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S C Schoenbaum

Publications and source records attributed to S C Schoenbaum.

At least 37 records · Page 2Linked to original sources
PubMed1990

Clinical practice guidelines at an HMO: development and implementation in a quality improvement model.

Harvard Community Health Plan (HCHP) is adapting to clinical medicine the managerial principles and methods of quality improvement theory that were originally developed and successfully applied in industrial settings. An essential step in applying the quality improvement cycle to clinical medicine is the setting of standards or specifications for clinical care. HCHP has chosen to focus its standard-setting efforts on the development of clinical algorithms, which provide an excellent basis for specifying and communicating optimal care processes and for evaluating actual clinical care. When implemented effectively, clinical algorithms may improve quality and decrease costs by guiding clinicians toward more standardized, high-quality, cost-effective clinical strategies and by facilitating more valid measurement of clinical process and outcomes. This article describes the evolution, structure, methods, and future agenda of the Algorithm Based Clinical Quality Improvement Process (ABCQIP) at HCHP.

Algorithms↗
PubMed1990

Improving influenza vaccination performance in an HMO setting: the use of computer-generated reminders and peer comparison feedback.

We evaluated a program for improving influenza immunization performance in a health maintenance organization (HMO). The HMO implemented several interventions successively from 1984-87: a postcard reminder to members at high risk for complications of influenza, a computer-generated reminder to the physician at the time of any primary care visit by high-risk patients, performance feedback to chiefs of service, and, finally, retrospective feedback to each physician comparing his/her performance with that of the other physicians. We examined immunization rates for a group of members older than age 65, a high-risk group under age 65, and a group of diabetic members who had not been subject to the reminders (vs a group who had been covered by the program). Vaccination rates were increased in those diabetic members who received reminders. Nevertheless, among members younger and older than age 65 whose experience was observed over three flu seasons, a significant increase in vaccination rates was not achieved until physician feedback was added to the program. We conclude that each element of the reminder and feedback program has contributed to the overall increase in vaccination rates at the HMO and that effective ongoing influenza immunization programs can be implemented in practice settings with appropriate systems support.

Aged↗
PubMed1990

Developing effective systems for delivery of vaccines.

Effective immunization performance depends on the development and continuous improvement of systems and processes in each of the settings in which vaccines are given. This article gives some examples of improved performance and the role of a variety of techniques such as reminders in achieving improved performance. Measurement of performance plays an important, indeed, essential role in quality improvement and has notably been lacking in immunization activities. For future improvement, it will be important to link policy-making with the remaining elements of the quality improvement cycle.

Aged↗
PubMed1989

The association of inter-pregnancy interval with small for gestational age births.

The association between small for gestational age (SGA) birth at term and inter-pregnancy interval was examined in a hospital cohort of 4489 multiparous women. The greatest risk of SGA birth was found in women with the shortest inter-pregnancy intervals. Even after adjusting for multiple confounding factors, women whose inter-pregnancy interval was 18 or fewer months (over one-third of women in the cohort) remained at twice the risk of giving birth to a term SGA infant when compared with women whose inter-pregnancy interval was 24-36 months. In a logistic regression analysis examining the occurrence of SGA birth in women with inter-pregnancy intervals of 36 months or less, a strong linear association was noted between these two factors. The association of term SGA birth with short inter-pregnancy interval could result from one or more physiologic factors that might act to limit fetal growth. In that case, short inter-pregnancy interval would represent a potentially preventable cause of SGA birth.

Birth Intervals↗
PubMed1988

Association of maternal hematocrit with premature labor.

An examination of the association of maternal hematocrit with the occurrence of premature birth revealed a continuous relationship between these two factors with an increasing rate of prematurity occurring with decreasing maternal hematocrit. The lowest risk of premature birth was found when maternal hematocrit was between 41% and 44%. Statistically increases in prematurity were noted at all hematocrit levels of less than or equal to 38%. A woman with a hematocrit of 37% had twice the risk of having a premature birth as a woman whose hematocrit was between 41% and 44% (p less than 0.01). In a logistic regression analysis with premature birth as the dependent variable and hematocrit as the only predictor variable, it was noted that decreasing the hematocrit by a single point was associated with a 24% increase in the risk of prematurity (odds ratio = 1.24) while a five-point decrease in hematocrit was associated with a tripling in the risk of prematurity (odds ratio = 2.98). In a multivariable logistic regression analysis hematocrit was noted to explain more of the variation in prematurity than any of the other risk factors included in the model. An investigation of this association in specific groups at high risk of having premature births revealed that 46% of the increased risk of prematurity in black women and 49% of the increased risk of prematurity in women receiving welfare was related to hematocrit or some factor associated with hematocrit.

Adult↗
PubMed1988

Adverse outcomes of pregnancy in women exposed to diethylstilbestrol in utero.

We analyzed data collected by interview and medical record review for 200 women exposed to diethylstilbestrol (DES) and 12,240 unexposed women to evaluate the relation between maternal DES exposure and outcomes of pregnancy. Low birth weight, short gestation, bleeding in the first trimester, toxemia, breech presentation and premature rupture of the membranes occurred more often among the exposed women. These relationships remained statistically significant after the use of linear regression and logistic regression analyses to control for multiple confounding factors. Both exposed women and their physicians should be aware of the possible relationship between maternal exposure to DES and late adverse outcomes of pregnancy. Close medical supervision of these women throughout pregnancy and delivery is recommended.

Demography↗
PubMed1987

Risk factors accounting for racial differences in the rate of premature birth.

In a hospital-based cohort of 8903 black and white women, we investigated medical and socioeconomic risk factors that may explain the known increase in premature births among black women. Among the medical conditions examined, only the maternal hematocrit level (or some related factor) explained a substantial proportion (60 percent) of the increased rate of premature births to black women. Four economic, demographic, and behavioral predictors of prematurity were also examined: age less than 20 years, single marital status, receiving welfare support, and not having graduated from high school. The number of these socioeconomic risk factors occurring in a woman was strongly predictive of premature birth of her infant, regardless of the particular risk factors present. The presence of any one factor was associated with a moderate increase in the risk of prematurity (7.0 percent as compared with 4.6 percent with no risk factors present); the presence of two or more characteristics was associated with a much higher risk (11.2 percent). When the number of these four risk factors pertaining to an individual woman was taken into account, race was no longer a significant predictor of premature birth (odds ratio, 1.22; 95 percent confidence interval, 0.94 to 1.59). When both the maternal hematocrit level and the number of the four socioeconomic risk factors were taken into account, essentially all of the racial variation in prematurity was explained, with the odds ratio for prematurity among blacks being 1.03 (95 percent confidence interval, 0.79 to 1.35). We conclude that the racial difference in the rate of premature birth is attributable to specific medical and socioeconomic characteristics.

Adult↗
PubMed1987

Economic impact of influenza. The individual's perspective.

The estimated average economic cost of influenza in the United States exceeds $1 billion each year, and the actual cost is more likely on the order of $3 to $5 billion per year. Benefit-cost models generally indicate that the benefits of influenza immunization for persons aged 65 and over outweigh the cost (when one excludes the cost of medical care in the additional years of healthy life gained by immunization). The low acceptance of influenza immunization suggests that individuals do not see the benefit-cost equation in the same way that policymakers do. This article presents a benefit-cost equation from an individual's perspective. The model demonstrates that pre-season immunization is cost-effective when the cost of a case of influenza, were it to occur, would be very high--as it is in persons under active medical care for heart or lung disease, for example. Immunization is also cost-effective for persons with a high income and a low cost of immunization--such as physicians themselves. The model further demonstrates that in the face of an actual epidemic, one can justify greater expenditures on protection against influenza, including immunization plus chemoprophylaxis or early chemotherapy. Finally, analysis of the model suggests the need for improved, less expensive systems for protecting individuals against influenza.

Absenteeism↗
PubMed1986

The relation of endometriosis to menstrual characteristics, smoking, and exercise.

We compared menstrual characteristics and constitutional factors in 268 white women with primary infertility due to endometriosis and in 3,794 white women admitted for delivery at seven collaborating hospitals from 1981 to 1983. Adjusting for confounding factors, including location, age, religion, and education, women with short-cycle lengths (less than or equal to 27 days) and longer flow (greater than or equal to one week) had more than double the risk for endometriosis compared with women with longer cycle lengths and shorter duration of flow. There was a trend for increasing risk for endometriosis to be associated with increasing menstrual pain. Adjusting for these menstrual characteristics, we found decreased risk for endometriosis associated with smoking or exercise that was largely confined to women who began either habit at an early age and were heavier smokers or more strenuous exercisers. We conclude that risk for endometriosis may relate to menstrual factors that predispose to greater pelvic contamination with menstrual products and to constitutional factors that influence endogenous hormonal levels.

Adolescent↗
PubMed1985

Tubal infertility and the intrauterine device.

To study the association between intrauterine devices (IUDs) and pelvic inflammatory disease, we compared contraceptive histories in 4185 while women--283 nulliparous women with primary tubal infertility, 69 women with secondary tubal infertility, and 3833 women admitted for delivery at seven collaborating hospitals from 1981 to 1983. The relative risk of tubal infertility associated with IUD use was calculated by means of multivariate logistic regression to control for confounding factors, including region, year of menarche, religion, education, smoking, and reported number of sexual partners. The adjusted risk of primary tubal infertility associated with any IUD use before a first live birth was 2.0 (95 per cent confidence limits, 1.5 to 2.6) relative to nonuse. Users of the Dalkon Shield had an adjusted risk of 3.3 (1.7 to 6.1), users of the Lippes Loop or Saf-T-Coil had a risk of 2.9 (1.7 to 5.2), and users of copper IUDs had a risk of 1.6 (1.1 to 2.4). Women who reported having only one sexual partner had no increased risk of primary tubal infertility associated with IUD use. The adjusted risk of secondary tubal infertility associated with use of a copper IUD after a first live birth was not statistically significant (1.5; 95 per cent confidence limits, 0.8 to 3.0), whereas the risk from similar use of noncopper devices was significant (2.8; 1.3 to 5.9). We conclude that tubal infertility is associated with IUD use, but less so with copper IUDs.

Adult↗
PubMed1985

Epidemiology of neonatal hyperbilirubinemia.

Interview and record review data from 12,023 singleton deliveries were analyzed to determine the relationships between neonatal hyperbilirubinemia (10 mg/dL or greater) and maternal characteristics. Confounding variables were controlled by multiple logistic regression analysis. There was a statistically significant positive relationship between hyperbilirubinemia and low birth weight, Oriental race, premature rupture of membranes, breast-feeding, neonatal infection, use of the "pill" at time of conception, instrumental delivery, and history of first trimester bleeding. Maternal smoking and black race were negatively related to hyperbilirubinemia and statistically significant. In this study, other previously suspected etiologic factors such as epidural anesthesia, parity, use of oxytocin in labor, and white race were not associated with hyperbilirubinemia.

Adult↗
PubMed1984

Discontinued use of intrauterine contraceptive device and pregnancy loss.

To evaluate the risk of spontaneous abortion among former intrauterine contraceptive device (IUD) users, we compared the contraceptive history of 328 women with a spontaneous abortion up to 28 weeks' gestation with that of 1715 women having a term delivery. A similar percentage of case and comparison subjects reported prior IUD use as well as IUD use within the year before pregnancy. However, IUD use lasting more than 12 months was associated with a 1.5-fold increase in the crude risk of spontaneous abortion up to 28 weeks' gestation (p less than 0.05), a 1.8-fold increased risk of first-trimester spontaneous abortion, and a 1.7-fold increased risk of incomplete abortion (p less than 0.01). The results were not altered by control of individual confounding factors. When confounding factors were controlled simultaneously in a multiple logistic regression analysis, the relative risks were 1.4, 1.7 and 1.6, respectively; however, they were no longer statistically significant. The results suggest that prolonged IUD use may be associated with a modest increase in risk of subsequent spontaneous abortion.

Abortion, Incomplete↗
PubMed1984

Work and pregnancy.

Pregnancy outcomes of 7,155 women who worked between one and nine months of pregnancy were compared with outcomes of 4,018 women who were not employed. There were no differences in rates of prematurity, Apgar score, birthweight, perinatal death rate, or malformation prevalence. Working women were divided into those who left employment during the first eight months and those who worked all nine months. The latter had a lower rate of adverse outcome than the other working group and the nonworking group. This indicates that working to term in the absence of contraindications does not impose an added risk on mother or infant. After control of confounding by parity and other relevant factors, an increased risk of prolonged gestational age was seen among primiparous working women. There was an increased risk of fetal distress among those women leaving work prior to nine months who were having their third or subsequent child. A small decrease in birth weight was seen among women who left work prior to term but not among those who worked all nine months. Overall the results are reassuring that working during pregnancy is not in itself a risk factor for adverse outcome.

Adolescent↗
PubMed1984

Fertility after induced abortion: a prospective follow-up study.

Abortion has been alleged to cause sterility. To address this issue, 1235 postabortal women, 912 women recently delivered, and 939 women from the authors' gynecology clinics were studied for as long as 3.5 years. Cumulative pregnancy rates were similar for abortion group patients, delivery group patients, and the previously pregnant clinic group. When pregnancy rates were examined by different assumptions as to entrance into follow-up, the abortion group differed only in a somewhat lower pregnancy rate after nine months, when the use of contraceptives was greater than that of the other two groups. Pregnancy rates for all three groups were influenced by age of subject, parity, race, marital and Medicaid status, and a history of urinary tract infections. Induced abortion status did not influence pregnancy rates except that women reporting three or more induced abortions had a higher pregnancy rate.

Abortion, Induced↗
PubMed1983

Lack of association between contraceptive usage and congenital malformations in offspring.

Previous reports have linked the use of oral contraceptives and spermicides to the occurrence of malformations in offspring. With information from 12,440 women interviewed during the delivery hospitalization, we found no relationship between contraceptive method and the occurrence of malformations. Whereas any unnecessary drug should be avoided during pregnancy, prior contraceptive method seems to be unrelated to the risk of congenital malformations.

Abortion, Induced↗
PubMed1983

The relationship between induced abortion and outcome of subsequent pregnancies.

We analyzed interview and record review data from 9,823 deliveries to evaluate the relationship between prior history of induced abortion and subsequent late pregnancy outcomes. Complications such as bleeding in the first and third trimesters, abnormal presentations and premature rupture of the membranes, abruptio placentae, fetal distress, low birth weight, short gestation, and major malformations occurred more often among women with a history of two or more induced abortions. A logistic regression analysis to control for multiple confounding factors showed that a history of one induced abortion was statistically significantly associated with first-trimester bleeding but with no other untoward pregnancy events, and a history of two or more induced abortions was statistically associated with first-trimester bleeding, abnormal presentations, and premature rupture of the membranes. While these relationships merit further research, the results of this study are largely reassuring. A history of one or more prior induced abortions does not appear to increase substantially the risk of adverse late outcomes of subsequent pregnancies.

Abortion, Induced↗