Biomedical subjects
R M Poses
Publications and source records attributed to R M Poses.
Relation of physician specialty and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy.
BACKGROUND: Controversy exists regarding who should provide care for those with HIV/AIDS. While previous studies have found an association between physician HIV experience and patient outcomes, less is known about the relationship of physician specialty to HIV/AIDS outcomes or quality of care. OBJECTIVE: To examine the relationship between choice of appropriate antiretroviral therapy (ART) to physician specialty and HIV/AIDS experience. DESIGN: Self-administered physician survey. PARTICIPANTS: Random sample of 2,478 internal medicine (IM) and infectious disease (ID) physicians. MEASUREMENTS: Choice of guideline-recommended ART. RESULTS: Two patients with HIV disease, differing only by CD4+ count and HIV RNA load, were presented. Respondents were asked whether ART was indicated, and if so, what ART regimen they would choose. Respondents' ART choices were categorized as "recommended" or not by Department of Health and Human Services guidelines. Respondents' HIV/AIDS experience was categorized as moderate to high (MOD/HI) or none to low (NO/LO). For Case 1, 72.9% of responding physicians chose recommended ART. Recommended ART was more likely (P <.01) to be chosen by ID physicians (88.2%) than by IM physicians (57.1%). Physicians with MOD/HI experience were also more likely (P <.01) to choose recommended ART than those with NO/LO experience. Finally, choice of ART was examined using logistic regression: specialty and HIV experience were found to be independent predictors of choosing recommended ART (for ID physicians, odds ratio [OR], 4.66; 95% confidence interval [95% CI], 3.15 to 6.90; and for MOD/HI experience, OR, 2.05; 95% CI, 1.33 to 3.16). Results for Case 2 were similar. When the analysis was repeated excluding physicians who indicated they would refer the HIV "patient," specialty and HIV experience were not significant predictors of choosing recommended ART. CONCLUSIONS: Guideline-recommended ART appears to be less likely to be chosen by generalists and physicians with less HIV/AIDS experience, although many of these physicians report they would refer these patients in clinical practice. These results lend support to current recommendations for routine expert consultant input in the management of those with HIV/AIDS.
Academic freedom and individual rights.
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Clinical factors that influence patients' desire for participation in decisions about illness.
BACKGROUND: Clinical practice often fails to optimize patient participation in decisions about serious illness. Prior studies are unclear about whether the type of decision and prior illness experience affect the patient's preferences for participation in decision making. Most studies of patient decision making have not addressed decisions about serious illness. OBJECTIVE: To determine whether the type of illness and nature of the decision predict the patient's preferences for involvement in making decisions. DESIGN: Study of randomly selected patients' responses to vignettes about cancer, acute myocardial infarction, and diabetes coupled with cross-sectional survey and chart review. SETTING: Outpatient Veterans Affairs medical clinic. PATIENTS: A total of 255 patients with a mean age of 63.2 years (95.2% male; 61.9% married). MAIN RESULTS: Patients wanted to share hypothesized major decisions with their physicians (mean score, 2.9; 1 = only physician, 5 = only patient) but wanted less involvement in hypothesized minor decisions (mean score, 2.5). Patients with recent severe heart disease (myocardial infarction, bypass surgery, angioplasty) wanted more involvement in decisions about acute myocardial infarction than did patients with stable angina or no heart disease; prior experience with diabetes did not affect decisions about diabetes. Factor analysis of the vignette items yielded 3 types of decisions that we consider to reflect major, minor, and patient behavior decisions. Mean scores were 2.9 for major decisions, 2.1 for minor decisions, and 2.7 for patient behavior decisions. CONCLUSIONS: Patients want to share in major decisions with their physicians but prefer to be less involved in minor decisions. For some illnesses, such as myocardial infarction, prior experience with the illness increases the patients' desire for participation in decision making. Arch Intern Med. 2000;160:2991-2996
Results of report cards for patients with congestive heart failure depend on the method used to adjust for severity.
BACKGROUND: The validity of outcome report cards may depend on the ways in which they are adjusted for risk. OBJECTIVES: To compare the predictive ability of generic and disease-specific survival prediction models appropriate for use in patients with heart failure, to simulate outcome report cards by comparing survival across hospitals and adjusting for severity of illness using these models, and to assess the ways in which the results of these comparisons depend on the adjustment method. DESIGN: Analysis of data from a prospective cohort study. SETTING: A university hospital, a Veterans Affairs (VA) medical center, and a community hospital. PATIENTS: Sequential patients presenting in the emergency department with acute congestive heart failure. MEASUREMENTS: Unadjusted 30-day and 1-year mortality across hospitals and 30-day and 1-year mortality adjusted by using disease-specific survival prediction models (two sickness-at-admission models, the Cleveland Health Quality Choice model, the Congestive Heart Failure Mortality Time-Independent Predictive Instrument) and generic models (Acute Physiology and Chronic Health Evaluation [APACHE] II, APACHE III, the mortality prediction model, and the Chadson comorbidity index). RESULTS: The community hospital's unadjusted 30-day survival rate (85.0%) and the VA medical center's unadjusted 1-year survival rate (60.9%) were significantly lower than corresponding rates at the university hospital (92.7% and 67.5%, respectively). No severity model had excellent ability to discriminate patients by survival rates (all areas under the receiver-operating characteristic curve < 0.73). Whether the VA medical center, the community hospital, both, or neither had worse survival rates on simulated report cards than the university hospital depended on the prediction model used for adjustment. CONCLUSIONS: Results of simulated outcome report cards for survival in patients with congestive heart failure depend on the method used to adjust for severity.
Qualitative research in health care. Antirealism is an excuse for sloppy work.
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The effect of anesthetic technique on postoperative outcomes in hip fracture repair.
BACKGROUND: The impact of anesthetic choice on postoperative mortality and morbidity has not been determined with certainty. METHODS: The authors evaluated the effect of type of anesthesia on postoperative mortality and morbidity in a retrospective cohort study of consecutive hip fracture patients, aged 60 yr or older, who underwent surgical repair at 20 US hospitals between 1983 and 1993. The primary outcome was defined as death within 30 days of the operative procedure. The secondary outcomes were postoperative 7-day mortality, postoperative myocardial infarction, postoperative pneumonia, postoperative congestive heart failure, and postoperative change in mental status. Numerous comorbid conditions were controlled for individually and by several comorbidity indices using logistic regression. RESULTS: General anesthesia was used in 6,206 patients (65.8%) and regional anesthesia in 3,219 patients (3,078 spinal anesthesia and 141 epidural anesthesia). The 30-day mortality rate in the general anesthesia group was 4.4%, compared with 5.4% in the regional anesthesia group (unadjusted odds ratio = 0.80; 95% confidence interval = 0.66-0.97). However, the adjusted odds ratio for general anesthesia increased to 1.08 (0.84-1.38). The adjusted odds ratios for general anesthesia versus regional anesthesia for the 7-day mortality was 0.90 (0.59-1.39) and for postoperative morbidity outcomes were as follows: myocardial infarction: adjusted odds ratio = 1.17 (0.80-1.70); congestive heart failure: adjusted odds ratio = 1.04 (0.80-1.36); pneumonia: adjusted odds ratio = 1.21 (0.87-1.68); postoperative change in mental status: adjusted odds ratio = 1.08 (0.95-1.22). CONCLUSIONS: The authors were unable to demonstrate that regional anesthesia was associated with better outcome than was general anesthesia in this large observational study of elderly patients with hip fracture. These results suggest that the type of anesthesia used should depend on factors other than any associated risks of mortality or morbidity.
One size does not fit all: questions to answer before intervening to change physician behavior.
BACKGROUND: Many interventions have been conducted to change physician behavior, but there is not much evidence regarding their effectiveness. A list of questions is proposed for those who would attempt such interventions: 1. Does the behavior (or decision making) need to be changed? This implies the next two questions. 1a. Is there a logical, evidence-based argument that one decision alternative is preferable for a particular situation? If the would-be behavior changer cannot make an evidence-based argument for changing behavior, there is little moral authority to intervene. 1b. Is there evidence that physicians are not choosing this decision alternative when they should? Interventions are often prompted by evidence that utilization of an alternative was too high or low, but physicians' decisions are not the only determinants of utilization. 2. What is the problem with the decision making? Common sense suggests that different problems require different solutions. Yet interventions are often pursued in the absence of clear information about the reasons physicians did not exhibit the preferred behavior. 3. How could the decision making best be changed? Finding the cognitive problems that caused "wrong" behavior should directly lead to the design of simple, targeted, effective interventions to change this behavior. The judgment and decision making psychology literature suggests that general instruction in reasoning and probability may improve judgments and decision processes. SUMMARY: Physicians' behavior appears to be resistant to change. Understanding why the behavior should be changed and what caused it may make the process of designing interventions more complicated. The resulting interventions, however, are more likely to be simple and successful.
Money and mission? Addressing the barriers to evidence-based medicine.
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Evidence and expertise revisited.
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Treating unrelated disorders in patients with chronic disease.
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Perioperative blood transfusion and postoperative mortality.
CONTEXT: The risks of blood transfusion have been studied extensively but the benefits and the hemoglobin concentration at which patients should receive a transfusion have not. OBJECTIVE: To determine the effect of perioperative transfusion on 30- and 90-day postoperative mortality. DESIGN: Retrospective cohort study. SETTING: A total of 20 US hospitals between 1983 and 1993. PARTICIPANTS: A total of 8787 consecutive hip fracture patients, aged 60 years or older, who underwent surgical repair. MAIN OUTCOME MEASURES: Primary outcome was 30-day postoperative mortality; secondary outcome was 90-day postoperative mortality. The "trigger" hemoglobin level was defined as the lowest hemoglobin level prior to the first transfusion during the time period or, for patients in the nontranfused group, as the lowest hemoglobin level during the time period. RESULTS: Overall 30-day mortality was 4.6% (n=402; 95% confidence interval [CI], 4.1%-5.0%); overall 90-day mortality was 9.0% (n=788; 95% CI, 8.4%-9.6%). A total of 42% of patients (n=3699) received a postoperative transfusion. Among patients with trigger hemoglobin levels between 80 and 100 g/L (8.0 and 10.0 g/dL), 55.6% received a transfusion, while 90.5% of patients with hemoglobin levels less than 80 g/L (8.0 g/dL) received postoperative transfusions. Postoperative transfusion did not influence 30- or 90-day mortality after adjusting for trigger hemoglobin level, cardiovascular disease, and other risk factors for death: for 30-day mortality, the adjusted odds ratio (OR) was 0.96 (95% CI, 0.74-1.26); for 90-day mortality, the adjusted hazard ratio was 1.08 (95% CI, 0.90-1.29). Similarly, 30-day mortality after surgery did not differ between those who received a preoperative transfusion and those who did not (adjusted OR, 1.23; 95% CI, 0.81-1.89). CONCLUSIONS: Perioperative transfusion in patients with hemoglobin levels 80 g/L (8.0 g/dL) or higher did not appear to influence the risk of 30- or 90-day mortality in this elderly population. At hemoglobin concentrations of less than 80 g/L (8.0 g/dL), 90.5% of patients received a transfusion, precluding further analysis of the association of transfusion and mortality.
How you look determines what you find: severity of illness and variation in blood transfusion for hip fracture.
PURPOSE: Utilization report cards are commonly used to assess hospitals. However, in practice, they rarely account for differences in patient populations among hospitals. Our study questions were: (1) How does transfusion utilization for hip fracture patients vary among hospitals? (2) What patient characteristics are associated with transfusion and how do those characteristics vary among hospitals? (3) Is the apparent pattern of variation of utilization among hospitals altered by controlling for these patient characteristics? SUBJECTS AND METHODS: We included consecutive hip fracture patients aged 60 years or older who underwent surgical repair between 1982 and 1993 in 19 hospitals from four states, excluding those who refused blood transfusion, had multiple trauma, metastatic cancer, multiple myeloma, an above the knee amputation, or were paraplegic or quadriplegic. The outcome of interest was postoperative blood transfusion. "Trigger hemoglobin" was the lowest hemoglobin recorded before transfusion or recorded at any time during the week before or after surgery for patients who were not transfused. RESULTS: There was considerable variation in transfusion among hospitals postoperatively (range 31.2% to 54.0%, P = 0.001). Trigger hemoglobin also varied considerably among hospitals. In unadjusted analyses, four of nine teaching and two of nine nonteaching hospitals had postoperative transfusion rates significantly higher than the reference (teaching) hospital, while one nonteaching hospital had a lower rate. In an analysis controlling for trigger hemoglobin and multiple clinical variables, one of nine teaching and four of nine nonteaching hospitals had rates higher than the reference hospital, while four teaching hospitals and one nonteaching hospital had lower rates. CONCLUSIONS: The apparent pattern of variation of transfusion among hospitals varies according to how one adjusts for relevant patient characteristics. Utilization report cards that fail to adjust for these characteristics may be misleading.
Qualitative research in medicine and health care: questions and controversy.
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Conclusions about why doctors change their practice were not supported by the data.
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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.
Estimation of adverse events in medical care.
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The effect of primary care training on patient satisfaction ratings.
This study examines the association between type of internal medicine training and satisfaction ratings among 509 patients who visited the clinic of an urban teaching hospital over a 3-month period in 1994. When controlling for patient, health-system, and other resident factors, primary care training was significantly associated with higher satisfaction ratings (cumulative odds ratio 1.53; 95% confidence interval 1.04, 2.25; p = .031) than categorical training. Using satisfaction ratings to rank the residents without adjusting for patient and health-system factors would have correctly classified only 27% of the residents in the lowest quartile. These findings have implications for both the education and potential employment of internists.