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Biomedical subjects

R M Centor

Publications and source records attributed to R M Centor.

At least 19 recordsLinked to original sources
PubMed2000

Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI.

CONTEXT: Issues of cost and quality are gaining importance in the delivery of medical care, and whether quality of care is better in teaching vs nonteaching hospitals is an essential question in this current national debate. OBJECTIVE: To examine the association of hospital teaching status with quality of care and mortality for fee-for-service Medicare patients with acute myocardial infarction (AMI). DESIGN, SETTING, AND PATIENTS: Analysis of Cooperative Cardiovascular Project data for 114,411 Medicare patients from 4361 hospitals (22,354 patients from 439 major teaching hospitals, 22,493 patients from 455 minor teaching hospitals, and 69,564 patients from 3467 nonteaching hospitals) who had AMI between February 1994 and July 1995. MAIN OUTCOME MEASURES: Administration of reperfusion therapy on admission, aspirin during hospitalization, and beta-blockers and angiotensin-converting enzyme inhibitors at discharge for patients meeting strict inclusion criteria; mortality at 30, 60, and 90 days and 2 years after admission. RESULTS: Among major teaching, minor teaching, and nonteaching hospitals, respectively, administration rates for aspirin were 91.2%, 86.4%, and 81.4% (P<.001); for angiotensin-converting enzyme inhibitors, 63. 7%, 60.0%, and 58.0% (P<.001); for beta-blockers, 48.8%, 40.3%, and 36.4% (P<.001); and for reperfusion therapy, 55.5%, 58.9%, and 55.2% (P =.29). Differences in unadjusted 30-day, 60-day, 90-day, and 2-year mortality among hospitals were significant at P<.001 for all time periods, with a gradient of increasing mortality from major teaching to minor teaching to nonteaching hospitals. Mortality differences were attenuated by adjustment for patient characteristics and were almost eliminated by additional adjustment for receipt of therapy. CONCLUSIONS: In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality. JAMA. 2000;284:1256-1262

Hospital Mortality↗
PubMed2000

What is heartburn worth? A cost-utility analysis of management strategies.

OBJECTIVE: To determine the best treatment strategy for the management of patients presenting with symptoms consistent with uncomplicated heartburn. METHODS: We performed a cost-utility analysis of 4 alternatives: empirical proton pump inhibitor, empirical histamine2-receptor antagonist, and diagnostic strategies consisting of either esophagogastroduodenoscopy (EGD) or an upper gastrointestinal series before treatment. The time horizon of the model was 1 year. The base case analysis assumed a cohort of otherwise healthy 45-year-old individuals in a primary care practice. MAIN RESULTS: Empirical treatment with a proton pump inhibitor was projected to provide the greatest quality-adjusted survival for the cohort. Empirical treatment with a histamine2 receptor antagonist was projected to be the least costly of the alternatives. The marginal cost-effectiveness of using a proton pump inhibitor over a histamine2-receptor antagonist was approximately $10,400 per quality-adjusted life year (QALY) gained in the base case analysis and was less than $50,000 per QALY as long as the utility for heartburn was less than 0.95. Both diagnostic strategies were dominated by proton pump inhibitor alternative. CONCLUSIONS: Empirical treatment seems to be the optimal initial management strategy for patients with heartburn, but the choice between a proton pump inhibitor or histamine2-receptor antagonist depends on the impact of heartburn on quality of life.

Anti-Ulcer Agents↗
PubMed1999

An intervention to increase physicians' use of adherence-enhancing strategies in managing hypercholesterolemic patients.

PURPOSE: Patients' lack of adherence to medical regimens frustrates many practicing physicians. This study was conducted to determine the effectiveness of a combined continuing medical education intervention in increasing physicians' adherence-enhancing skills and improving hypercholesterolemic patients' health. METHOD: A prospective, randomized, controlled trial was designed using a nested cohort of 28 community physicians throughout Alabama and 222 of their hypercholesterolemic outpatients. The intervention, carried out in 1998, consisted of three interactive case audio-conferences plus chart reminders. Physicians' learning was measured by unannounced standardized patients, and patients' health by serum cholesterol levels, weight, knowledge of hypercholesterolemia, self-reported dietary habits, and health status. RESULTS: No significant difference was found in the numbers of physician adherence-enhancing strategies, although the number did increase within the treatment group. There were significant differences in the intervention group's patients' knowledge of cholesterol management (p = .008) and significant reductions in their self-reported consumption of dietary fats (p = .002). A significant difference was found in the serum cholesterol level of men in the intervention group nine months after the intervention (p = .02). CONCLUSION: Combining a series of interactive case audio-conferences with chart reminders shows promise in increasing physicians' adherence-enhancing strategies. In chronic disease management, the problem of enhancing adherence remains complex.

Adult↗
PubMed1999

The art and science of searching MEDLINE to answer clinical questions. Finding the right number of articles.

The current medical environment makes information retrieval a matter of practical importance for clinicians. Many avenues present themselves to the clinician, but here we focus on MEDLINE by summarizing the current state of the art and providing an innovative approach for skill enhancement. Because new search engines appear rapidly, we focus on generic principles that can be easily adapted to various systems, even those not yet available. We propose an idealized classification system for the results of a MEDLINE search. Type A searches produce a few articles of high quality that are directly focused on the immediate question. Type B searches yield a large number of articles, some more relevant than others. Type C searches produce few or no articles, and those that are located are not germane. Providing that relevant, high-quality articles do exist, type B and C searches may often be improved with attention to search technique. Problems stem from poor recall and poor precision. The most daunting task lies in achieving the balance between too few and too many articles. By providing a theoretical framework and several practical examples, we prepare the searcher to overcome the following barriers: a) failure to begin with a well-built question; b) failure to use the Medical Subject Headings; c) failure to leverage the relationship between recall and precision; and d) failure to apply proper limits to the search. Thought and practice will increase the utility and enjoyment of searching MEDLINE.

Clinical Medicine↗
PubMed1998

Interpreting cost analyses of clinical interventions.

OBJECTIVE: In the present era of cost containment, physicians need reliable data about specific interventions. The objectives of this study were to assist practitioners in interpretation of economic analyses and estimation of their own costs of implementing recommended interventions. DATA SOURCES: MEDLINE search from 1966 through 1995 using the text words cost or expense and medical subject heading (MeSH) terms costs and cost analysis, cost control, cost of illness, cost savings, or cost-benefit analysis. STUDY SELECTION: The 4 eligibility criteria were clinical trial with random assignment; health care quality improvement intervention tested; effects measured on the process or outcome of care; and cost calculation mentioned in the report. DATA EXTRACTION: After independent abstraction and after consensus development, financial data were entered into a costing protocol to determine which costs related to the intervention were provided. DATA SYNTHESIS: Of 181 articles, 97 (53.6%) included actual numbers on the costs of the intervention. Of 97 articles analyzed, the most frequently reported cost figures were in the category of operating expenses (direct cost, 61.9%; labor, 42.3%; and supplies, 32.0%). General overhead was not presented in 91 (93.8%) of the 97 studies. Only 14 (14.4%) of the 97 studies mentioned start-up costs. The text word $ in the abstract and the most useful MeSH index term of cost-benefit analysis appeared with nearly equal frequency in the articles that included actual cost data (37.1 % vs 35.1%). Two thirds of articles indexed with the MeSH term cost control did not include cost figures. CONCLUSIONS: Statements regarding cost without substantiating data are made habitually in reports of clinical trials. In clinical trial reports presenting data on expenditures, start-up costs and general overhead are frequently disregarded. Practitioners can detect missing information by placing cost data in a standardized protocol. The costing protocol of this study can help bridge care delivery and economic analyses.

Clinical Protocols↗
PubMed1997

Physicians' survival predictions for patients with acute congestive heart failure.

BACKGROUND: Current guidelines suggest that patients with low likelihoods of survival may be excluded from intensive care. Patients with new or exacerbated congestive heart failure are frequently but not inevitably admitted to critical care units. OBJECTIVE: To assess how well physicians could predict the probability of survival for acutely ill patients with congestive heart failure, and in particular how well they could identify patients with small chances of survival. METHODS: This was a prospective cohort study done in the emergency departments of a university hospital, a Veterans Affairs medical center, and a community hospital. The study population was consecutive adults for whom new or exacerbated congestive heart failure, diagnosed clinically, was a major reason for the emergency department visit. Physicians caring for the study patients in the emergency departments recorded their judgments of the numeric probability that each patient would survive for 90 days and for 1 year. The patients vital status at 90 days and 1 year was ascertained by multiple means, including interview, chart review, and review of hospital and state databases. RESULTS: By calibration curve analysis, the physicians underestimated survival probability at both 90 days and 1 year, particularly for patients they judged to have the lowest probabilities of survival. Their predictions had modest discriminating ability (receiver operating characteristic curve areas, 0.66 [SE = 0.020] for 90 days; 0.63 [SE = 0.017] for 1 year). The physicians identified only 15 patients they judged to have a 90-day survival probability of 10% or less, whose survival rate was actually 33.3%. CONCLUSIONS: Physicians have great difficulty predicting survival for patients with acute congestive heart failure and cannot identify patients with poor chances of survival. Current triage guidelines that suggest patients with poor chances of survival may be excluded from critical care may be impractical or harmful.

Acute Disease↗
PubMed1997

Choice of long-term strategy for the management of patients with severe esophagitis: a cost-utility analysis.

BACKGROUND & AIMS: Omeprazole has shown remarkable efficacy and safety in the treatment of patients with gastroesophageal reflux disease (GERD); similarly, laparoscopic techniques have allowed less morbidity in patients undergoing fundoplication procedures. Concerns about the long-term cost and safety of both strategies have prompted a debate of their role in long-term management of patients with severe erosive esophagitis. METHODS: A cost-utility analysis was performed to compare two strategies: laparoscopic Nissen fundoplication (LNF) vs. omeprazole. A two-stage Markov model was used to obtain cost and efficacy estimates; all estimates were discounted at 3% per year. The time horizon was 5 years. Sensitivity analyses were performed on all relevant variables. RESULTS: Both strategies were similarly effective (4.33 quality-adjusted life years per patient), with omeprazole less expensive than LNF ($6053 vs. $9482 per patient). At 10 years, LNF and omeprazole costs were similar. Efficacy estimates were extremely sensitive to changes in quality of life associated with postoperative symptoms and long-term use of medication. CONCLUSIONS: Medical therapy is the preferred treatment strategy for most patients with severe erosive esophagitis. Individuals with a long life expectancy are good candidates for LNF if postoperative morbidity is low and GERD symptoms remain abated for many years.

Adult↗
PubMed1997

Physicians' judgments of the risks of cardiac procedures. Differences between cardiologists and other internists.

OBJECTIVES: The authors compared judgments of the population risks of invasive cardiac procedures made by cardiologists and other internal medicine physicians. Our main hypotheses were that cardiologists' judgments would differ from those made by the other physicians and that cardiologists' judgments would be more accurate than those of other physicians. METHODS: This was a cross-sectional survey of senior staff and physician-trainees at two teaching hospitals affiliated with a US medical school, Emergency Department physicians at a community hospital in the same metropolitan area, and senior staff and trainees at two teaching hospitals affiliated with a UK school. Judgments of the risks of severe morbidity and death due to Swan-Ganz catheterization, cardiac catheterization, percutaneous coronary angioplasty, and coronary artery bypass grafting were assessed. RESULTS: Nineteen cardiologists judged the risks of severe morbidity due to all procedures and the risks of death due to all procedures except coronary artery bypass grafting to be significantly lower than did the 78 other internists. Cardiologists more frequently made accurate judgments of the rates of morbidity and death due to cardiac catheterization than did the other internists; other internists more frequently made accurate judgments for the rates of morbidity due to Swan-Ganz catheterization. CONCLUSIONS: Disagreements about the risks of procedures may arise from a paucity of published data, or from an over-supply of confusing data.

Angioplasty, Balloon, Coronary↗
PubMed1996

Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction.

OBJECTIVE: To compare the use of medications in African-American and Caucasian elderly Medicare patients hospitalized with acute myocardial infarction (AMI) in Alabama. DESIGN: Retrospective medical record review. SETTING: All acute care hospitals in Alabama. PATIENTS: All Medicare patients with a principal discharge diagnosis of AMI from June 1992 through February 1993. We excluded those patients less than 65 years of age and those of ethnicity other than African-American or Caucasian (N = 4,052). MEASUREMENTS: We first performed a crude analysis using all cases to compare by race the use of thrombolysis, beta-adrenergic blockade, and aspirin in the setting of AMI. In addition, we developed a multivariable model with receipt of therapy as the outcome and demographics, severity of illness, comorbidity, and algorithm-determined candidacy for therapy as covariates. The algorithms, developed as part of the Cooperative Cardiovascular Project, were designed to identify an "ideal" pool of candidates for each therapy. MAIN RESULTS: For all cases, 9.2% (95% confidence interval [CI] 6.8, 12.1) of African Americans received thrombolysis compared with 17.3% (95% CI 16.0, 18.6) of Caucasians. Approximately 16.4% of patients received beta-adrenergic blockade, and 45.1% received aspirin, both with no racial difference. By multivariate analysis, the adjusted odds ratio for African Americans receiving thrombolysis was 0.55 (95% CI 0.41, 0.76). The corresponding odds ratio was 1.25 (95% CI 0.99, 1.59) for beta-adrenergic blockade and 1.13 (95% CI 0.96, 1.37) for aspirin. African Americans presented later after the onset of chest pain, but the refusal rate of thrombolytic therapy did not differ. CONCLUSIONS: According to this analysis, Alabama physicians used beta-adrenergic blockade and aspirin equivalently in African Americans and Caucasians. African Americans received thrombolysis less often according to the crude analysis. The multivariable analysis suggests less use of thrombolytics, even after adjusting for several covariates including indication by clinical algorithm. However, the small number of African-American patients deemed ideal candidates for thrombolysis attenuates the precision of this finding.

Adrenergic beta-Antagonists↗
PubMed1992

Controlled trial using computerized feedback to improve physicians' diagnostic judgments.

The goal of this study was to test an innovative method to improve physicians' diagnostic judgments by integrating the use of a computer program (employing cognitive feedback to teach a clinical rule that predicts the probability of streptococcal pharyngitis), a traditional lecture, and periodic disease-prevalence reports. In a controlled trial using pre- and postintervention measures involving 885 patients, the authors compared the effects of the integrated method on the diagnostic judgments of seven experienced physicians at a university health service (from 1982 to 1985) with the effects of the lecture alone on the judgments of seven experienced physicians at a different university health service (1986 to 1987). The integrated method significantly improved the quality of the physicians' judgments as measured by calibration curves and Brier scores, and increased the level of agreement between the physicians' judgments and those made by the clinical prediction rule. The lecture alone produced less improvement in the quality of the physicians' judgments, and decreased the level of agreement with the rule. The authors conclude that this method, based on cognitive psychology, is a promising educational tool.

Computer-Assisted Instruction↗
PubMed1992

Screening for drinking disorders in the elderly using the CAGE questionnaire.

OBJECTIVE: To assess the performance of the CAGE questionnaire in identifying elderly medicine outpatients with drinking problems. DESIGN: Cross-sectional design, with the alcohol module of the Diagnostic Interview Schedule as the criterion standard. SETTING: The outpatient medical practice of an urban university teaching hospital. PATIENTS: Consecutive patients 18 years or older who signed a consent form approved by the university's institutional review board. For this study, 323 patients greater than or equal to 60 years old. MAIN OUTCOME MEASURES: Sensitivity, specificity, receiver operating characteristics (ROC) curve and positive predictive value for CAGE scores of 0-4 for patients 60 years or older. RESULTS: Thirty-three percent of the sample group met study criteria for a history of drinking problems, including 63% of the male patients and 22% of the female patients. The sensitivity and specificity for a cut-off score of one for all patients was 86% and 78%, respectively, and 70% and 91% for a cut-off of two. The calculation of the area under the ROC curve was .86, and the positive predictive value of CAGE scores of 0-4 were 33%, 66%, 79%, 82%, and 94%, respectively. The predictive value for any score was higher in males than females, reflecting the higher prevalence of problems in the male population. CONCLUSIONS: The CAGE can effectively discriminate elderly patients with a history of drinking problems from those without such a history. The chosen cut-off score should consider the prevalence of drinking problems in the population being tested.

Aged↗
PubMed1991

Screening for alcohol abuse using CAGE scores and likelihood ratios.

OBJECTIVE: To assess the performance of the CAGE (acronym referring to four questions, see below) questionnaire in discriminating between medicine outpatients with and without an alcohol abuse or dependence disorder. DESIGN: A cross-sectional design of a sample of consecutive patients who received both the alcohol module of the diagnostic interview schedule and the CAGE (Cut down, Annoyed, Guilty, Eye-opener) screening questionnaire. SETTING: The outpatient medical practice of an urban university teaching hospital. PATIENTS: All patients 18 years or older who signed a consent form approved by the university's institutional review board. MEASUREMENT: Calculation of the sensitivity, specificity, receiver operating characteristic (ROC) curve, and likelihood ratio for CAGE scores of 0 to 4. RESULTS: Thirty-six percent of the sample group met criteria for a history of alcohol abuse or dependence. A CAGE score of 2 or more was associated with a sensitivity and specificity of 74% and 91%. The calculated area under the ROC curve was 0.89, whereas the likelihood ratios for CAGE scores of 0 to 4 were 0.14, 1.5, 4.5, 13, and 100, respectively. These ratios were associated with posterior probabilities for an abuse or dependence disorder of 7%, 46%, 72%, 88%, and 98%, respectively. CONCLUSION: Clinicians can improve their ability to estimate a patient's risk for an alcohol abuse or dependence disorder using likelihood ratios for CAGE scores.

Adult↗
PubMed1990

Clinical and microbiological evidence for endemic pharyngitis among adults due to group C streptococci.

Group C beta-hemolytic streptococci cause rare epidemic outbreaks of pharyngitis, but their role in sporadic endemic pharyngitis has been uncertain. We addressed the question of whether non-group A beta-hemolytic streptococci are associated with endemic pharyngitis in two ways. First, we compared rates of isolation from throat swabs of group A, B, C, and G and ungrouped beta-hemolytic streptococci ("culture negative") in adult patients vs those rates in controls. Second, we collected in standardized form clinical indexes of patients with pharyngitis: signs and symptoms graded for severity, the examining physician's subjective estimate of the probability of streptococcal pharyngitis, a logistic regression score predicting streptococcal pharyngitis, and whether antibiotic therapy was prescribed. After collecting data and cultures on 1425 patients with sore throats and cultures on 284 controls, we found the following: group C streptococci were isolated significantly more frequently in patients with sore throats than in controls (6% vs 1.4%); four clinical signs and two symptoms distinguished group C-associated pharyngitis as more severe than culture-negative pharyngitis; and six clinical signs and one symptom distinguished group C-associated pharyngitis as less severe than group A pharyngitis. Physicians' subjective estimates, logistic regression scores, and antibiotic treatment all characterized group C-associated pharyngitis as more severe than culture-negative sore throats but less severe than group A pharyngitis. From these data we present the first definitive evidence that group C streptococci are associated with endemic pharyngitis, show that clinical presentation distinguishes a group of patients with group C-associated pharyngitis from populations with culture-negative sore throats and from those with group A pharyngitis. Physicians' response to that presentation merits consideration in the context of rapid group-specific diagnosis of streptococcal pharyngitis by group A antigen tests.

Adult↗
PubMed1989

Risk factors for attempted suicide during adolescence.

It is unknown whether adolescents can provide the information necessary to identify their risk for attempted suicide. The present study was designed to determine whether data collected directly from adolescents can be used to develop a simple model for differentiating suicidal from nonsuicidal adolescents. Patients aged 13 to 19 years hospitalized for medical complications of serious suicide attempts (n = 56) or for acute illnesses unrelated to injuries or ingestions (n = 248) completed self-administered questionnaires pertaining to psychosocial function, recent stress, alcohol and drug use, and health care use. Compared with ill adolescents, suicidal adolescents had poorer mental health, impulse control, family relationships, and school performance; higher 3-month stress scores and alcohol-use scores; and more use of 7 of 12 drugs (P less than .05). Compared with ill adolescents, suicidal adolescents were more likely to report previous suicide attempts (39% vs 10%, P less than .001) and previous mental health care (27% vs 8%, P less than .001) but were less likely to identify a primary care site (61% vs 87%, P less than .001). In a logistic regression model based on previous suicide attempts, previous mental health care, poor school performance, marijuana use, and dependence on the emergency room for primary care, 84% of the suicidal and 55% of the ill adolescents were correctly identified. If validated prospectively, these five self-administered questions may constitute a helpful screen for the rapid identification of suicidal adolescents.

Adolescent↗
PubMed1988

Effects of low dose oral iodide supplementation on thyroid function in normal men.

Previous studies have demonstrated that short-term oral iodide administration, in doses ranging from 1500 micrograms to 250 mg/day, has an inhibitory effect on thyroid hormone secretion in normal men. As iodide intake in the USA may be as high as 800 micrograms/d, we investigated the effects of very low dose iodide supplementation on thyroid function. Thirty normal men aged 22-40 years were randomly assigned to receive 500, 1500, and 4500 micrograms iodide/day for 2 weeks. Blood was obtained on days 1 and 15 for measurement of serum T4, T3, T3-charcoal uptake, TSH, protein-bound iodide (PBI) and total iodide, and 24 h urine samples were collected on these days for measurement of urinary iodide excretion. TRH tests were performed before and at the end of the period of iodide administration. Serum inorganic iodide was calculated by subtracting the PBI from the serum total iodide. We found significant dose-related increases in serum total and inorganic iodide concentrations, as well as urinary iodide excretion. The mean serum T4 concentration and free T4 index values decreased significantly at the 1500 micrograms/day and 4500 micrograms/day doses. No changes in T3-charcoal uptake or serum T3 concentration occurred at any dose. Administration of 500 micrograms iodide/day resulted in a significant increase (P less than 0.005) in the serum TSH response to TRH, and the two larger iodide doses resulted in increases in both basal and TRH-stimulated serum TSH concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1987

The adult respiratory distress syndrome. Cell populations and soluble mediators in the air spaces of patients at high risk.

In order to better understand the modulation of polymorphonuclear neutrophil influx into the lung during the development of the adult respiratory distress syndrome (ARDS), we evaluated bronchoalveolar lavage fluids from control subjects (n = 9), patients at high risk of developing ARDS (n = 12), and patients with ARDS (n = 11) for cellular and protein content and capacity to promote neutrophil adhesion to tissue culture plastic. Analysis of the lavage fluids from high risk patients and patients with ARDS showed an 8- to 10-fold increase in the total number of cells, an increase in the percentage of neutrophils present (control subjects = 1 +/- 0.4%, high risk = 53 +/- 8%, ARDS = 70 +/- 7%), and a 10- to 40-fold increase in protein content. The adherence of normal neutrophils to plastic surfaces after pretreatment with either concentrated lavage fluid, ultrafiltrates of BALF, or plasma samples was determined to evaluate the neutrophil adherence-promoting activity of each. Lavage fluid from high risk patients and patients with ARDS promoted an approximate 3-fold increase in neutrophil adherence when compared with control lavage fluid. Neutrophil adhesion-promoting activity of the plasma and lavage filtrates (mw less than 500 daltons) was not significantly different from that of control subjects. The adherence-promoting activity found in ARDS lavage was stable at 56 degrees C for 30 min.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗