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Biomedical subjects

J R Feussner

Publications and source records attributed to J R Feussner.

At least 55 records · Page 3Linked to original sources
PubMed1993

The clinical efficacy assessment program of the American College of Physicians.

The experience of the American College of Physicians (ACP) in evaluating the clinical literature and publishing clinical guidelines spans more than a decade. The ACP uses an evidence-based method for the development of clinical practice guidelines for diagnostic technologies and treatments. The approach of the Clinical Efficacy Assessment Program (CEAP) involves collation, methodologic review, and analysis of the clinical literature. The process focuses on the safety, contraindications, efficacy, limitations, and cost of diagnostic technologies or treatments. To ensure a balanced perspective of the evidence, methodologic and content experts cooperate to prepare a summary paper. Strengths of this evidence-based approach include: (1) focus on the needs of practicing internists; (2) identification of all pertinent clinical literature; (3) integration of expert opinion when literature is inadequate; (4) recommendations based on high-quality scientific evidence; (5) preparation of conservative guidelines when evidence is lacking; and (6) reevaluation of past guidelines as new evidence becomes available. Limitations of the process include: (1) access only to published research; (2) use of criteria for scientific quality that are not standardized across projects; (3) published recommendations based on small numbers of high-quality research products; (4) compromise with expert opinion when evidence is limited; and (5) ad hoc management of conflict between experts when scientific evidence is sparse. The process produces credible recommendations that may improve physician knowledge and acceptance of practice guidelines.

Clinical Medicine↗
PubMed1993

Cost effectiveness analysis of early zidovudine treatment of HIV infected patients.

OBJECTIVE--To compare cost effectiveness of early and later treatment with zidovudine for patients infected with HIV. DESIGN--Markov chain analysis of cost effectiveness based on results of use of health care and efficacy from a trial of zidovudine treatment. SETTING--Seven Veterans Affairs medical centres in the United States. SUBJECTS--338 patients with symptomatic HIV infection and a lymphocyte count of 200 x 10(6) to 500 x 10(6) CD4 cells/l. INTERVENTIONS--Zidovudine 1500 mg/day started either at recruitment to the trial or when CD4 cell count fell below 200 x 10(6)/l. MAIN OUTCOME MEASURES--Health care costs and rates of disease progression between six clinical states of HIV infection. RESULTS--Patients given early treatment with zidovudine remained without AIDS for an extra two months at a cost of $10,750 for each extra month without AIDS (at 1991 costs). Cost effectiveness ratio was most sensitive to the cost of zidovudine and to the quality of life of patients receiving early treatment. At treatment of 500 mg/day the cost effectiveness ratio for early treatment was $5432 for each extra month without AIDS. Patients given early treatment experienced more side effects, and if their quality of life was devalued by 8% compared with patients treated later the two treatments were equivalent in terms of quality adjusted months of life without AIDS. CONCLUSIONS--Early treatment with zidovudine is expensive and is very sensitive to the cost of zidovudine and to potential reductions in quality of life of patients who experience side effects. Doctors should reconsider early treatment with zidovudine for patients who experience side effects that substantially compromise their quality of life.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Long-term survival of veterans with traumatic spinal cord injury.

OBJECTIVE: To investigate the long-term survival of veterans with traumatic spinal cord injury (SCI). DESIGN: Survival in a retrospective inception cohort of veterans suffering service-connected traumatic SCI is compared with survival among veterans disabled by other conditions, survival among nondisabled veterans, and a population-based life table. SETTING: Subjects were identified from a national census of veterans with service-connected disabilities, using a selection algorithm based on disability codes. PATIENTS: A retrospective cohort of 5545 male veterans with traumatic SCI, surviving at least 3 months after injury, is compared with a stratified random sample of 7077 disabled veterans without SCI, a stratified random sample of 6967 nondisabled veterans, and a life table formed from similarly aged American males. MAIN OUTCOME MEASURE: Survival curves, extending from 3 months to 40 years after injury. RESULTS: The mean life expectancy of veterans suffering traumatic SCI and surviving at least 3 months is an additional 39 years after injury, 85% that of similarly aged American males. Although survival with traumatic SCI was comparable to that of the disabled control subjects for approximately 20 years after onset, a clear deficit occurred beyond this point. Older age at injury is a stronger predictor of poorer long-term survival than is complete quadriplegia. CONCLUSIONS: Among patients who survive the acute phase of their traumatic SCI, long-term survival is relatively good. Health care planners, providers, and communities should anticipate an increasing number of persons aging with SCI.

Adult↗
PubMed1993

Teaching cardiovascular examination skills: results from a randomized controlled trial.

PURPOSE: To evaluate the effectiveness of a teaching program designed to improve interns' cardiovascular examination skills. PARTICIPANTS: All 56 interns rotating on a mandatory 4-week inpatient cardiology service during 1 academic year (July 1989-June 1990). METHODS: We randomly assigned interns to receive either an eight-session physical diagnosis course ("teaching group") taught on the cardiology-patient simulator ("Harvey") or to receive no supplemental teaching ("control group"). Before and immediately after the teaching or control period, the interns were evaluated on three preprogrammed simulations (mitral regurgitation, MR; mitral stenosis, MS; aortic regurgitation, AR). Immediately after the control or the intervention period, the interns also evaluated patient volunteers. RESULTS: There were no baseline differences in the interns' ability to correctly identify the disease simulations. Both the intervention and the control interns showed similar, moderate improvement in their diagnostic ability on the simulator. The intervention interns improved on MR from 42% correct to 54% correct; on MS from 8% correct to 23% correct; and on AR from 46% correct to 58% correct. The intervention and the control interns performed similarly on patient volunteers: for MR, 20% correct versus 31%; for AR, 29% correct versus 33%; and for aortic sclerosis, 64% correct versus 33%, respectively. CONCLUSIONS: The interns had difficulty correctly identifying three valvular heart disease simulations before and after an educational intervention employing a cardiovascular-patient simulator. At no time did the proportion of correct responses exceed 64%. Our teaching intervention during internship was either of insufficient intensity or of insufficient duration to produce significant improvement in cardiovascular diagnostic skills.

Cardiology↗
PubMed1993

Impact of social support on outcome in first stroke.

BACKGROUND AND PURPOSE: The purpose of this study is to examine the impact of social support on outcome after first stroke in a prospective cohort study. Although modest evidence exists for the importance of several psychosocial factors, studies have failed to use widely recognized measures of outcome and social support, have failed to control for time since onset, and have not used longitudinal techniques. METHODS: Forty-six surviving patients were followed for 6 months after stroke. Recovery was measured using repeated measures of functional status as indicated by the Barthel Index of activities of daily living. Perceived social support was measured at 1, 3, and 6 months after onset. Repeated-measures multivariate analysis of variance was used to analyze changes in functional status. RESULTS: Significant differences were found across levels of social support in trajectories of functional status (p = 0.002). A significant three-way interaction between stroke severity, social support, and outcome was also found (p = 0.012). Patients with more severe stroke and the largest amount of social support attained an average Barthel Index that was 68 points (65%) higher than the group reporting the least support. CONCLUSIONS: High levels of social support were associated with faster and more extensive recovery of functional status after stroke. Social support may be an important prognostic factor in recovery from stroke. Socially isolated patients may be at particular risk for poor outcome.

Activities of Daily Living↗
PubMed1993

Screening for prostate cancer. Does it make a difference?

Susan's father, Sidney Smith, is 63 years old. Recently he has heard on radio and television talk shows that a new test, the Prostate Specific Antigen (PSA), is now available to check for prostate cancer. During his general check-up visit to your office, he mentions this test and wants to know more. He is in excellent health and his urinary review of systems reveals only a slight decrease in the intensity of his urinary stream. On examination he has moderate prostate enlargement but no palpable nodules. His stool test is Hemoccult negative. The remainder of his examination is normal.

Humans↗
PubMed1993

Screening for asymptomatic diseases in your patients. Practical tips for doing it right.

Ms. Smith is a 64-year-old white woman who comes to the office for a "check-up." She has had a slight "weight problem" and some "high blood pressure," but has been in otherwise good health. She is 64 inches tall, weighs 186 pounds, and her blood pressure is 145/90. At the conclusion of an otherwise normal exam, the topic of health screening regarding breast cancer comes up. She declines a mammogram stating that she checks herself "pretty often" and that no other physician has ever felt lumps. Besides, she is "too old to worry about getting mammograms now," and one of her best friends told her that mammograms "really hurt bad."

Diagnostic Tests, Routine↗
PubMed1993

A cost-effectiveness analysis of hepatitis B vaccine in predialysis patients.

OBJECTIVE: Our objective was to assess the cost effectiveness of hepatitis B vaccine in predialysis patients. DATA SOURCES: Costs were calculated from estimated rates of health services use and unit costs of resource use. Efficacy data were based on probability estimates from the medical literature and included vaccination response rates, anticipated hepatitis B virus (HBV) infection rates, and outcomes from HBV. STUDY DESIGN: Costs and effectiveness of HBV vaccination was modeled with a decision tree constructed to analyze three vaccination strategies for patients with renal insufficiency: vaccine given prior to dialysis, vaccine given at time of dialysis, and no vaccine. Sensitivity analyses were performed to assess the effect of varying important clinical and cost variables. DATA COLLECTION/EXTRACTION METHODS: All analyses were based on efficacy and cost estimates derived from the medical literature. Analyses were conducted with the aid of SMLTREE software. PRINCIPAL FINDINGS: The number of patients requiring vaccination per case of HBV prevented was higher for dialysis patients (625 vaccinees/case prevented) than for predialysis patients (434 vaccinees/case prevented). The cost-effectiveness ratios were $25,313/case of HBV prevented for vaccination at the time of dialysis and $31,111 for the predialysis vaccine. When a higher HBV infection rate (based on clinical trial data) was substituted in the analysis, the cost effectiveness of a predialysis vaccination strategy improved to $856 per case prevented. Results were sensitive to the cost of the vaccine and the incidence of HBV infection in dialysis patients. For the predialysis strategy to become cost saving, the price of the vaccine would have to decrease from $114 to $1.50, or the incidence of infection would have to increase from 0.6 percent to 38 percent, holding all other variables constant. CONCLUSIONS: Additional HBV infection can be prevented by immunizing predialysis patients, but the cost is high. Decisions concerning vaccination policy should be influenced by local prevalence of HBV infection.

Cost of Illness↗
PubMed1992

Assessing housestaff diagnostic skills using a cardiology patient simulator.

OBJECTIVE: To assess the cardiovascular physical examination skills of internal medicine housestaff. DESIGN: Cross-sectional assessment of housestaff performance on three valvular abnormality simulations conducted on the cardiology patient simulator, "Harvey." Evaluations were done at the beginning (session I) and end (session II) of the academic year. SETTING: Duke University Medical Center internal medicine training program. SUBJECTS: Sixty-three (59%) of 107 eligible internal medicine housestaff (postgraduate years 1 through 3) agreed to participate and completed session I; 60 (95%) completed session II. MEASUREMENTS: All volunteers were tested on three preprogrammed simulations (mitral regurgitation, mitral stenosis, and aortic regurgitation). RESULTS: The overall correct response rates for all housestaff were 52% for mitral regurgitation, 37% for mitral stenosis, and 54% for aortic regurgitation. No difference was noted in correct response rates between sessions I and II. For mitral regurgitation, correct assessment of the contour of the holosystolic murmur predicted a correct diagnosis (P = 0.002). For mitral stenosis, identification of an opening snap and proper characterization of the mitral area diastolic murmur predicted a correct diagnosis (P < 0.0001). No individual observations were noted for the aortic regurgitation simulation, whose identification by the housestaff was associated with a correct diagnosis. CONCLUSIONS: Housestaff had difficulty establishing a correct diagnosis for simulations of three common valvular heart diseases. Accurate recognition of a few "key" observations was associated with a correct diagnosis in two of the three diseases. Teaching housestaff to elicit and interpret a few critical signs accurately may improve their physical diagnosis abilities.

Cardiology↗