Rethinking utilization review.
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Diagnostic Services↗
Biomedical subjects
M F Shapiro
Publications and source records attributed to M F Shapiro.
Validation of a new measure of diarrhea.
Adequate measures of diarrheal disease are important to assess severity for clinical use and outcomes research. We developed a questionnaire to assess diarrhea severity and complications, and administered it to 205 HIV positive patients with diarrhea, fever, or weight loss. Noteworthy variations in stool form were reported by individuals and across subjects. Self-reported diarrhea correlated with the occurrence of any stool pictured without form. However, verbal descriptors "loose" and "semiformed" had little value in assessment of diarrheal disease. Both verbal and pictorial stool descriptors correlated well with diarrhea complications (pain, urgency, tenesmus, incontinence, and nocturnal diarrhea). By factor analysis, discomfort and nondiscomfort diarrhea complications loaded on different factors, consistent with clinical experience that discomfort is a distinct problem in diarrheal disease. In summary we have developed an instrument to precisely characterize diarrhea severity that correlates well with clinically important events such as incontinence and abdominal pain.
Abdominal Pain↗
Inconsistent contraceptive use among female college students: implications for intervention.
The authors evaluated the longitudinal consistency of use of contraceptive and barrier methods among female college students attending a student health clinic. The majority of students using unreliable methods of contraception during follow-up did not report unreliable contraceptive use at the baseline observation. Of 213 women who participated, 33% used unreliable contraception; 9% only at baseline, 14% only during 6-month follow-up, and 9% at both. Selection of a contraceptive method varied considerably over time. Of those using the oral contraceptive pill at baseline, 31% did not use this method during follow-up, and 43% of those using condoms at baseline had intercourse without a condom during follow-up. Single observations are inadequate to detect unreliable contraceptive use in this population; cross-sectional studies will fail to detect important transitions in contraceptive use. Interventions to prevent pregnancy and sexually transmitted disease among female college students should include a focus on the consistency of contraceptive use.
Adult↗
Access to medical care and health-related quality of life for low-income persons with symptomatic human immunodeficiency virus.
Despite growing interest in the accessibility of medical care and health-related quality of life for persons infected with human immunodeficiency virus, an association between these variables has not been documented. The authors conducted a cross-sectional study of access to care and its association with health-related quality of life among 205 persons of low income infected with the human immunodeficiency virus with constitutional symptoms and/or diarrhea at one public and one Veterans Administration hospital, using a 9-item measure of perceived access and a 55-item health-related quality of life instrument. Problems with access were widespread: 55% traveled for longer than 30 minutes to their usual source of care (compared with 9% to 12% of general populations in national surveys), 49% had problems meeting costs of care, and 48% had problems with clinic hours (compared with 23% in national surveys). In multivariate analyses, uninsured patients reported worse access than patients with Medicaid or Veterans Administration insurance, particularly for meeting the cost of care (P < 0.01). Adjusted health-related quality of life scores in this sample were far lower (by about 1 SD) than those of subjects in a large national acquired immune deficiency syndrome clinical trial. For 8 of 11 health-related quality of life subscales, worse perceived access was significantly (P < 0.05) associated with poorer health-related quality of life, even after controlling for T-4 lymphocyte count, symptoms and other factors. Access and health-related quality of life measures similar to those used in this study may prove useful in future evaluations of medical care systems serving poor, clinically ill populations infected with human immunodeficiency virus.
Acquired Immunodeficiency Syndrome↗
Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988.
OBJECTIVES: The purpose of the study was to compare use of invasive cardiovascular procedures among Latino, Asian, African-American, and White patients. METHODS: In a cross-sectional study of hospital discharge data, multiple logistic regression was used to model use of coronary artery angiography, bypass graft surgery, and angioplasty among adult Los Angeles County residents discharged from California hospitals between 1986 and 1988 with primary diagnoses consistent with possible ischemic heart disease. RESULTS: After potential demographic, socioeconomic, and clinical confounders, including hospital procedure volume, were controlled, Latinos were less likely than Whites to undergo angiography (odds ratio [OR] = 0.90) and bypass graft surgery (OR = 0.87). African Americans were less likely to receive bypass graft surgery (OR = 0.62) and angioplasty (OR = 0.80). Asians were as likely as Whites to receive each procedure. The impact of adjustment for hospital procedure volume was greater for Latinos and Asians than for African Americans. CONCLUSIONS: Administrative data suggest that disparities in use of invasive cardiovascular procedures are not limited to African Americans. Hospital procedure volume appears to be an important factor related to such disparities. The causes of racial/ethnic differences in reported procedure rates remain unclear.
Adult↗
Geographic variation in rates of selected surgical procedures within Los Angeles County.
OBJECTIVE: We explore the contribution of income and ethnicity to geographic variation in utilization of surgical procedures. DATA SOURCES/STUDY SETTING: We assessed the use of eight procedures from 1986 through 1988 among residents of Los Angeles County using data from the California Discharge Dataset, the 1980 census, and other secondary sources. Procedures chosen for evaluation were coronary artery bypass grafting (CABG), coronary artery angioplasty, permanent pacemaker insertion, mastectomy, simple hysterectomy, transurethral prostate resection (TURP), carotid endarterectomy, and appendectomy. STUDY DESIGN: The amount of inter-zip code variation for each procedure was first measured using various estimates including the analysis of variance coefficient of variation (CVA). Population-weighted multivariate regression analysis was used to model variation in age- and gender-adjusted rates of procedure use among 236 residential zip codes. PRINCIPAL FINDINGS: Highest-variation procedures were coronary artery angioplasty (CVA = .392) and carotid endarterectomy (CVA = .374). The procedures with the lowest degree of variation were cardiac pacemaker implantation (CVA = .194) and hysterectomy (CVA = .195). Variation was significantly related to income (carotid endarterectomy) and either African American or Latino zip code ethnicity for all procedures except pacemaker implantation. For all procedures except appendectomy, the direction of the effect was toward fewer procedures with lower income. However, the effect of African American or Latino population ethnicity varied. CONCLUSIONS: In this large urban area both population ethnicity and socioeconomic status are significantly associated with the geographic utilization of selected surgical procedures.
Age Factors↗
Comparison of health-related quality of life in clinical trial and nonclinical trial human immunodeficiency virus-infected cohorts.
Clinical trials randomly assign treatments and select participants to maximize internal validity, but such selection threatens generalizability by excluding important groups with the diseases under study. Particularly in human immunodeficiency virus (HIV) disease, the results of clinical trials are applied broadly to populations, despite limited representation by minorities and disadvantaged groups. Health-related quality of life (HRQOL), which is increasingly recognized as an important outcome in these studies, may be sensitive to differences that affect generalization of trial results to target populations. This study compared HRQOL in two HIV-infected cohorts: 1) multicenter AIDS Clinical Group Trials in which most subjects are white, privately insured, and high-income (n = 1,907); and 2) a study of ethnically diverse, low-income patients recruited from public clinics (n = 205). Both studies included 30 HRQOL items developed in the Medical Outcomes Study (MOS) and items on symptoms, medications, and demographic characteristics. HRQOL scores were significantly lower in the nontrial sample (P < 0.001) by about one standard deviation, even after direct adjustment for clinical and demographic characteristics, and also after comparison of the nontrial sample with the most symptomatic in the trial sample. The relationships of characteristics with HRQOL differed between nontrial and trial samples, suggesting problems generalizing results from HIV clinical trials to important target populations. HRQOL measures such as those from the MOS can be useful in detecting differences that affect generalization.
Acquired Immunodeficiency Syndrome↗
Sexual behavior of individuals infected with the human immunodeficiency virus. The need for intervention.
BACKGROUND: Public health efforts to stop the spread of the human immunodeficiency virus (HIV) emphasize behavior change among all persons at risk of infection. Yet efficient physician-based intervention might be targeted toward persons infected with HIV. To evaluate the need for intervention among HIV-infected persons attending a continuity clinic, we determined the prevalence of behaviors risky for new transmission of HIV and the characteristics of HIV-infected individuals participating in such behavior. METHODS: Cross-sectional structured survey of 227 HIV-infected patients attending an urban HIV continuity-of-care clinic. RESULTS: Nine percent of the subjects had vaginal, anal, or oral sex without a condom with an HIV-negative last sex partner (24% of whom were unaware that the subject was HIV infected) and an additional 13% with an HIV-status-unknown last sex partner (41% were unaware that the subject was HIV infected). Subjects used a condom for intercourse more often with a partner they knew to be HIV negative than HIV-status-unknown or HIV-positive (84% vs 59% vs 51%). Subjects with more lifetime male sexual partners were more likely to have had sex without a condom with an HIV-negative or HIV-status-unknown partner. CONCLUSION: The HIV-infected individuals in this clinic setting participate in a substantial amount of sexual behavior placing others at risk of new HIV infection. Physicians must address such behaviors, and programs specifically aimed at reducing such behavior should be a public health priority.
Adult↗
The contributions of authors to multiauthored biomedical research papers.
OBJECTIVE: To determine the contributions of each author to multiauthored biomedical research papers. DESIGN: Mailed, self-administered survey. PARTICIPANTS: A total of 184 first authors from a consecutive sample of 200 papers with four or more authors published in 10 leading biomedical journals. MAIN OUTCOME MEASURES: First authors' ratings of which authors had made substantial contributions to the following: initial conception of the study, design of the study, provision of needed resources, collection of data, analysis and interpretation of data, and writing the first draft of the paper or revising drafts for important intellectual content. RESULTS: The contributions of nonfirst authors varied greatly within and among papers. Even second and last authors--though they generally contributed more than other nonfirst authors--were markedly inconsistent in the extent and pattern of their contributions. Time spent on the research differed among authors by orders of magnitude. An appreciable number of authors made few or no substantial contributions to the research. CONCLUSIONS: The nature and extent of contributions of nonfirst authors to biomedical research reported in multiauthored papers cannot reliably be discerned (or discounted) by authorship or order of authors. The two core purposes of scientific authorship--to confer credit and denote responsibility for research--are not adequately being met by these authorship practices.
Authorship↗
When patients first suspect and find out they are infected with the human immunodeficiency virus: implications for prevention.
To evaluate how individuals infected with the human immunodeficiency virus (HIV) became aware of their infection, when they first suspected they were infected with HIV and factors associated with suspecting HIV infection, we surveyed 227 patients at an urban outpatient HIV clinic. Though nearly all patients acknowledged risk factors for HIV, 60% reported that they did not suspect that they were infected until they received a positive HIV antibody test result. Non-white patients were less likely to suspect HIV infection prior to testing than white subjects (p < 0.03). Subjects not suspecting infection more often received HIV testing through a screening program or during a medical encounter (p = 0.02) and were less likely to be told by others that they might be infected (p = 0.001) than patients suspecting infection prior to testing. Forty-eight percent of subjects who suspected HIV infection prior to testing waited one year or more before obtaining their HIV antibody test. Interventions to reduce faulty personal HIV risk perception are needed to promote earlier HIV diagnosis.
AIDS Serodiagnosis↗
The clinical application of prediction models in medicine--predicting Mycobacterium avium complex bacteremia.
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AIDS-Related Opportunistic Infections↗
A rapid preadmission method for predicting inpatient course of disease for patients with HIV-related Pneumocystis carinii pneumonia.
Pneumocystis carinii pneumonia (PCP) has been the most common reason for hospitalization and the most common cause of death for persons with HIV infection. Hospital mortality rates for PCP range from 10 to 60%. Studies that evaluate differences in hospital mortality rates must control for differences in patient severity of illness. We developed a simple staging system for categorizing severity of illness in patients with PCP. We analyzed the relation between clinical factors and in-hospital mortality for 576 hospitalized patients with HIV-related PCP treated at 56 hospitals for the years 1987 to 1990. Four stages of PCP could be identified based on three routinely measured clinical variables: alveolar-arterial oxygen difference, total lymphocyte count, and body mass index. The mortality rate increased by stage: 1% for Stage 1, 8% for Stage 2, 23% for Stage 3, and 48% for Stage 4. The four-stage severity system compared well with previous models developed for AIDS and for PCP, and is easier to use in clinical practice. Our staging system identifies patients with a high and low risk of in-hospital death upon admission. Physicians may benefit from consideration of PCP stage in deciding on management strategies. In addition, researchers involved in clinical trials of new agents for PCP might consider stratification by PCP stage in order to define homogenous groups.
AIDS-Related Opportunistic Infections↗
[Medical interns and AIDS: perceptions and attitudes in 3 French regions].
This study has been conducted to clarify certain issues regarding residency training with regard to acquired immunodeficiency syndrome (AIDS). The objective was to evaluate resident physicians' experiences in, and attitudes toward, the care of persons with AIDS in France. The design was a cross sectional study, using a self administered mailed questionnaire to 627 residents in 3 French areas: Ile-de-France, Nord-Pas de Calais and Province-Côte d'Azur, with a follow up of non responders. The subjects of this study were a random sample of residents in the second year of specialty medicine or family medicine residencies (biological residents, surgeons, public health residents and research residents were excluded). The response rate was 56%. More than half of residents indicated that their training was deficient in AIDS ambulatory care and less of 40% felt competent to provide usual and primary care for AIDS patients. The social and psychosocial aspect of care seems to be the greatest difficulties for them. About the half of residents reported at least one needle stock contaminated by a patient's blood. Needle stick injuries from patients known to have HIV infection were reported by 8% of them. About 25% expressed great concern about the professional risk of HIV contamination and 24% indicated it is dangerous to provide care for AIDS patients. It appears that an important component of future education in medical residency programs should emphasize strategies to address social and psychosocial issues in the medical care of AIDS patients and to decrease the risk of needle stick injuries.
Accidents, Occupational↗
Is the spirit of capitalism undermining the ethics of health services research?
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Capitalism↗
The effect of alternative case-mix adjustments on mortality differences between municipal and voluntary hospitals in New York City.
OBJECTIVE: This study investigated how mortality differences between groups of municipal versus voluntary hospitals are affected by case-mix adjustment methods. DATA SOURCES AND STUDY SETTING: We sampled about 10,000 random admissions from administrative data for patients hospitalized with each of six conditions in hospitals in New York City during 1984-1987. STUDY DESIGN: We developed logistic regression models adjusting for age and gender, for principal diagnosis, for "limited other diagnoses" (secondary diagnoses that were very unlikely to result from care received), for "full other diagnoses" (all secondary diagnoses irrespective of whether they might have been due to care received), for previous diagnoses, and for other variables. PRINCIPAL FINDINGS: For five of the six conditions, when the limited other diagnoses adjustment was used there was higher mortality in the municipal hospitals (p < .05), with 3.3 additional deaths/100 admissions for myocardial infarction, 1.2 for pneumonia, 8.3 for stroke, 2.8 for head trauma, and 0.8 for hip repair. However, when the full other diagnoses adjustment was used, differences remained significant only for stroke (4.3 additional deaths/100 admissions) and head trauma (1.3) (p < .05). CONCLUSIONS: Estimates of mortality differences between New York City municipal and voluntary hospitals are substantially affected by which secondary diagnoses are used in case-mix adjustment. Judgments of quality should not be based on administrative data unless models can be developed that validly capture level of sickness at admission.
Adolescent↗
AIDS-related risk behavior, knowledge, and beliefs among women and their Mexican-American sexual partners who used intravenous drugs.
OBJECTIVE: To assess the risk behaviors, knowledge, and beliefs regarding human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) among women and their sexual partners who were Mexican-American men who used intravenous drugs. DESIGN: Survey of male methadone users and their female sexual partners. PARTICIPANTS AND SETTING: Mexican-American male clients at a methadone clinic in Los Angeles, Calif, were consecutively recruited for the study. A method similar to partner contact tracing was used to identify female subjects. One hundred subjects, representing 50 male-female pairs of sexual partners, answered identical questionnaires. The responses from females were compared with those from their male partners. RESULTS: Seventy-four percent of the females disclosed that they used intravenous drugs, and 88% knew that their male partners were intravenous drug users. Of subjects who used intravenous drugs, 73% (27/37) of females and 88% (44/50) of males currently injected themselves and shared uncleaned needles. Seventy-six percent of females and 84% of males never used a condom during the previous year, and about 20% of both sexes had more than one sexual partner. Even though most of the females understood how HIV was transmitted and recognized themselves as at risk for AIDS, they continued to share needles unsafely and place themselves at risk for acquiring HIV infection through sex. CONCLUSION: This group of females and their male sexual partners engaged in multiple behaviors that may contribute to the further propagation of HIV infection.
Acquired Immunodeficiency Syndrome↗
Mortality differences between New York City municipal and voluntary hospitals, for selected conditions.
To determine if mortality differences between municipal and voluntary hospitals in New York City persist after adjustment for computerized administrative data (age, sex, principal diagnosis, and secondary diagnosis), six conditions in those hospitals from 1984 through 1987 were studied. Unadjusted mortality was significantly higher in municipal hospitals for myocardial infarction, stroke, and head trauma, and lower for congestive heart failure and pneumonia. Adjustment using administrative data eliminated differences for myocardial infarction, congestive heart failure, and pneumonia, but not for stroke and head trauma. We conclude that adjustment using administrative data eliminates some but not all mortality differences between municipal and voluntary hospitals. Medical record review is needed to determine why these differences persist.
Diagnosis-Related Groups↗
Effect of HIV antibody testing and AIDS education on communication about HIV risk and sexual behavior. A randomized, controlled trial in college students.
OBJECTIVE: To evaluate the effects of human immunodeficiency virus (HIV) antibody testing and education about HIV infection on communication about sexual risk behaviors for HIV transmission. DESIGN: Randomized, controlled trial with three arms. SETTING: University student health center. PATIENTS: Of 2196 heterosexual university students attending the student health clinic for medical care, 435 were interested in education about HIV and HIV testing and were randomly assigned to three groups. Follow-up at 6 months was done in 370 subjects (85%): 90 control subjects, 144 subjects who received education alone, and 136 subjects who received education plus HIV testing. MEASUREMENTS AND RESULTS: Subjects who received HIV testing plus education questioned sexual partners about their HIV status more than subjects receiving education alone or those in the control group (56%, 42%, and 41% of subjects, respectively; P = 0.01). No consistent differences among groups in the number of sexual partners or in the use of condoms were found at follow-up. CONCLUSIONS: Heterosexual university students who received education about HIV infection plus HIV testing had increased communication with sexual partners about the risk for HIV infection after 6 months. Further reduction in risk behaviors for HIV transmission may require additional interventions in this population.
AIDS Serodiagnosis↗