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Biomedical subjects

Michael J Fine

Publications and source records attributed to Michael J Fine.

At least 19 recordsLinked to original sources
PubMed2006

Advancing health disparities research within the health care system: a conceptual framework.

We provide a framework for health services-related researchers, practitioners, and policy makers to guide future health disparities research in areas ranging from detecting differences in health and health care to understanding the determinants that underlie disparities to ultimately designing interventions that reduce and eliminate these disparities. To do this, we identified potential selection biases and definitions of vulnerable groups when detecting disparities. The key factors to understanding disparities were multilevel determinants of health disparities, including individual beliefs and preferences, effective patient-provider communication; and the organizational culture of the health care system. We encourage interventions that yield generalizable data on their effectiveness and that promote further engagement of communities, providers, and policymakers to ultimately enhance the application and the impact of health disparities research.

Attitude to Health↗
PubMed2006

Racial differences in 30-day mortality for pulmonary embolism.

OBJECTIVES: Previous studies reported a higher incidence of in-hospital mortality for Black patients who had pulmonary embolism than for White patients. We used a large statewide database to compare 30-day mortality (defined as death within 30 days from the date of latest hospital admission) for Black and White patients who were hospitalized because of pulmonary embolism. METHODS: The study cohort consisted of 15531 discharged patients who had been treated for pulmonary embolism at 186 Pennsylvania hospitals between January 2000 and November 2002. We used random-effects logistic regression to model 30-day mortality for Black and White patients, and adjusted for patient demographic and clinical characteristics. RESULTS: The unadjusted 30-day mortality rates were 9.0% for White patients, 10.3% for Blacks, and 10.9% for patients of other or unknown race. When adjusted for severity of disease using a validated clinical prognostic model for pulmonary embolism, Black patients had 30% higher odds of 30-day mortality compared with White patients at the same site (adjusted odds ratio = 1.3; 95% confidence interval, 1.1,1.6). Neither insurance status nor hospital volume was a significant predictor of 30-day mortality. CONCLUSION: Black patients who had pulmonary embolism had significantly higher odds of 30-day mortality compared with White patients.

Adolescent↗
PubMed2006

Associations of race with depression and symptoms in patients on maintenance haemodialysis.

BACKGROUND: Although studies have shown that African American haemodialysis patients report better overall quality of life than Whites, racial differences in depression and symptom burden remain less well characterized. The aim of this study was to compare these domains between African American and White patients on chronic haemodialysis. METHODS: We surveyed African American and White maintenance haemodialysis patients. Depression was assessed using the Beck Depression Inventory (BDI) and Cognitive Depression Index (CDI). Symptoms were evaluated using the Dialysis Symptom Index (DSI). RESULTS: Among the 82 Whites and 78 African Americans enrolled, there were no racial differences in the prevalence of depression (27% in African Americans vs 27% in Whites, P = 1.0), BDI Scores (11.2 vs 10.9, P = 0.6) or CDI scores (6.0 vs 6.0, P = 0.9). Symptom burden was substantial in both African Americans and Whites (median number of symptoms 8.5 and 9.0, respectively) with no racial differences in the overall burden or severity of symptoms. However, based on a single item, African Americans were more likely to describe their religious/spiritual beliefs as "very important". Adjustment for demographic and treatment characteristics had no impact on the associations of race with depression or symptoms. CONCLUSIONS: Depression and symptoms are highly prevalent in both African American and White haemodialysis patients, without racial differences in these health-related domains. In exploratory analyses, spiritual/religious beliefs appear to be of greater importance to African Americans. The relevance of these observations to the advantages in quality of life and survival among African Americans on haemodialysis warrants further investigation.

Black or African American↗
PubMed2006

Associations of increases in serum creatinine with mortality and length of hospital stay after coronary angiography.

The absence of a universally accepted definition of radiocontrast nephropathy (RCN) has hampered efforts to characterize effectively the incidence and the clinical significance of this condition. The objective of this study was to identify a clinically relevant definition of RCN by assessment of the relationships between increases in serum creatinine (Scr) of varying magnitude after coronary angiography and clinical outcomes. An electronic medical database was used to identify all patients who underwent coronary angiography at the University of Pittsburgh Medical Center during a 12-yr period and abstract Scr levels before and after angiography, as well as demographic characteristics and comorbid conditions. Changes in Scr after angiography were categorized into mutually exclusive categories on the basis of absolute and relative changes from baseline levels, with a separate category denoting "unknown" change. Discrete proportional odds models were used to examine the association between increases in Scr and 30-d in-hospital mortality and length of stay. A total of 27,608 patients who underwent coronary angiography were evaluated. Small absolute (0.25 to 0.5 mg/dl) and relative (25 to 50%) increases in Scr were associated with risk-adjusted odds ratios for in-hospital mortality of 1.83 and 1.39, respectively. Larger increases in Scr generally were associated with greater risks for these clinical outcomes. Small increases in Scr after the administration of intravascular radiocontrast are associated with adverse patient outcomes. This observation will help guide the post-procedure care of patients who undergo coronary angiography and has important implications for future studies that investigate RCN.

Aged↗
PubMed2006

A prediction rule to identify low-risk patients with pulmonary embolism.

BACKGROUND: A simple prognostic model could help identify patients with pulmonary embolism who are at low risk of death and are candidates for outpatient treatment. METHODS: We randomly allocated 15,531 retrospectively identified inpatients who had a discharge diagnosis of pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our rule to predict 30-day mortality using classification tree analysis and patient data routinely available at initial examination as potential predictor variables. We used data from a European prospective study to externally validate the rule among 221 inpatients with pulmonary embolism. We determined mortality and nonfatal adverse medical outcomes across derivation and validation samples. RESULTS: Our final model consisted of 10 patient factors (age > or = 70 years; history of cancer, heart failure, chronic lung disease, chronic renal disease, and cerebrovascular disease; and clinical variables of pulse rate > or = 110 beats/min, systolic blood pressure < 100 mm Hg, altered mental status, and arterial oxygen saturation < 90%). Patients with none of these factors were defined as low risk. The 30-day mortality rates for low-risk patients were 0.6%, 1.5%, and 0% in the derivation, internal validation, and external validation samples, respectively. The rates of nonfatal adverse medical outcomes were less than 1% among low-risk patients across all study samples. CONCLUSIONS: This simple prediction rule accurately identifies patients with pulmonary embolism who are at low risk of short-term mortality and other adverse medical outcomes. Prospective validation of this rule is important before its implementation as a decision aid for outpatient treatment.

Age Factors↗
PubMed2006

Development and validation of a smoking media literacy scale for adolescents.

OBJECTIVES: To develop a smoking media literacy (SML) scale by using empiric survey data from a large sample of high school students and to assess reliability and criterion validity of the scale. DESIGN: On the basis of an established theoretical framework, 120 potential items were generated, and items were eliminated or altered on the basis of input from experts and students. Cross-sectional responses to scale items, demographics, smoking-related variables, and multiple covariates were obtained to refine the scale and determine its reliability and validity. SETTING: One large Pittsburgh, Pa, high school. PARTICIPANTS: A total of 1211 high school students aged 14 to 18 years. MAIN OUTCOME MEASURES: Current smoking, susceptibility to smoking, attitudes toward smoking, and smoking norms. RESULTS: Factor analysis demonstrated a strong 1-factor scale with 18 items (alpha = 0.87). After controlling for all covariate data, SML had a statistically significant and independent association with current smoking (P = .01), susceptibility (P<.001), and attitudes (P<.001), but not norms (P = .42). Controlling for all covariates, an increase of 1 point on the 10-point SML scale was associated with a 22% decrease in the odds of being a smoker and a 31% decrease in the odds of being susceptible to smoking. CONCLUSIONS: Smoking media literacy can be measured with excellent reliability and concurrent criterion validity. Given the independent association between SML and smoking, media literacy may be a promising tool for future tobacco control interventions.

Adolescent↗
PubMed2006

Association of cigarette smoking and media literacy about smoking among adolescents.

PURPOSE: To determine whether media literacy concerning tobacco use is independently associated with two clinically relevant outcome measures in adolescents: current smoking and susceptibility to smoking. METHODS: We asked high school students aged 14-18 years to complete a survey that included a validated 18-item smoking media literacy (SML) scale, items assessing current smoking and susceptibility to future smoking, and covariates shown to be related to smoking. We used logistic regression to assess independent associations between the two outcome measures and SML. RESULTS: Of the 1211 students who completed the survey, 19% reported current smoking. Controlling for all potential confounders of smoking, we found that an increase of one point (out of 10) in SML was independently associated with an odds ratio for smoking of .84 (95% confidence interval [CI] .71-.99). Compared with students below the median score on the SML scale, students above the median had an odds ratio for smoking of .57 (95% CI .37-.87). Of the students who were nonsmokers, 40% were classified as susceptible to future smoking. Controlling for all potential confounders of smoking, we found that an increase of one point (out of 10) was independently associated with and an odds ratio for smoking susceptibility of .68 (95% CI .58-.79). Compared with students below the median SML, students above the median SML had an odds ratio for smoking susceptibility of .49 (95% CI .35-.68). CONCLUSIONS: In this sample of high school students, higher SML is independently associated with reduced current smoking and reduced susceptibility to future smoking.

Adolescent↗
PubMed2006

The emergency department triage of community-acquired pneumonia project data and documentation systems: a model for multicenter clinical trials.

Multicenter clinical trials are complex undertakings that require significant resources to ensure efficient, high quality research. This paper describes the goals, design, and implementation of a multicenter clinical trial database management system to support this aim. A large number of study sites or patients, and the goal of automatically generating large portions of data management infrastructure from common metadata, motivated the development of the system. This paper also describes extensions for a generalized project documentation system, and discusses plans for further extensions and improvements based on observed strengths, limitations, and anticipated technological change.

Community-Acquired Infections↗
PubMed2006

Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial.

BACKGROUND: Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting. OBJECTIVE: To identify the factors associated with the hospitalization of low-risk patients with pneumonia. METHODS: We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments. RESULTS: Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to outpatient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III. CONCLUSIONS: Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contraindications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.

Cluster Analysis↗
PubMed2006

Severe sepsis in community-acquired pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course?

STUDY OBJECTIVES: Most natural history studies of severe sepsis are limited to ICU populations. We describe the onset and timing of severe sepsis during the hospital course for patients hospitalized with community-acquired pneumonia (CAP). We also determine the ability of the systemic inflammatory response syndrome (SIRS) and other proposed risk stratification scores measured at emergency department (ED) presentation to predict progression to severe sepsis, septic shock, or death. DESIGN: Retrospective analysis of a prospective observational outcome study from the Pneumonia Patient Outcomes Research Team (PORT). SETTING: Four academic medical centers in the United States and Canada between October 1991 and March 1994. PARTICIPANTS: The 1,339 patients hospitalized for CAP in the PORT study cohort, and a random subset of 686 patients for whom we had information for SIRS criteria. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: All subjects had infection (CAP). Severe sepsis was defined as new-onset acute organ dysfunction in this cohort, using consensus criteria. Severe sepsis developed in one half of the patients (n = 639, 48%), nonpulmonary organ dysfunction developed in 520 patients (39%), and septic shock developed in 61 subjects (4.5%). Severe sepsis and septic shock were present at ED presentation in 457 patients (71% of severe sepsis cases) and 27 patients (44% of septic shock cases), respectively. While SIRS was common at presentation (82% of the subset of 686 had two SIRS criteria), it was not associated with increased odds for progression to severe sepsis (odds ratios [ORs], 0.65 and 0.89 for two or more SIRS criteria and three or more SIRS criteria, respectively), septic shock (ORs, 0.80 and 0.55), or death (ORs, 0.65 and 0.39), with poor discrimination (all receiver operating characteristic [ROC] areas under the curve < 0.5). The pneumonia severity index was associated with severe sepsis (p < 0.001) with moderate discrimination (ROC, 0.63). CONCLUSIONS: Severe sepsis is common in hospitalized CAP patients, occurring early in the hospital course. SIRS criteria do not appear to be useful predictors for progression to severe sepsis in CAP.

Cohort Studies↗
PubMed2005

Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial.

BACKGROUND: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice. OBJECTIVE: To compare the effectiveness and safety of 3 guideline implementation strategies. DESIGN: Cluster-randomized, controlled trial. SETTING: 32 emergency departments in Pennsylvania and Connecticut. PATIENTS: 3219 patients with a clinical and radiographic diagnosis of pneumonia. INTERVENTIONS: The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12). MEASUREMENTS: Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients. RESULTS: More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P = 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P < 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1%; low-intensity group, 23.0%; P < 0.001). No statistically significant differences in safety outcomes were observed across interventions. LIMITATIONS: Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial. CONCLUSIONS: Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients.

Aged↗
PubMed2005

Validation of a model to predict adverse outcomes in patients with pulmonary embolism.

AIMS: To validate a model for quantifying the prognosis of patients with pulmonary embolism (PE). The model was previously derived from 10 534 US patients. METHODS AND RESULTS: We validated the model in 367 patients prospectively diagnosed with PE at 117 European emergency departments. We used baseline data for the model's 11 prognostic variables to stratify patients into five risk classes (I-V). We compared 90-day mortality within each risk class and the area under the receiver operating characteristic curve between the validation and the original derivation samples. We also assessed the rate of recurrent venous thrombo-embolism and major bleeding within each risk class. Mortality was 0% in Risk Class I, 1.0% in Class II, 3.1% in Class III, 10.4% in Class IV, and 24.4% in Class V and did not differ between the validation and the original derivation samples. The area under the curve was larger in the validation sample (0.87 vs. 0.78, P=0.01). No patients in Classes I and II developed recurrent thrombo-embolism or major bleeding. CONCLUSION: The model accurately stratifies patients with PE into categories of increasing risk of mortality and other relevant complications. Patients in Risk Classes I and II are at low risk of adverse outcomes and are potential candidates for outpatient treatment.

Aged↗
PubMed2005

Derivation and validation of a prognostic model for pulmonary embolism.

RATIONALE: An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment. OBJECTIVES: To develop a clinical prediction rule that accurately classifies patients with pulmonary embolism into categories of increasing risk of mortality and other adverse medical outcomes. METHODS: We randomly allocated 15,531 inpatient discharges with pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our prediction rule using logistic regression with 30-day mortality as the primary outcome, and patient demographic and clinical data routinely available at presentation as potential predictor variables. We externally validated the rule in 221 inpatients with pulmonary embolism from Switzerland and France. MEASUREMENTS: We compared mortality and nonfatal adverse medical outcomes across the derivation and two validation samples. MAIN RESULTS: The prediction rule is based on 11 simple patient characteristics that were independently associated with mortality and stratifies patients with pulmonary embolism into five severity classes, with 30-day mortality rates of 0-1.6% in class I, 1.7-3.5% in class II, 3.2-7.1% in class III, 4.0-11.4% in class IV, and 10.0-24.5% in class V across the derivation and validation samples. Inpatient death and nonfatal complications were <or= 1.1% among patients in class I and <or= 1.9% among patients in class II. CONCLUSIONS: Our rule accurately classifies patients with pulmonary embolism into classes of increasing risk of mortality and other adverse medical outcomes. Further validation of the rule is important before its implementation as a decision aid to guide the initial management of patients with pulmonary embolism.

Acute Disease↗
PubMed2005

Prevalence, severity, and importance of physical and emotional symptoms in chronic hemodialysis patients.

The prevalence, severity, and clinical significance of physical and emotional symptoms in patients who are on maintenance hemodialysis remain incompletely characterized. This study sought to assess symptoms and their relationship to quality of life and depression. The recently developed Dialysis Symptom Index was used to assess the presence and the severity of 30 symptoms. The Illness Effects Questionnaire and Beck Depression Inventory were used to evaluate quality of life and depression, respectively. Correlations among symptom burden, symptom severity, quality of life, and depression were assessed using Spearman correlation coefficient. A total of 162 patients from three dialysis units were enrolled. Mean age was 62 y, 48% were black, 62% were men, and 48% had diabetes. The median number of symptoms was 9.0 (interquartile range 6 to 13). Dry skin, fatigue, itching, and bone/joint pain each were reported by > or =50% of patients. Seven additional symptoms were reported by >33% of patients. Sixteen individual symptoms were described as being more than "somewhat bothersome." Overall symptom burden and severity each were correlated directly with impaired quality of life and depression. In multivariable analyses adjusting for demographic and clinical variables including depression, associations between symptoms and quality of life remained robust. Physical and emotional symptoms are prevalent, can be severe, and are correlated directly with impaired quality of life and depression in maintenance hemodialysis patients. Incorporating a standard assessment of symptoms into the care provided to maintenance hemodialysis patients may provide a means to improve quality of life in this patient population.

Aged↗
PubMed2005

Effect of both elevated troponin-I and peripheral white blood cell count on prognosis in patients with suspected myocardial injury.

We found a high white blood cell count (>11,000/mul) to be of additive prognostic value to high troponin-I levels in predicting risk of recurrent nonfatal myocardial infarctions and all-cause mortality in patients who present with acute coronary syndromes and non-ST-elevation myocardial infarctions. A high troponin-I level or white blood cell count increased the odds ratio of an event to 2.2 (95% confidence interval 1.0 to 4.73, p = 0.05), but high values for the 2 markers increased the odds ratio to 4.5 (95% confidence interval 1.42 to 14.21, p = 0.01).

Aged↗
PubMed2005

Predicting dire outcomes of patients with community acquired pneumonia.

Community-acquired pneumonia (CAP) is an important clinical condition with regard to patient mortality, patient morbidity, and healthcare resource utilization. The assessment of the likely clinical course of a CAP patient can significantly influence decision making about whether to treat the patient as an inpatient or as an outpatient. That decision can in turn influence resource utilization, as well as patient well being. Predicting dire outcomes, such as mortality or severe clinical complications, is a particularly important component in assessing the clinical course of patients. We used a training set of 1601 CAP patient cases to construct 11 statistical and machine-learning models that predict dire outcomes. We evaluated the resulting models on 686 additional CAP-patient cases. The primary goal was not to compare these learning algorithms as a study end point; rather, it was to develop the best model possible to predict dire outcomes. A special version of an artificial neural network (NN) model predicted dire outcomes the best. Using the 686 test cases, we estimated the expected healthcare quality and cost impact of applying the NN model in practice. The particular, quantitative results of this analysis are based on a number of assumptions that we make explicit; they will require further study and validation. Nonetheless, the general implication of the analysis seems robust, namely, that even small improvements in predictive performance for prevalent and costly diseases, such as CAP, are likely to result in significant improvements in the quality and efficiency of healthcare delivery. Therefore, seeking models with the highest possible level of predictive performance is important. Consequently, seeking ever better machine-learning and statistical modeling methods is of great practical significance.

Community-Acquired Infections↗