or more doubled over the study period. Our results suggest that increased per-capita use among the elderly that is unrelated to aging of the population should be the main focus of future policy attention. Additional analyses are needed to determine the underlying dynamics of this dramatic increase in rates of use among the elderly.

Adolescent↗
PubMed1989

Controlling health expenditures--the Canadian reality.

Canada and the United States have conducted a large-scale social experiment on the effects of alternative ways of funding expenditures for health care. Two very similar societies, with (until recently) very similar systems of providing health care, have adopted radically different systems of reimbursement. The results of this experiment are of increasing interest to Americans, because the Canadian approach has avoided or solved several of the more intractable problems facing the United States. In particular, overall health expenditures have been constrained to a stable share of national income, and universality of coverage (without user charges) eliminates the problems of uncompensated care, individual burdens of catastrophic illness, and uninsured populations. The combination of cost control with universal, comprehensive coverage has surprised some American observers, who have questioned its reality, its sustainability, or both. We present a comparison of the Canadian and American data on expenditures, identifying the sectors in which the experience of the two nations diverges most, and describing the processes of control. In any system, cost control involves conflict between providers and payers. Political processes focus this conflict, whereas market processes diffuse it. But the stylized political combat in Canada may result in less intrusion on the professional autonomy of the individual physician than is occurring in the United States.

Attitude of Health Personnel↗
PubMed1989

The communicative effectiveness index: development and psychometric evaluation of a functional communication measure for adult aphasia.

Groups of aphasic patients and their spouses generated a series of communication situations that they felt were important in their day-to-day life. Using criteria to ensure that the situations were generalizable across people, times, and places, we reduced the number of situations to 36 and constructed an index that allowed the significant others of 11 recovering and 11 stable aphasic individuals to rate their partners' performance in the situations on two occasions 6 weeks apart. These data were then used to evaluate the psychometric properties of the Communicative Effectiveness Index (CETI) as a measure of change in functional communication ability. Further application of a generalization criterion reduced the final index to 16 situations. Results showed the CETI to be internally consistent and to have acceptable test-retest and interrater reliability. It was valid as a measure of functional communication according to the pattern of correlations found with other measures (Western Aphasia Battery, Speech Questionnaire, and global ratings). Finally, it was responsive to functionally important performance change between testings. Further research with the CETI and its usefulness for clinicians and researchers are discussed.

Aged↗
PubMed1989

Regionalization of coronary artery bypass surgery. Effects on access.

Coronary artery bypass surgery (CABS) has been regionalized in the province of Ontario since the introduction of the procedure in the 1970s. The authors examined the effect of regionalization on the age-adjusted surgery rates in the 38 counties of southern Ontario and found that county surgical rates were not related to whether the county had a referral center, bordered on a county with a referral center, or did not border on such a county (R2 = 0.019, P = 0.712). In addition, surgical rates were not related to the distance in miles to the nearest referral center (R2 = 0.019, P = 0.440). The authors also examined the relationship between the referral center providing care to the county and surgical rates and found a significant relationship between rates of surgery and referral center regardless of whether a strict rule (R2 = 0.741, P less than 0.0001), a majority rule (R2 = 0.514, P less than 0.0001), or a plurality rule (R2 = 0.497, P less than 0.0001) was used to assign counties to referral centers. The authors conclude that CABS rates are more related to the center serving the county than to the distance of the county from a referral center and discuss this finding in relation to access to care and its impact on costs and quality.

Coronary Artery Bypass↗
PubMed1989

Accommodating rapid growth in physician supply: lessons from Israel, warnings for Canada.

Most developing countries find themselves grappling with the implications of rapid growth in physician supply. The purpose of this article is to search for lessons or warnings for Canada (and, ultimately, elsewhere) in the manner in which Israel has chosen to accommodate its huge supply of physicians. Under extremely conservative assumptions about immigration, and assuming rates of domestic training of physicians at levels somewhat lower than at present, Canada's physician supply will continue to grow at rates in excess of general population growth for at least the next 45 years. In this article we describe the Israeli health care system from a perspective of identifying the consequences of accommodating a physician supply about 50 percent higher than that in Canada. A number of key "accommodation attributes" (low physician incomes, restricted access to hospitals for general practitioners, intramedical-professional conflicts over income and authority, a flourishing black market) are argued to be more than simply products of a unique cultural and political system, but also symptoms of a system vastly oversupplied with physicians. Early signs in Canada of similar "products" of a growing physician supply are noted. While a two-country comparison makes drawing lessons somewhat speculative, the coincidence of events suggests that these trends in Canada warrant, if not immediate action, at least careful monitoring.

Adult↗
PubMed1989

The long good-bye: the great transformation of the British Columbia hospital system.

Much is made of the "threat" an aging population poses to North American health care systems. In this article, we present hospital utilization data from British Columbia over the period 1969-1985, which reinforce our earlier (Barer, Evans, Hertzman, et al. 1987) conclusion: it is not aging per se that poses the threat; rather, it is what we are choosing (through our health care system) to do to and with our elderly. In 1969, British Columbia hospital patients over 65 years of age and staying longer than 60 days accounted for 12.5 percent of all days; by 1985/86, they were accounting for 39 percent. Furthermore, in 1985/86, 1 patient in 200 was using one-quarter of all patient days and dying at the end of the process, and 2 patients in 100 (who stayed over 60 days whether discharged alive or dead) were accounting for almost one-half of all days.

Adolescent↗
PubMed1988

The role of evidence in the consensus process. Results from a Canadian consensus exercise.

As part of a consensus conference on cesarean birth, the ten-member consensus panel rated 224 clinical scenarios on their appropriateness for a cesarean section. Ratings were obtained before and immediately after the consensus conference. The level of agreement (consensus) among panelists was assessed separately for scenarios with good research evidence (evidence scenarios) and for those with conflicting, poor, or no evidence (nonevidence scenarios). For each scenario, consensus between panelists was measured as total agreement, partial agreement, or disagreement on the appropriateness of a cesarean section. Before the conference, total or partial agreement existed for a larger percentage of evidence than nonevidence scenarios (85% vs 30%), with the pattern reversed for disagreements (15% vs 70%). After the conference, possible improvement in the level of consensus actually occurred for 71% of the evidence and only 24% of the nonevidence scenarios. Thus, the consensus process, as structured here, was sensitive to the availability of good evidence and suggests that aspects of both expert and public processes can successfully be combined. However, an improvement could be made in the process by grading final recommendations according to the availability of rigorous research evidence.

Breech Presentation↗
PubMed1988

Monitoring the diffusion of a technology: coronary artery bypass surgery in Ontario.

Technology assessment involves not only examining technologies before they are released but also their diffusion into practice once they have been released. In this study we show how basic analysis of a large administrative data set, combined with a review of evidence on effectiveness, can be used as the first step in technology assessment. We analyze the use of coronary artery bypass surgery (CABS) in the province of Ontario, Canada. The annual number of procedures increased 52 per cent over a seven-year period between 1979 and 1985. Large increases in CABS rates in the over-65 population accounted for more than half of this increase in procedures. Increased rates of surgery in the over-65 population are unlikely to be caused by increased prevalence of coronary artery disease and may be the result of a change in clinical attitude toward the use of CABS. This change is discussed in the context of the evidence on the effectiveness and cost-effectiveness of CABS. We conclude that there is a need to carefully monitor and evaluate the use of technologies especially in the elderly.

Adult↗
PubMed1987

Aging and health care utilization: new evidence on old fallacies.

The proportion of the population in the older age groups will increase dramatically over the next four decades. Furthermore, current per capita rates of hospital and medical care utilization rise sharply with age beyond the age of about 55. However, demographic trends alone do not imply health care cost increases in excess of what is supportable by normal economic growth. A 'cost crisis' will only occur if per capita rates of utilization among the elderly increase faster than for the general population. In this paper we present some descriptive data from published sources suggesting that this has been the case over the recent past in one Canadian province. The implications for the policy debate over the effects of an aging population are discussed.

Adolescent↗
PubMed1987

Patient versus clinician item generation for quality-of-life measures. The case of language-disabled adults.

Using nominal group process to develop a measure of quality of life, two groups of aphasic patients and a group of rehabilitation clinicians generated separate lists of important functional communication situations. Comparison of the lists by raters who were blind to their source revealed that the two patient lists were more similar to each other than were either of the patient lists to the clinician list; clinicians underestimate the patients' focus on social needs; patients, rather than clinicians, generated the more specific and concrete situations, which are of use in a quality-of-life measure. The study demonstrates that language-disabled adults can generate items for a quality-of-life measure (hence, this should be possible in almost any other disease group), and that clinician-generated items are not fully representative of patient values.

Aphasia↗