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Biomedical subjects

L Rubenstein

Publications and source records attributed to L Rubenstein.

At least 19 recordsLinked to original sources
PubMed2001

Psychological screening of children for participation in nontherapeutic invasive research.

BACKGROUND: The need for children to participate in research has raised concerns about ethical issues surrounding their participation. OBJECTIVES: To describe a protocol of preresearch psychological screening and postresearch outcomes and to present the results of the screening process for a nontherapeutic, invasive research study. DESIGN AND SETTING: Descriptive study carried out at The University of Iowa Hospitals and Clinics, Iowa City. PARTICIPANTS: Twenty-eight children (mean age, 10.6 years) were screened, with 4 not completing the research study and another 4 unavailable for psychological follow-up. MAIN OUTCOME MEASURES: Prescreening interviews with parent and child and screening measures of appropriate child cognitive abilities and behavior; postscreening parent and child questionnaires. RESULTS: Of the 4 children who did not complete the research study, 3 were identified with increased anxiety during the screening and were advised to not participate in the study. The primary motivator for participation was monetary reimbursement (14 parents [82%]; 15 children [75%]), followed by altruistic reasons (10 parents [59%]; 4 children [20%]). Before participating, none of the children reported concerns related to participating in the study. However, on follow-up, 9 (45%) of the children reported that they had had concerns before participating. Follow-up assessment showed that parents underestimated their children's concerns related to sexual development assessment and intravenous insertion. CONCLUSIONS: Children with increased anxiety may not be appropriate participants in potentially anxiety-provoking research. Children's reports of concerns may change from preparticipation to postparticipation, and discrepancies may exist between parent and child reports of concerns with research participation. Further research is needed to ensure children's safe participation in research.

Adolescent↗
PubMed2001

Two-year effects of quality improvement programs on medication management for depression.

BACKGROUND: Significant underuse of evidence-based treatments for depression persists in primary care. We examined the effects of 2 primary care-based quality improvement (QI) programs on medication management for depression. METHODS: A total of 1356 patients with depressive symptoms (60% with depressive disorders and 40% with subthreshold depression) from 46 primary care practices in 6 nonacademic managed care organizations were enrolled in a randomized controlled trial of QI for depression. Clinics were randomized to usual care or to 1 of 2 QI programs that involved training of local experts who worked with patients' regular primary care providers (physicians and nurse practitioners) to improve care for depression. In the QI-medications program, depression nurse specialists provided patient education and assessment and followed up patients taking antidepressants for up to 12 months. In the QI-therapy program, depression nurse specialists provided patient education, assessment, and referral to study-trained psychotherapists. RESULTS: Participants enrolled in both QI programs had significantly higher rates of antidepressant use than those in the usual care group during the initial 6 months of the study (52% in the QI-medications group, 40% in the QI-therapy group, and 33% in the usual care group). Patients in the QI-medications group had higher rates of antidepressant use and a reduction in long-term use of minor tranquilizers for up to 2 years, compared with patients in the QI-therapy or usual care group. CONCLUSIONS: Quality improvement programs for depression in which mental health specialists collaborate with primary care providers can substantially increase rates of antidepressant treatment. Active follow-up by a depression nurse specialist in the QI-medications program was associated with longer-term increases in antidepressant use than in the QI model without such follow-up.

Adult↗
PubMed2001

Initiation of nonselective alpha1-antagonist therapy and occurrence of hypotension-related adverse events among men with benign prostatic hyperplasia: a retrospective cohort study.

BACKGROUND: Treatment of benign prostatic hyperplasia (BPH) with nonselective alpha1 antagonists such as terazosin, doxazosin, and prazosin results in blood pressure reduction due to vasodilation. OBJECTIVE: Using claims data from a large Medigap plan, we examined the effect of initiating nonselective alpha1-antagonist therapy on the incidence of hypotension-related adverse events likely to be associated with vascular alpha-adrenoreceptor antagonism in patients with BPH. METHODS: Medical and prescription claims data were obtained from the MEDSTAT Group for 53,824 men with a diagnosis code for BPH during the study period (January 1995-December 1997). We examined the rate of possible hypotension-related adverse events (diagnosis codes for hypotension, syncope, dizziness, fractures, and other injuries) per 10,000 person-days for men who began therapy with alpha1 antagonists and for a random sample of nonusers, stratified by prior use of other antihypertensive agents. RESULTS: After adjusting for baseline differences in event rates, those who initiated alpha1-antagonist therapy (n = 1564) had a significantly greater increase in hypotension-related adverse-event rates in the 4 months after initiation (vs the 4 months before initiation) than randomly selected nonusers (n = 8641) (increase of 1.82 vs decrease of 0.02 events per 10,000 person-days among those not taking antihypertensive agents; increase of 0.94 vs 0.69 events per 10,000 person-days among those taking other antihypertensive agents; P < 0.01). This increase began earlier and lasted longer among patients taking other antihypertensive agents. Those who discontinued their alpha1 antagonist had a higher rate of hypotensive events at baseline than those who did not (5.09 vs 3.19 events per 10,000 person-days among those using other antihypertensive agents; 3.62 vs 2.27 events per 10,000 person-days among those not using other antihypertensive agents; P < 0.05). CONCLUSIONS: Initiation of nonselective alpha1-antagonist therapy for the treatment of BPH increases the risk of a cluster of clinical events consistent with vascular alpha-adrenoreceptor antagonism. This effect is seen during a 4-month period around the initiation date. Prior initiation of other antihypertensive medication increases this effect. Urologists should consult with a patient's primary care physician about use of other antihypertensive agents before initiating nonselective alpha1-antagonist therapy for BPH.

Accidental Falls↗
PubMed2000

The role of competing demands in the treatment provided primary care patients with major depression.

OBJECTIVE: To examine whether competing demands explain the appearance of inadequate primary care depression treatment observed at a single visit. DESIGN: A cross-sectional patient survey. PARTICIPANTS AND SETTING: Two hundred forty patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices, representing 77.4% of the depressed patients identified through 2-stage screening of more than 11,000 primary care attenders. MAIN OUTCOME MEASURES: In patients with elevated depressive symptoms, discussing depression as a possible diagnosis in untreated patients, and changing depression management in treated patients. RESULTS: Physicians and patients discussed depression in 46 (47.9%) of 96 untreated patients; physicians changed depression treatment recommendations in 87 (60.4%) of 144 treated patients with current symptoms. Chronic physical comorbidity decreased the odds that physicians and untreated patients discussed depression as a possible diagnosis (odds ratio = 0.66, P = .01). New problems decreased the odds that treatment recommendations would be changed in treated patients who remained depressed (odds ratio = 0.39, P = .05). Physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients reported antidepressant medication was acceptable (odds ratio = 4.57, P = .01) and less likely to discuss depression if patients reported specialty care counseling was acceptable (odds ratio = 0.33, P = .05). CONCLUSIONS: The attention depression gets during a given medical visit is less associated with the severity of the patient's depressive symptoms than with the number or recency of other problems the patient has. If competing demands provide ongoing barriers to depression treatment, interventions will be needed to assure that patients with chronic physical problems receive high-quality mental health care in the primary care setting.

Antidepressive Agents↗
PubMed2000

Quality Enhancement Research Initiative in Mental Health.

The Veterans Administration (VA) recently introduced its Quality Enhancement Research Initiative (QUERI) to facilitate the translation of best practices into usual clinical care. The Mental Health QUERI (MHQ) was charged with developing strategic plans for major depressive disorder (MDD) and schizophrenia. Twenty percent or more of VA service users are affected by 1 of these 2 disorders, disorders that often have a devastating impact on affected individuals. Despite the increasing availability of efficacious treatments for each disorder, substantial gaps remain between best practices and routine care. In this context, the MHQ identified steps critical to the success of a sustained process of rapid-cycle health care improvement for MDD and schizophrenia, including research initiatives to close gaps in knowledge of best treatment practices, demonstration projects to close gaps in practice and to expand understanding of effective strategies for implementing clinical guidelines, targeted enhancements of the VA information system, and research and dissemination initiatives to increase the availability of resources to support the accelerated incorporation of best practices into routine care. This article presents an overview of the elements in the initial MHQ strategic plans and the rationale behind them.

Benchmarking↗
PubMed2000

Appropriateness of the decision to transfer nursing facility residents to the hospital.

OBJECTIVES: To develop and test a standardized instrument, the purpose of which is to assess (1) whether skilled nursing facilities (SNFs) transfer residents to emergency departments (ED) inappropriately, (2) whether residents are admitted to hospitals inappropriately, (3) and factors associated with inappropriate transfers. DESIGN: A structured implicit review (SIR) of medical records. SETTING AND PARTICIPANTS: Using nested random sampling in eight community SNFs, we identified SNF and hospital records of 100 unscheduled transfers to one of 10 hospitals. MEASUREMENTS: Seven trained physician reviewers assessed appropriateness using a SIR form designed for this study (2 independent reviews per record, 200 total reviews). We measured interrater reliability with kappa statistics and used bivariate analysis to identify factors associated with assessment that transfer was inappropriate. RESULTS: In 36% of ED transfers and 40% of hospital admissions, both reviewers agreed that transfer/admit was inappropriate, meaning the resident could have been cared for safely at a lower level of care. Agreement was high for both ED (percent agreement 84%, kappa .678) and hospital (percent agreement 89%, kappa .779). When advance directives were considered, both reviewers rated 44% of ED transfers and 45% of admissions inappropriate. Factors associated with inappropriateness included the perceptions that: (1) poor quality of care contributed to transfer need, (2) needed services would typically be available in outpatient settings, and (3) the chief complaint did not warrant hospitalization. CONCLUSIONS: Inappropriate transfers are a potentially large problem. Some inappropriate transfers may be associated with poor quality of care in SNFs. This study demonstrates that structured implicit review meets criteria for reliable assessment of inappropriate transfer rates. Structured implicit review may be a valuable tool for identifying inappropriate transfers from SNFs to EDs and hospitals.

Advance Directives↗
PubMed1998

The UDHR and The Limits of Medical Ethics: The Case of South Africa.

The leadership of South Africa's medical profession remained silent in the face of gross human rights violations by the apartheid government or affirmatively defended the government's conduct. While there were strong cultural and economic reasons for this alliance between leaders of the medical profession and the apartheid state, the leadership also embraced western medical ethics. As a result, when confronted about its conduct, it continually sought to defend its behavior on traditional ethical grounds. This article looks at the nature of that "ethical defense" in three areas, torture in detention, racial discrimination in health services, and breach of confidentiality in the case of political activists. The article concludes that the rules of medical ethics left too great a space for making such a defense and urges that ethical rules consistent with the Universal Declaration of Human Rights be adopted.

Journal Article↗
PubMed1996

Rehabilitation after hip fracture--equal opportunity for all?

OBJECTIVES: To determine whether factors unrelated to clinical appropriateness affect use of physical and occupational therapy (PT/OT) in elderly Medicare patients with acute hip fracture. DESIGN: Bivariate and multivariate analysis of detailed clinical data retrospectively gathered from medical records and of nonclinical variables obtained through linkage with the American Hospital Association data base. SETTING: 297 randomly selected hospitals from 5 states. PATIENTS: 2,762 elderly Medicare patients hospitalized with a primary diagnosis of acute hip fracture who were hospitalized during 1981-1982 or 1985-1986. INTERVENTION: Observational study. MAIN OUTCOME MEASURES: Initiation and intensity of PT/OT while in the acute hospital. RESULTS: We found evidence that factors not relevant to clinical appropriateness, such as race, hospital size, and state, significantly affect whether patients receive any PT/OT after acute fracture, as well as the intensity of PT/OT. For example, after controlling for patient clinical characteristics, we found that 63% of African-American patients received low-intensity PT/OT in comparison to 43% among non-African-American, and we found threefold differences among states both in initiation of PT/OT and in the intensity of its use. Overall, clinical characteristics had relatively greater influence on whether patients started PT/OT, whereas factors not relevant to clinical appropriateness had relatively greater influence on how much rehabilitation was provided. CONCLUSION: There are significant disparities in use of rehabilitation after hip fracture, only partially explained by patient clinical characteristics. Factors without obvious relevance to the clinical appropriateness of PT/OT exert a significant influence on use of rehabilitation services, particularly on the intensity of their use.

Black or African American↗
PubMed1994

Strategies to overcome barriers to early detection of cancer among older adults.

If health professionals wish to help increase the number of older adults who get screened regularly to detect cancer at an early stage, they must first understand the barriers to screening that older people experience. This paper discusses the barriers older women face regarding mammography screening. Data from American Association of Retired Persons research are presented, and strategies being implemented across the country are discussed. Barriers that older men face in terms of screening for prostate cancer and preventive health in general are also addressed. Finally, specific recommendations for health providers to use to educate seniors are offered.

Aged↗
PubMed1993

Who pays for published research?

OBJECTIVE: To determine the extent of unfunded research published in major medical journals. DESIGN: Review of original research completed in the United States and published in 23 official journals of internal medicine and neurology during 1 month in 1991. Investigators were contacted to confirm lack of funding. MAIN OUTCOME MEASURE: Percentage of unfunded, published original research. RESULTS: One hundred ninety-six articles were evaluated. There was at least one unfunded study in 78% of journals. Forty-five published studies (23%) were unfunded. Among those 45 studies, 7% were clinical trials, 9% were cohort studies, 18% were cross-sectional or case-control studies, 53% were case series, and 13% were surveys. Thirteen unfunded studies involved procedures that presumably were performed for research purposes and not as part of routine patient care. CONCLUSIONS: Nearly one quarter of original research published in major medical journals was unfunded. Seven percent of published research involved direct clinical costs that were not accounted for by the investigators. These costs may have been passed on to study participants or third-party payers.

Periodicals as Topic↗
PubMed1993

Argon laser scatter photocoagulation in treatment of branch retinal vein occlusion. A prospective clinical trial.

The objective of this prospective study was to ascertain whether scatter argon laser photocoagulation to the involved sector in major branch retinal vein occlusion and ischemic hemicentral retinal vein occlusion (a) prevents development of retinal and/or optic disk neovascularization and vitreous hemorrhage, and (b) affects visual acuity, visual fields and macular retinal lesions. The study was done in 271 eyes allocated to either treated (n = 61 eyes) or untreated (n = 210) groups. In this study, on an average follow-up of 3.6 years, the laser treatment (1) significantly reduced the risk of development of retinal neovascularization and vitreous hemorrhage, (2) did not affect the visual acuity and macular retinal lesions, and (3) produced a significant worsening in the peripheral visual fields compared to the untreated eyes. In view of our findings, we recommend that argon laser photocoagulation treatment should be given only when neovascularization is seen and not otherwise, because in the latter case, its detrimental effects may outweigh its beneficial ones.

Aged↗
PubMed1992

The short-term effect of patient health status assessment in a health maintenance organization.

This study was designed to test the short-term effects of health assessment on the process of care and patient satisfaction. The 29 Chart physicians used the Dartmouth COOP Charts to measure their adult patients' health status during a single clinical encounter; the 27 control clinicians used no measure of health status. We compared the change between baseline and post-intervention information for a sample of all study clinicians' patients. Most of the patients were female (67%), well educated (70% had at least a college education) and young (approximately 90% were aged 59 years or younger). We found that the ordering of tests and procedures for women was increased by exposure to the COOP Charts (52% vs. 35%; p < 0.01); the effect in men was not as significant (37% vs. 23%: p = 0.06). Although women reported no change in satisfaction with care, men claimed that the clinician helped in the management of pain (p = 0.02). We conclude that the use of health status measures during a single clinical encounter in an HMO changes clinician test ordering behaviour and may improve the help male patients receive for pain conditions. The long-term impact of these management changes is not known.

Episode of Care↗
PubMed1992

Arch length considerations due to the curve of Spee: a mathematical model.

Arch length analysis should consider discrepancies not only within the sagittal plane but also within the vertical and transverse planes. The vertical deviation of the occlusal plane from a flat plane is known as the curve of Spee. The purpose of this study was to produce a mathematical model of the mandibular arch form in three planes of space and to determine the effect that the curve of Spee has on arch circumference. Two mandibular arch forms, the catenary and the Bonwill-Hawley, were examined. The curve of Spee was modeled as a cylinder perpendicular to the midsagittal plane centered on the arch anteroposteriorly. A mathematical distance formula was used to calculate arch circumferences from the central fossa of the first molars for 10 arches with curves of Spee ranging from 0 to 10 mm. This procedure was repeated for arch circumferences extending from the central fossa of the second molars. Plots for the difference in arch circumferences verses depth of the curve of Spee showed that the relationship between these two variables is not linear and is less than one to one. This model showed that clinical practice of allowing 1 mm of arch circumference for leveling each millimeter of curve of Spee overestimates the amount of arch circumference needed to flatten the curve of Spee.

Child↗
PubMed1992

Benefits and obstacles of health status assessment in ambulatory settings. The clinician's point of view. The Dartmouth Primary Care COOP Project.

In the past decade physicians have identified the need to expand patient assessment to include global function and quality of life. During the same period, the busy clinic has evolved into the location where this assessment seems most appropriate. Integrating functional health assessment into a busy clinical practice is difficult because the necessary steps require time, thought, recording, and follow-up. Attention to the office ecosystem is very important before any patient care management method is introduced. The clinician must transform the results of health status screening into a specific functional diagnosis. The clinician has to understand the sensitivity, specificity, and predictive value of the measure for a preliminary diagnosis to be made. Often, additional measurements must be taken to establish a specific diagnosis. These steps encompass assessment linkage. Once the specific cause for the dysfunction is recognized, the clinician then has to determine the need for special resources. This is called the resource linkage. By following the steps outlined in this paper, the clinician should be able to overcome many obstacles for functional health status assessment in busy ambulatory settings.

Activities of Daily Living↗
PubMed1991

Targeting health advocacy efforts toward the older population.

Three American Association of Retired Persons health education programs addressing the prevention, detection, and treatment of cancer illustrate successful strategies for mobilizing older adults to be advocates for their own health. Programs include a national initiative to decrease smoking among adults older than 50 years of age, community education efforts to increase mammography use among older women, and peer education workshops designed to teach older patients consumer skills that will enable them to make informed treatment decisions.

Aged↗
PubMed1990

Explaining variations in hospital death rates. Randomness, severity of illness, quality of care.

We used administrative (Part A Medicare) data to identify a representative sample of 1126 patients with congestive heart failure and 1150 with acute myocardial infarction in hospitals with significant unexpectedly high inpatient, age-sex-race-disease-specific death rates ("targeted") vs all other ("untargeted") hospitals in four states. Although death rates in targeted hospitals were 5.0 to 10.9 higher per 100 admissions than in untargeted hospitals, 56% to 82% of the excess could result from purely random variation. Differences in the quality of the process of care (based on a medical record review) could not explain the remaining statistically significant differences in mortality. Comparing targeted hospitals with subsets of untargeted ones, eg, those with lower than expected death rates, did not affect this conclusion. Severity of illness explained up to 2.8 excess deaths per 100 admissions for patients with myocardial infarction. Identifying hospitals that provide poor-quality care based on administrative data and single-year death rates is unlikely; targeting based on time periods greater than 1 year may be better.

Aged↗