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Biomedical subjects

R S Dittus

Publications and source records attributed to R S Dittus.

16 recordsLinked to original sources
PubMed1991

Oral corticosteroid therapy for patients with stable chronic obstructive pulmonary disease. A meta-analysis.

PURPOSE: To evaluate the effectiveness of oral corticosteroid therapy in patients with stable chronic obstructive pulmonary disease. DATA IDENTIFICATION: An English-language literature search using MEDLINE (1966 to 1989) and a bibliographic review of all retrieved articles identified 33 original studies of oral corticosteroid use in chronic obstructive pulmonary disease published since 1951. STUDY SELECTION: We submitted a photocopy of each study's "methods" section to three nonstudy physician-investigators who used nine explicit criteria to independently assess study quality. Ten studies met all criteria and five studies met some of the criteria. DATA EXTRACTION: To compare outcomes across all qualifying studies, we defined response to therapy as a 20% or greater increase in the baseline forced expiratory volume in 1 second (FEV1); we defined the treatment effect size for each study as the proportion of patients who responded to corticosteroid therapy minus the proportion of patients who responded to placebo. Potential confounding variables as related to eligibility criteria and treatment protocols were also assessed for each study. RESULTS OF DATA SYNTHESIS: Among ten studies that met all nine criteria, we found no significant differences in eligibility criteria, treatment protocol, or study design. No association was found between treatment effect size and publication date, study size, mean patient age, or FEV1. These studies had reported effect sizes ranging from 0% to 56%; we calculated a weighted mean effect size of 10% (95% CI, 2% to 18%). When studies meeting only some of the criteria were included in the calculation, the weighted mean effect size was 11% (95% CI, 4% to 18%). CONCLUSIONS: Patients with stable chronic obstructive pulmonary disease receiving oral corticosteroid therapy have a 20% or greater improvement in baseline FEV1 approximately 10% more often than similar patients receiving placebo.

Administration, Oral↗
PubMed1990

Flexible sigmoidoscopy plus air contrast barium enema versus colonoscopy for suspected lower gastrointestinal bleeding.

A randomized, controlled trial was performed to compare the diagnostic yields and cost-effectiveness of two strategies for the evaluation of nonemergent lower gastrointestinal bleeding. Three hundred eighty patients aged greater than or equal to 40 yr were randomized to undergo initial flexible sigmoidoscopy plus air contrast barium enema or colonoscopy; 332 completed the initial studies. Initial colonoscopy detected more cases of polyps less than 9 mm in size, adenomas, and arteriovenous malformations but fewer cases of diverticulosis. No significant difference was found between strategies in the number of patients detected with cancers or polyps greater than or equal to 9 mm in size. In both strategies, cancers were more common in subjects aged greater than or equal to 55 yr (8% overall) than in those aged less than 55 yr (1%). Among patients aged less than 55 yr with suspected lower gastrointestinal bleeding, initial flexible sigmoidoscopy plus air contrast barium enema is a more cost-effective strategy for the detection of colonic neoplasms than initial colonoscopy. However, initial colonoscopy is more cost effective for those aged greater than or equal to 55 yr.

Barium Sulfate↗
PubMed1989

Quantifying uncertainty in medical decisions.

Effective handling of uncertainty is one of the central problems in medical decision making. The sources and effects of uncertainty in medical decision making are examined and some new quantitative approaches for solving the associated problems are outlined. To handle uncertainty in the branching probabilities and node utilities for probability trees representing alternative treatment strategies, a public domain software package that can be used for the construction, analysis and comparison of probability trees with random parameters was developed. To facilitate specification of the random variables that arise in medical decision making problems, public domain software packages for both data-driven and subjective estimation of probability densities from the Johnson translation system of distributions have also been developed. For the analysis of complex problems that cannot be adequately represented by probability trees or by simple stochastic processes such as Markov chains, network simulation approaches that are oriented toward the sequence of activities seen by individual patients in the course of treatment are described.

Computer Simulation↗
PubMed1989

Unsuspected pulmonary tuberculosis in a community teaching hospital.

Tuberculosis remains a significant clinical and public health problem in the United States. To determine if a significant proportion of hospitalized patients diagnosed as having pulmonary tuberculosis were not suspected of the disease following initial patient assessment, we retrospectively reviewed the microbiology records of a 515-bed community teaching hospital and identified all patients with culture-proven Mycobacterium tuberculosis infection hospitalized between January 1983 and December 1987. Pulmonary tuberculosis was not suspected in 13 (42%) of 31 patients with active disease. These patients were elderly (92% aged 65 years or older vs 8% aged less than 65 years), had a delay in respiratory isolation (6 vs 1 days) and diagnosis (8 vs 3 days), in addition to a longer hospitalization (16 vs 11 days) with increased mortality (46% vs 11%). Inadequate diagnosis may contribute to the persistence of morbidity and mortality from tuberculosis in this country.

Adult↗
PubMed1988

The care of elderly patients with hip fracture. Changes since implementation of the prospective payment system.

We hypothesized that the care provided to elderly patients with hip fracture in community hospitals has changed since the implementation of prospective payment systems (PPS) in 1983. We reviewed records of elderly patients admitted with hip fracture to a large community hospital from 1981 to 1986. During that period, the mean length of hospitalization decreased (from 21.9 to 12.6 days; P less than 0.0001), inpatient physical therapy decreased (from 7.6 to 6.3 sessions; P less than 0.04), and the maximal distance walked before discharge fell (from 27 to 11 m [93 to 38 ft]; P less than 0.0001). Concomitantly, the proportion of patients discharged to nursing homes rose (from 38 to 60 percent; P less than 0.0001), as did the proportion remaining in nursing homes one year after hospitalization (from 9 to 33 percent; P less than 0.0001). Neither in-hospital mortality nor one-year mortality changed significantly. As compared with beneficiaries of conventional Medicare after the implementation of PPS, HMO enrollees had shorter hospitalizations (7.3 vs. 14.0 days; P less than 0.0001), received less physical therapy (3.5 vs. 7.1 sessions; P less than 0.0001), walked shorter distances at discharge (3 vs. 13 m [11 vs. 44 ft]; P less than 0.01), and were more frequently transferred to nursing homes (83 vs. 55 percent; P less than 0.01). One year later, however, fewer HMO patients remained in nursing homes (16 vs. 35 percent; P less than 0.07). We conclude that since the implementation of PPS, hospitals have reduced the amount of care given to patients with hip fracture and have shifted much of the rehabilitation burden to nursing homes. The increase in the number of such patients remaining in nursing homes one year after the fracture suggests that the overall quality of care for these patients may have deteriorated.

Aged↗
PubMed1988

Cost-effective management of patients following myocardial infarction: the impact of ischemia on alternative approaches.

Following uncomplicated myocardial infarction patients are at varying risk for cardiovascular morbidity and mortality. In order to identify and treat high risk patients, various management approaches can be employed. We performed a decision analysis to examine the cost-effectiveness of seven alternative strategies under the assumption that prognosis is affected by both the location of anatomic obstruction and the degree of myocardial ischemia. Strategies included combinations of angiography and two theoretical diagnostic tests capable of detecting ischemia with different degrees of accuracy. The strategy associated with the lowest overall six month mortality initiated testing with the diagnostic test most sensitive for ischemia, slightly better than proceeding initially to angiography. Initial use of a test sensitive for ischemia was also considerably more cost-effective than proceeding directly to angiography. Future analyses evaluating the role of diagnostic tests in coronary artery disease should incorporate the dimension of ischemia.

Coronary Disease↗
PubMed1987

Changing patterns of hip fracture care before and after implementation of the prospective payment system.

We tested the hypothesis that since the implementation of the prospective payment system (PPS), elderly patients hospitalized for hip fractures receive shorter, less care-intensive hospitalizations and are more frequently institutionalized. In blinded fashion, we reviewed the charts of elderly patients with hip fractures admitted to a municipal hospital from 1981 through 1985. Demographic and clinical characteristics of patients treated before implementation of the PPS were similar to patients treated thereafter. After implementation of the PPS, the mean length of hospitalization fell from 16.6 to 10.3 days, and the mean number of physical therapy sessions received decreased from 9.7 to 4.9. Concomitantly, the proportion of patients discharged to a nursing home increased (21% to 48%), as did the proportion receiving nursing home care at six months after discharge (13% to 39%). This increase in long-term nursing home placement suggests that the quality of care for elderly patients with hip fractures may have deteriorated.

Aged↗
PubMed1987

Cost-effectiveness analysis of patient management alternatives after uncomplicated myocardial infarction: a model.

Quantitative decision analyses provide a means whereby the effectiveness, in terms of patient outcome, and costs of diverse clinical approaches to the care of patients with cardiovascular disease can be made explicit and understandable. Increasingly, the profession is being required to justify the costs of clinical care to society, government and third party payers. Such justifications can be effectively presented when structured in decision analytic format. To demonstrate the utility of decision analysis and its extension--cost-effectiveness analysis--as a technique for presenting the rationale for clinical practices and technology utilization, the Cardiovascular Norms Committee of the American College of Cardiology sponsored a model cost-effectiveness analysis. Alternative management options, 6 month mortality and costs for the post-myocardial infarction patient were compared. The options included exercise electrocardiography, exercise thallium scintigraphy and coronary angiography, followed by coronary artery bypass surgery for patients with left main coronary disease only or patients with left main disease, three vessel disease or single or double vessel disease and a significant amount of myocardium in jeopardy. Within the constraints of the model, proceeding directly to angiography for risk stratification was the most effective approach, lowering expected mortality from 8% to approximately 3%. The marginal costs for this strategy, however, were high. The most cost-effective approach was to screen patients initially with exercise electrocardiography.

Angiography↗
PubMed1987

Debt, moonlighting, and career decisions among internal medicine residents.

In the study reported here, medical residents were surveyed to determine their patterns of educational indebtedness, the effects of debt on their decisions about training and career, the frequency with which they begin making loan payments during training, the extent to which they moonlight and the reasons for doing so, and their opinions about the effects of moonlighting on house staff training. A total of 223 residents from four residency programs were surveyed; 181 responded. Most (86 percent) had educational debt (mean = $20,500), and more than half of those with debt were making loan payments. Forty percent of the residents moonlighted, and moonlighting was related to the presence of educational debt, monthly loan payments, and number of dependents.

Career Choice↗
PubMed1986

Cost-effectiveness of culturing for Chlamydia trachomatis. A study in a clinic for sexually transmitted diseases.

We have evaluated the cost-effectiveness of using cell culture to test for chlamydial infections in 9979 patients at a clinic for sexually transmitted diseases. From results of cultures, we have established prevalence data and, using decision-theory analysis, have calculated costs and probabilities of various outcomes. According to their histories and presenting signs and symptoms, patients were classified as at high or low risk for chlamydial infections. Empiric treatment of all patients attending the clinic was the most cost-effective strategy, followed by empiric treatment of high-risk women and culture-based treatment of low-risk women. Obtaining cultures for men at high and low risk was not cost-effective. If universal treatment is not provided, the most cost-effective strategy appears to be empiric therapy in patients at high risk for chlamydial infections and therapy based on diagnostic test results in women at low risk.

Adolescent↗
PubMedDate not supplied

General internal medicine and technologically less developed countries.

OBJECTIVE: To assess the international health activities of departments of medicine, divisions of general medicine, and general medicine faculty and the interest among departments of medicine in joint international health ventures. DESIGN: 15-item, mailed questionnaire. PARTICIPANTS: 100 chiefs of divisions of general medicine associated with training programs in internal medicine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Completed questionnaires were returned by 87 division chiefs representing 1,355 general medicine faculty. 49% of division had faculty with six weeks' experience in less developed countries. 8.5% of general medicine faculty had six weeks' experience in less developed countries. 7.6% of general medicine faculty were interested in spending extended time in less developed countries. 19% of departments had formal collaborations with schools in less developed countries. 45% of departments were interested in affiliations with U.S. institutions for the purpose of joint international health ventures. CONCLUSIONS: The international health interests of current general medicine faculty may not be satisfied. Departmental and divisional encouragement of international interests would increase the number of U.S. general internists participating in less developed countries. The authors discuss the potential for greater involvement of general medicine faculty in international health.

Attitude of Health Personnel↗
PubMedDate not supplied

Institutionalized patients with hip fractures: characteristics associated with returning to community dwelling.

The authors sought to identify patient- and nursing home-specific characteristics associated with a return to community living among patients with hip fractures discharged initially to nursing homes. One hundred eighty-nine free-living elderly patients were admitted for hip fractures to a 1,120-bed community hospital during 1984-1986. At hospital discharge, 114 (60%) of these patients were institutionalized. One year later, 49/114 (43%) had returned to the community. Three factors independently correlated with patients' return to community living: being discharged to a nursing home with a large ratio of annual admissions to number of beds (RR = 2.51, 95% CI 1.65, 3.94), achieving any in-hospital ambulation (RR = 4.24, 95% CI 1.77, 8.14), and receiving conventional Medicare insurance (RR = 0.37, 95% CI 0.05, 0.53). These data suggest the existence of patient and nursing home features that identify those institutionalized patients with hip fractures who are more likely to return to community dwelling.

Age Factors↗