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Biomedical subjects

Laurence F McMahon

Publications and source records attributed to Laurence F McMahon.

12 recordsLinked to original sources
PubMed2006

Contribution of infection to increased mortality in women after cardiac surgery.

BACKGROUND: Women have higher mortality rates after coronary artery bypass graft (CABG) surgery compared with men. Explanations for this sex difference are controversial. The objective of this study was to assess whether infection contributes to the increased risk of mortality in women. METHODS: We conducted a cohort study of 9218 Michigan Medicare beneficiaries hospitalized for CABG surgery. The prevalence of infection at any site during hospitalization was determined. Patients were followed up for 100 days after surgery to assess vital status. Analyses were conducted using proportional hazards regression and population attributable risk. RESULTS: Women hospitalized for CABG surgery were more likely to have an infection than men (16.1% vs 9.8%, P<.001), regardless of age, race, type of admission, hospital volume, or presence of comorbidities. Infections of the respiratory tract, urinary tract, digestive tract, and skin and subcutaneous tissue were more common in women than in men. The risk of death in men increased 3-fold with infection, whereas the risk in women increased 1.8-fold. The interaction between infection and sex on mortality was significant after adjusting for age, type of admission, and presence of comorbidities (P = .008). The unadjusted percentage of deaths attributable to female sex was 13.9%, which decreased to 0.3% when adjusted for infection. Of the excess deaths in women, 96% could be accounted for by the differential distribution of infection between the sexes. CONCLUSION: The increased risk of mortality after CABG surgery in women may be explained by underlying differences in the prevalence of infection among men and women.

Aged↗
PubMed2005

Effects of work hour reduction on residents' lives: a systematic review.

CONTEXT: The Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003, partly out of concern for residents' well-being in the setting of sleep deprivation. These limitations are likely to also have an impact on other aspects of the lives of residents. OBJECTIVE: To summarize the literature regarding the effect of interventions to reduce resident work hours on residents' education and quality of life. DATA SOURCES: We searched the English-language literature about resident work hours from 1966 through April 2005 using MEDLINE, EMBASE, and Current Contents, supplemented with hand-search of additional journals, reference list review, and review of abstracts from national meetings. STUDY SELECTION: Studies were included that assessed a system change designed to counteract the effects of resident work hours, fatigue, or sleep deprivation; included an outcome directly related to residents; and were conducted in the United States. DATA EXTRACTION: For each included study, 2 investigators independently abstracted data related to study quality, subjects, interventions, and findings using a standard data abstraction form. DATA SYNTHESIS: Fifty-four articles met inclusion criteria. The interventions used to decrease resident work hours varied but included night and day float teams, extra cross-coverage, and physician extenders. Outcomes included measures of resident education (operative experience, test scores, satisfaction) and quality of residents' lives (amount of sleep, well-being). Interventions to reduce resident work hours resulted in mixed effects on both operative experience and on perceived educational quality but generally improved residents' quality of life. Many studies had major limitations in their design or conduct. CONCLUSIONS: Past interventions suggest that residents' quality of life may improve with work hour limitations, but interpretation of the outcomes of these studies is hampered by suboptimal study design and the use of nonvalidated instruments. The long-term impact of reducing resident work hours on education remains unknown. Current and future interventions should be evaluated with more rigorous methods and should investigate links between residents' quality of life and quality of patient care.

Education, Medical↗
PubMed2004

Systematic review: effects of resident work hours on patient safety.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) mandated new work hours rules for all residency programs in July 2003. PURPOSE: To critically evaluate the evidence that adhering to the ACGME standards will improve patient safety. DATA SOURCES: Searches of electronic databases (MEDLINE, EMBASE, PREMEDLINE, and Current Contents) and other methods to identify the English-language literature for studies on resident work hours for the years 1966 to 2004. STUDY SELECTION: Studies that assessed a system change designed to counteract the effects of work hours, fatigue, or sleep deprivation and that included an outcome related to patient safety were included. Seven studies met these criteria. DATA EXTRACTION: Two investigators abstracted data from all included studies by using a standard data abstraction form; each study was rated according to established criteria to assess study design quality. DATA SYNTHESIS: Interventions used were float systems, other cross-coverage systems, or unspecified schedule changes. Outcomes included mortality, adverse events, and medication errors. The results suggest that introducing such interventions has an unclear effect on selected patient safety indicators. Specifically, some indicators (such as mortality) may not change after interventions, while other indicators may improve or worsen. LIMITATIONS: This analysis is limited by the study designs of the included studies, the diversity of interventions in the studies, and the possibility of publication bias favoring studies that demonstrated statistically significant differences. CONCLUSION: Evidence on patient safety is insufficient to inform the process of reducing resident work hours.

Continuity of Patient Care↗
PubMed2003

Characteristics of primary care physicians and their practices associated with mammography rates for older women.

BACKGROUND: Mammography screening rates are below national recommendations for older women. Understanding the relation between the characteristics of primary care physicians (PCPs) and mammography rates for older women can help to target screening improvement efforts. METHODS: Subjects were 2527 PCPs practicing in Michigan between 1997 and 1998. A cross-sectional design used Medicare data to identify women age 68 years or older in 1998 whom PCPs treated in 1997-1998 and to determine whether these women had a mammogram between 1996 and 1998. Eligible women were Medicare beneficiaries age 65 years or older by 1996, residing in Michigan from 1996 to 1998, without specified comorbidities likely to affect decisions regarding mammography. Correlations and multiple regressions examined the relation between this score and characteristics of both PCPs and their practice populations of older women. RESULTS: Mammography rates across physicians' practices ranged from 3-100% (mean = 59%, standard deviation = 17%). Five predictors accounted for 55% of the variance in mammography rates across practices. Higher mammography rates were found to be independently related to physicians who have: a lower mean age for female Medicare patients, a higher mean number of physicians billing for patients' care, a lower mean number of inpatient admissions, obstetrics/gynecology practices, and a higher mean education level in patient's zip code (beta weights >/= 0.25, P < 0.0001). CONCLUSIONS: PCPs vary substantially with regard to mammography rates for older women. Mammography rates vary more with the population of patients in physicians' practices than with commonly measured personal characteristics of physicians. Mammography rates should be adjusted for patient population to target individual PCPs with low mammography rates for interventions.

Age Factors↗
PubMed2003

5-Year mammography rates and associated factors for older women.

BACKGROUND: Major national interventions occurred in the early and mid-1990s to increase mammography screening rates among older women. The current study examined mammography utilization by older women during this period. Relation between mammography utilization and demographic measures and health care-related factors also were examined. METHODS: A cross-sectional design examined variations in mammography during the 5 years between 1993 to 1997 in a representative sample of 10,000 female Medicare beneficiaries in Michigan age >or= 65 years in 1993. Medicare and census data were used. Separate analyses were performed for having undergone any mammogram and, for the 5680 women who had undergone a mammogram, the number of mammograms. Relations were examined between mammography utilization and 15 demographic variables (e.g., age and African-American race) and health care-related variables (e.g., inpatient admissions and number of physicians involved in care). RESULTS: In the 5 years 43% of older women had no evidence of having undergone a mammogram. Those with any mammogram averaged 2.8 mammograms. Meaningful independent predictors of both having undergone a mammogram and having more than one mammogram were more physicians involved in care, fewer inpatient admissions, and younger age. Having undergone a mammogram also was found to be associated with seeing an obstetrician/gynecologist. CONCLUSIONS: Even with screening mammography as a covered benefit and after several national informational campaigns, the current study found that in 5 years, 60% of older women either had not undergone a mammogram or had undergone only 1. Intervention efforts should emphasize screening based on functional status, not age. This message should be targeted to physicians as well as to older women without claims for recent mammograms and who are likely to be in good health.

Aged↗
PubMed2003

Differences in the reporting of care-related patient injuries to existing reporting systems.

BACKGROUND: This study compared the number of care-related injuries reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) with the number reported to 15 mandatory-reporting states. METHODS: The primary outcome measure was the number of patient injuries reported to each in 1999. RESULTS: In all categories examined, the number of reports submitted by accredited hospitals to states equaled or exceeded the number reported to JCAHO. DISCUSSION: State-reporting systems identified a greater number of care-related injuries than did the JCAHO system. Although JCAHO received fewer reports from accredited hospitals, its process requires an analysis of the event and a prevention plan, and it disseminates the lessons learned from reported events. For adverse event reporting to improve patient safety, there must be assurances that lessons are learned from these events, preventive measures are taken, and information is shared so others may benefit without having to experience the same adverse event. CONCLUSION: This study represents an early attempt to understand the system characteristics that influence hospital reporting of care-related patient injuries. As reporting systems become more prevalent and standardized, the influence of factors such as legal protections, confidentiality, and technology on reporting should be better understood.

Health Care Surveys↗
PubMed2003

Personalized targeted mailing increases mammography among long-term noncompliant medicare beneficiaries: a randomized trial.

OBJECTIVES: The study purpose was to increase mammography screening among older women by identifying female Medicare beneficiaries without a recent mammogram and assesses the cost-effectiveness of a personalized targeted mailing encouraging them to have a mammogram. METHODS: A randomized paired controlled trial included 1229 pairs of women matched on zip code, race, and urban or rural county. Postintervention mammography claims were measured from November 1997 through December 1998. The subjects were female Medicare beneficiaries age > or = 70, living in Michigan for > or = 5 years, having no significant comorbidity likely to affect screening, and no mammogram for > or = 5 years. Intervention subjects received a personally addressed letter from the Medical Director of Michigan Medicare with materials emphasizing the individual's lack of use of the Medicare mammography screening benefit, reasons for screening, and how to be screened. RESULTS: Women who received the mailing were 60% more likely to have a subsequent mammogram (OR 1.6, P <0.005), with diagnostic mammograms increasing more than screening mammograms (2.8% vs. 0.8%). The absolute increase was greatest for women age 70 to 79, 10.6% in the intervention group versus 6.5% for controls, odds ratio 1.7 (P <0.02). A statewide Medicare intervention in Michigan would cost of 108,000 US dollars to 238,000 US dollars, producing 3500 to 4300 additional mammograms at 31 US dollars to 55 US dollars per additional mammogram. CONCLUSION: The intervention increased mammography among long-term noncompliant older women, particularly increasing diagnostic mammograms. This approach can be directly implemented in other states and nationally. It may also be useful for other preventive services.

Aged↗
PubMed2003

Use of critical pathways to improve efficiency: a cautionary tale.

BACKGROUND: Critical pathways are healthcare management plans that specify patient goals and the sequence and timing of actions necessary to achieve these goals with optimal efficiency. More than 80% of hospitals in the United States use critical pathways for at least some of their patients. Unfortunately, critical pathway effectiveness in improving clinical efficiency is unclear. OBJECTIVES: To assess whether critical pathways have been successful in reducing patient length of stay (LOS) and resource utilization in our tertiary-care academic medical center. STUDY DESIGN: A before-and-after observational study using multivariate linear regression analyses. METHODS: We identified all critical pathways initiated in our medical center between 1993 and 1996 in which at least 50 adult patients would be evaluated in the year preceding and succeeding pathway implementation; 13 pathways satisfied these inclusion criteria. Using a before-and-after design, multivariate linear regression was used to evaluate each pathway's effect on average monthly LOS and resource utilization after adjusting for case mix and secular trends. RESULTS: Three of the 13 pathways were associated with a statistically significant immediate decrease in inpatient LOS: acute myocardial infarction (20.7% decrease; P = .001), cesarean section (14.6% decrease; P = .03), and kidney transplantation (24.5% decrease; P = .003). Only 1 pathway, percutaneous transluminal coronary angioplasty (PTCA), produced a statistically significant decrease in LOS slope (a decrease of 5.2% per month; P = .001). Two pathways were accompanied by a statistically significant immediate reduction in ancillary resource utilization: kidney transplantation (26.4% decrease; P = .001) and community-acquired pneumonia (21.8% decrease; P = .002). Only the PTCA pathway produced a statistically significant decrease in resource utilization slope during the 12-month follow-up period (a decrease of 8.4% per month; P < .001). CONCLUSIONS: Although some pathways did reduce LOS or resource utilization or both, most pathways reduced neither. Because substantial resources must be expended on pathway development, implementation, and maintenance, future efforts should be placed on further evaluating the effectiveness of critical pathways and understanding the reasons behind their success or failure before additional resources are consumed for this management strategy.

Critical Pathways↗
PubMed2002

Shifting costs from high-cost to low-cost diagnosis-related groups?

Hospitals are commonly compared with each other within diagnosis-related group (DRG) categories. Administrators infer that hospitals with a higher cost per case within a DRG are less efficient than hospitals with a lower cost per case after case mix and severity adjustment. The authors assess whether hospitals that carry a heavy load of high-cost DRGs potentially distribute the added expenses of treating these patients onto their lower cost DRGs using data gathered from the 47 hospitals in the University Hospital Consortium database between January 1994 and December 1995. The results indicate that given standard hospital allocation practices, some of the costs associated with high-cost patients were likely shifted downward, thereby inflating the cost per case for less expensive patients. As researchers adopt more benchmarking methodologies, it is important to recognize that standard accounting practices in which cost shifting from one class of patient to another may impair the ability to understand the actual cost structure for classes of patients.

Benchmarking↗