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Biomedical subjects

P D Cleary

Publications and source records attributed to P D Cleary.

At least 19 recordsLinked to original sources
PubMed1998

A conceptual model of the effects of health care organizations on the quality of medical care.

There has been a great deal of interest in recent years in developing measures of health care quality that can be used to characterize and study the effects of health plans. However, because of the recent emergence of diverse types of health care organizations, it is often difficult to know which parts of a plan should be combined for analysis purposes. Also, simple taxonomies of health maintenance organizations (eg, staff, independent practice associations, group, and network) no longer adequately describe the diverse types of organizations that have become common. In this article we describe these trends, explain why older taxonomies of health care plans are not adequate, and present a new framework for characterizing and studying the effects of diverse types of plans.

Capitation Fee↗
PubMed1998

Differences in the professional satisfaction of general internists in academically affiliated practices in the greater-Boston area. Ambulatory Medicine Quality Improvement Project Investigators.

Managed care has created more professional constraints for general internists. We surveyed 198 general internists at 12 academically affiliated practices in the greater-Boston area to examine professional satisfaction. Overall, these physicians were moderately satisfied (mean of 59.1 on a 100-point scale). Before adjustment, women had lower overall satisfaction than men, as well as poorer satisfaction with the domains of career concerns and patient access. Gender had no independent effect on satisfaction after adjustment for age, income, percentage of time providing direct patient care, work status, and site. Younger physicians also had lower overall satisfaction, and these differences remained after adjustment. Improvements in professional satisfaction may be required to ensure the continued recruitment of young physicians, particularly women, into general internal medicine.

Academic Medical Centers↗
PubMed1997

Clinical predictors of declines in physical functioning in persons with AIDS: results of a longitudinal study.

OBJECTIVE: This study was performed in an attempt to determine clinical correlates of declines in physical functioning in people with AIDS. DESIGN: An 8-month longitudinal cohort study was performed at three sites in Boston, Massachusetts: a private academic group practice, an AIDS clinic at a public teaching hospital, and a staff-model health maintenance organization. Intermediate activities of daily living (IADLs), 10 symptoms and symptom complexes, mental health, and weight loss were assessed by interview in 201 persons with AIDS. Clinical diagnoses, comorbidities, laboratory results, and use of selected medications were assessed by chart review. RESULTS: Participants were young (mean age, 36 years), 92% were male, 35% were nonwhite, and 27% had a history of injection drug use. The mean 8-month decrement in physical functioning was 9.6 points on a 100-point scale, and mean weight loss was 2.3 kg. After adjusting for baseline functioning, age, sex, race, and educational level, independent predictors of the 8-month IADL score included worsening fatigue (p = .0002), worsening neurologic symptoms (p = .001), weight loss (p = .0001), Candida esophagitis (p = .020), hypertension (p = .0005), depression (p = .004), and gastrointestinal (GI) disease (p = .018, model R2 = 0.56). CONCLUSIONS: Two symptom complexes (fatigue and neurologic symptoms), three comorbidities (hypertension, depression, and GI disease), and weight loss were significant independent predictors of 8-month IADL scores after statistically controlling for baseline IADL score and sociodemographic variables. These clinical factors are potential targets for interventions designed to improve physical functioning.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Health care quality. Incorporating consumer perspectives.

The goal of this article is to address, from the perspective of users of the health care system (consumers), the following questions: What are the most important health care quality gaps and/or challenges; what major changes should we anticipate in this area in the near future; and what should be the role of federal and state agencies, accreditation organizations, and philanthropic foundations in addressing these challenges? We discuss the needs, challenges, and potential action steps for increasing the prominence of the user's perspective in 3 areas: (1) the conceptualization and definition of quality; (2) the measurement of quality; and (3) routine quality assessment and improvement. The article concludes by making recommendations about the role that different agencies and organizations can and should play in meeting these challenges.

Community Participation↗
PubMed1997

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument.

OBJECTIVES: This study developed a new acquired immunodeficiency syndrome (AIDS) severity system by including diagnostic, physiological, functional, and sociodemographic factors predictive of survival. METHODS: Three-hundred five persons with AIDS in Boston were interviewed; their medical records were reviewed and vital status ascertained. RESULTS: Overall median (+/- SD) survival for the cohort from the first interview until death was 560 +/- 14.4 days. The best model for predicting survival, the Boston AIDS Survival Score, included the Justice score (stage 2 relative hazard [RH] = 1.25, 95% confidence interval [CI] = 0.80, 1.96; stage 3 RH = 1.76, 95% CI = 1.15, 2.70), a newly developed opportunistic disease score (Boston Opportunistic Disease Survival Score; stage 2 RH = 1.35, 95% CI = 0.90, 2.02; stage 3 RH = 2.10, 95% CI = 1.38, 3.18), and measures of activities of daily living (any intermediate limitations, RH = 1.84, 95% CI = 1.05, 3.21; any basic limitations, RH = 2.60, 95% CI = 1.44, 4.69). This model had substantially greater predictive power (R2 = .17, C statistic = .68) than the Justice score alone (R2 = .09, C statistic = .61). CONCLUSIONS: Incorporating data on clinically important events and functional status into a physiologically based system can improve the prediction of survival with AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Clinical predictors of functioning in persons with acquired immunodeficiency syndrome.

To help clinicians better assess and treat functional disabilities in persons with acquired immunodeficiency syndrome (AIDS), the authors estimate empirical relations among biologic and physiologic variables, symptoms, and physical functioning in persons with AIDS. The sample of 305 persons with AIDS for this cross-sectional analysis came from three sites in Boston, Massachusetts: a hospital-based group practice, a human immunodeficiency virus clinic at a city hospital, and a staff-model health maintenance organization. Physical functioning, 10 AIDS-specific symptoms, and mental health were assessed by interview. Clinical diagnoses, comorbidities, health habits such as smoking, laboratory results, and selected medication use were assessed by chart review. Significant predictors of physical functioning P < 0.01, R2 = .58) in a multivariable regression model included energy/fatigue, neurologic symptoms, fever symptoms, a lower hemoglobin level, and current non-pneumonia bacterial infection. Ninety-six percent of the explained variance in physical functioning was accounted for by three symptom complexes: energy/fatigue, neurologic symptoms, and fever symptoms. Significant predictors of energy/fatigue in multivariable models included poorer mental health, lower white blood cell count, longer time since diagnosis, and weight loss (P < 0.01, R2 =.36). Significant predictors of neurologic symptoms included poorer mental health, weight loss, and no zidovudine use (P < 0.001, R2 = .30). Predictors of fever symptoms included poorer mental health, no zidovudine use, weight loss, and history of asthma or chronic obstructive pulmonary disease (P < 0.05, R2 = .25). In conclusion, symptom reports were strong predictors of physical functioning. Poorer mental health and weight loss were correlated consistently with worse symptoms, and not using zidovudine was correlated with worse neurologic and fever symptoms. These variables, and the others the authors identified, may represent mutable determinants of physical functioning in persons with AIDS, and potential targets for specific clinical interventions.

Acquired Immunodeficiency Syndrome↗
PubMed1996

The influence of health-related quality of life and social characteristics on hospital use by patients with AIDS in the Boston Health Study.

OBJECTIVES: The authors examine whether health-related quality of life (HRQL) and social factors were independent predictors of future hospital use for persons with acquired immunodeficiency syndrome (AIDS). METHODS: A panel of 305 patients with AIDS treated at three provider settings in the Boston, Massachusetts area were enrolled during 1990 and 1991. Data were collected at baseline study enrollment and again 4 months later. Patient interviews, hospital bills, and medical charts were used to measure hospital use (admissions and days during the 4 months after enrollment), sociodemographic characteristics (age, gender, race, education, insurance, homelessness, alcohol use, and AIDS risk factors), disease burden (patient severity and a three-level opportunistic diseases and complications score), HRQL (patient-reported symptoms, activities of daily living, neuropsychological status, and global health assessment), system of care, and use of prophylactic drugs. Logistic regression was used to estimate the odds of admission. Total days of hospital care by patients with at least one admission were analyzed using multiple linear regression. Clinical models of hospital use were developed first from the variables measuring disease burden and system of care. Models estimating the associations between hospital use and all other predictor variables measured at baseline then were estimated using stepwise techniques, controlling for variables in the core model. RESULTS: Patients were more likely than their reference groups to be hospitalized if they had serious opportunistic diseases (adjusted odds ratio [OR] = 2.7), had poorer neuropsychological status (OR = 1.9), were non-white (OR = 2.0), or were homeless (OR = 3.3) (all P < or = 0.05). Activities of daily living were associated moderately (OR = 1.3; P = 0.07). Only system of care and neuropsychological status predicted total hospital days. CONCLUSIONS: The results indicate that future hospital use by persons with AIDS may be influenced by social and other health-related factors in addition to the more clinically related characteristics that are recorded in a medical chart. It therefore may be appropriate to assess these factors when considering options for intervention or when comparing patterns of use among patient groups or settings.

Acquired Immunodeficiency Syndrome↗
PubMed1996

What information do consumers want and need?

This paper reviews information from surveys and focus group studies about how consumers define high-quality care and the types of information they want when making decisions about which health plan to join. The authors also interviewed consumer advocacy groups and persons responsible for disseminating health plan information to Medicare enrollees in various types of managed care plans to learn about the types of plan information that Medicare enrollees most often request. They describe the types of information that should be made available to consumers and the challenges involved in making this information understandable and useful.

Community Participation↗
PubMed1996

Variability in patient experiences at 15 New York City hospitals.

To examine how patient experiences of the interpersonal aspects of quality of care varied among a group of 15 New York City hospitals, and the extent to which hospital and patient characteristics explained interhospital variability, a telephone survey was conducted with 3,423 randomly selected patients discharged from 15 New York City hospitals. Bivariate analysis, multiple linear regression, and least square means were used to assess the effects of 5 hospital characteristics and 15 patient characteristics on reports about problems with care. Outcome measures included patients' reported problems with selected aspects of care, patients' ratings of care, and patients' willingness to recommend the hospitals from which they had been discharged. The 15 hospitals varied widely in the rates at which patients reported problems with their care (10.7-21.7, mean = 14.8, p < 0.001). A multivariate model showed that patients in fair or poor health, those without a regular doctor, younger patients, and minorities other than black and Hispanic were more likely to report problems with aspects of their care. Medicaid volume was also a strong, significant predictor of problem scores. Patient reports can be used to measure differences in quality of interpersonal care among hospitals. Only some of these differences are explained by patient and hospital characteristics, indicating that other factors facilitate or inhibit the delivery of high-quality interpersonal care.

Adolescent↗
PubMed1995

Physical and psychosocial functioning of women and men after coronary artery bypass surgery.

OBJECTIVE: To assess whether physical and psychosocial functioning differs between women and men after coronary artery bypass surgery. DESIGN: Observational cohort study. SETTING: Major teaching hospital. PATIENTS: A total of 454 consecutive patients who received coronary artery bypass surgery from June 1989 through March 1990. MAIN OUTCOME MEASURES: Nurse reviewers collected data on the severity of coronary artery disease and coexisting illnesses from medical records. A mailed survey measuring instrumental activities of daily living (IADLs), social activities, mental health, and vitality was completed by 306 (70.2%) of 436 patients who were alive 6 months after surgery. Functioning on each scale was adjusted for age, marital status, education, severity of angina, recent myocardial infarction, congestive heart failure, and coexisting illnesses at the time of surgery. RESULTS: Before surgery, women were much more likely than men to have had class IV angina (50.9% vs 30.4%), a recent myocardial infarction (32.1% vs 18.0%), and congestive heart failure (34.0% vs 17.6%) (all P < .002). On a range from 0 (severe impairment) to 100 (no impairment), adjusted postoperative functioning was equivalent for women and men in IADLs (86.7 vs 89.1), social activities (95.2 vs 95.3), mental health (72.6 vs 76.0), and vitality (58.1 vs 62.5) (all P > .20). Women reported similar or greater adjusted improvements than men for IADLs (27.2 vs 19.6, P = .08), social activities (20.8 vs 8.0, P = .002), mental health (11.2 vs 5.7, P = .05), and vitality (22.2 vs 12.9, P = .04). CONCLUSIONS: Women were more severely ill than men at the time of coronary artery bypass surgery, but women and men reported similar physical and psychosocial functioning 6 months after surgery. These findings demonstrate important functional benefits of this procedure among both women and men.

Activities of Daily Living↗
PubMed1995

The clinical course of palpitations in medical outpatients.

OBJECTIVE: The aim of this study was to describe the longitudinal course of patients who were referred for ambulatory electrocardiographic monitoring because of palpitations. METHODS: A prospective, follow-up examination was conducted of patients who had been studied 6 months previously when referred for monitoring. The inception cohort consisted of 145 consecutive patients with palpitations and 70 asymptomatic, nonpatient volunteers. At follow-up, the patients completed the same research battery as at inception, consisting of structured interviews and self-report questionnaires. These assessed cardiac symptoms, medical care use, role impairment, somatization, hypochondriacal fears and beliefs, and psychiatric disorder. RESULTS: At 6 months' follow-up, 130 patients with palpitations (89.7% of the original cohort) and 69 nonpatients (98.6%) were reinterviewed. Eighty-four percent of the patients had recurrent palpitations during the 6-month follow-up period. At follow-up, patients with palpitations scored significantly higher than the comparison group on measures of cardiac symptoms and role impairment, and had made more physician visits in the preceding 6 months. They had a higher prevalence of panic disorder and more psychopathologic symptoms, somatized more, and were more hypochondriacal. Psychiatric symptoms and the tendency to amplify bodily sensation, measured at inception, were significant but modest predictors of subsequent palpitations. There was considerable confusion and misunderstanding among patients as to the findings of their ambulatory electrocardiogram and the presence or absence of panic disorder. CONCLUSIONS: Patients with palpitations remain symptomatic and functionally impaired and have increased rates of physician visits in the 6 months following Holter monitoring. They also continue to have elevated rates of panic disorder and to evidence some confusion about the cause of their symptoms.

Persons with Disabilities↗
PubMed1995

Variation in the use of cardiac procedures after acute myocardial infarction.

BACKGROUND: There are large geographic differences in the frequency with which coronary angiography and revascularization are performed. We attempted to assess whether differences in case mix or in the treatment of specific groups of patients may explain this variability. We also assessed the consequences of various patterns of treatment. METHODS: We studied patients covered by Medicare who were 65 to 79 years of age and were admitted to 478 hospitals with acute myocardial infarctions during 1990 in New York (1852 patients), where the rate of use of cardiac procedures is low, and in Texas (1837 patients), where the rate of use of such procedures is high. We compared the patterns of treatment of clinically similar groups of patients in the two states. We also compared mortality rates and measures of the health-related quality of life. RESULTS: Coronary angiography was performed more often in Texas than in New York (45 percent vs. 30 percent, P < 0.001). The frequency of use in Texas was significantly higher than that in New York for all the clinical subgroups of patients analyzed except those at greatest risk for reinfarction. Over a two-year period, the adjusted likelihood of death was lower in New York than in Texas (hazard ratio, 0.87; 95 percent confidence interval, 0.78 to 0.98). Patients from Texas were 41 percent more likely to report angina (P = 0.002) and 62 percent more likely to say they could not perform activities requiring energy expenditure of 5 or more metabolic equivalents than patients from New York approximately two years after infarction (P < 0.001). CONCLUSIONS: Physicians in Texas were more likely to perform angiography than physicians in New York for patients whose conditions allowed more discretion in the use of cardiac procedures. On average, there appears to be no advantage with respect to mortality or health-related quality of life to performing the procedures at the higher rate used in Texas.

Aged↗
PubMed1995

Prognostic stratification in critically ill patients with acute renal failure requiring dialysis.

BACKGROUND: Despite the widespread availability of dialytic and intensive care unit technology, the probability of early mortality in critically ill persons with acute renal failure is distressingly high. Previous efforts to predict outcome in this population have been limited by small sample size and the absence of uniform exclusion criteria. Additionally, data obtained decades ago may not apply today owing to changes in case mix. METHODS: The medical records of 132 consecutive patients in the intensive care unit with acute renal failure who required dialysis from 1991 through 1993 were evaluated by a blinded reviewer. RESULTS: The overall in-hospital mortality rate was 70%. Twelve readily available historical, clinical, and laboratory variables were significantly associated with in-hospital mortality. Multivariate logistic regression analysis showed that mechanical ventilation, malignancy, and nonrespiratory organ system failure were independently associated with in-hospital mortality. Using a 95% positivity criterion, this model identified 24% of high-risk patients who died, without misclassification of any survivors. Of those who survived to hospital discharge, 33% were dialysis dependent and 28% were institutionalized long-term. CONCLUSIONS: Among critically ill patients, acute renal failure requiring dialysis is an ominous condition with a high risk of in-hospital mortality. This risk appears to depend largely on comorbid conditions, such as the need for mechanical ventilation and underlying malignancy. While this prognostic model requires prospective validation, it appears to identify a substantial fraction of patients for whom dialysis may be of limited or no benefit.

Acute Kidney Injury↗
PubMed1995

Linking clinical variables with health-related quality of life. A conceptual model of patient outcomes.

Our model proposes a taxonomy or classification scheme for different measures of health outcome. We divide these outcomes into five levels: biological and physiological factors, symptoms, functioning, general health perceptions, and overall quality of life. In addition to classifying these outcome measures, we propose specific causal relationships between them that link traditional clinical variables to measures of HRQL. As one moves from left to right in the model, one moves outward from the cell to the individual to the interaction of the individual as a member of society. The concepts at each level are increasingly integrated and increasingly difficult to define and measure. AT each level, there are an increasing number of inputs that cannot be controlled by clinicians or the health care system as it is traditionally defined.

Activities of Daily Living↗
PubMed1995

Predictors of blood loss during total hip replacement surgery.

OBJECTIVE: To determine total blood loss and transfusion requirements during primary total hip replacement (THR) surgery; and, to identify predictors of increased blood loss. METHODS: This was a prospective cohort study of 295 consecutive patients undergoing primary THR at a 700-bed teaching hospital in Boston, Massachusetts. The main outcome measures were the total blood loss, which was defined (in units) as the initial hematocrit minus final hematocrit divided by 3 plus the number of units transfused, and the number of autologous and homologous units of blood transfused. RESULTS: The mean total blood loss was 3.6 units, and the mean total units transfused was 2.1. Univariate predictors of greater total blood loss (at P < 0.05) included being male, receiving general anesthesia, and higher American Society of Anesthesiologists (ASA) class. In multiple linear regression models which controlled for demographic and clinical variables (age, race, marital status, education, smoking history, obesity, underlying disease, payor status, cemented prosthesis, comorbidity, and season of operation), being male, receiving general anesthesia, and having an ASA score of 3 predicted greater total blood loss. CONCLUSION: Preoperative characteristics can help determine which patients should donate either more or less than the customary 2 units of blood.

Aged↗