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Biomedical subjects

S D Fihn

Publications and source records attributed to S D Fihn.

At least 55 records · Page 3Linked to original sources
PubMed1996

Length of hospital stay after acute myocardial infarction in the Myocardial Infarction Triage and Intervention (MITI) Project registry.

OBJECTIVES: This study sought to identify current trends in length of stay in patients with an acute myocardial infarction and to evaluate which demographic, clinical, procedural and hospital-related factors explain the variation and reduction in length of stay observed during the study period. BACKGROUND: Hospital length of stay is an important contribution to cost of care. Previous studies of length of stay after acute myocardial infarction have been performed largely on administrative data bases and do not reflect current practice patterns. METHODS: We used univariate and multivariate models to evaluate which demographic, clinical and administrative factors influenced length of stay in 11,932 patients with acute myocardial infarction admitted to 19 Seattle-area hospitals between 1988 and 1994. RESULTS: Length of hospital stay decreased from (mean +/- SD) 8.5 +/- 8.2 to 6.0 +/- 5.8 days during the study period. Demographic and clinical characteristics known at the time of admission explained only 6% of variation in length of stay, whereas hospital complications, procedure use and type of admitting hospital explained an additional 27% of variation. The use of primary angioplasty and early diagnostic coronary angiography predicted a shorter length of stay; however, none of the measured variables explained the 29% reduction in length of stay that occurred between 1988 and 1994. CONCLUSIONS: Although hospital complications, procedure use and hospital characteristics are important predictors of length of hospital stay, none of these factors explains the 29% reduction in length of stay observed in postmyocardial infarction patients between 1988 and 1994. It is likely that unmeasured economic and administrative factors play important roles in influencing hospital length of stay.

Aged↗
PubMed1996

Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines.

BACKGROUND: A multisite, randomized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing (AD) and continuous quality improvement (CQI) teams-on the implementation of national guidelines for the primary care of hypertension and depression. STUDY: Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound (Seattle) and two at academic medical centers-were randomized in blocks along with their primary care patients to receive AD alone, AD plus CQI, or usual care. A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8-9 minutes. Each CQI team, which met, on average, 14 times in nine months, devised at least one intervention (for example, weight loss counseling for hypertensives by nurse practitioners). RESULTS: The detailing endeavors differed greatly across organizations. Although all teams generally worked well together, organizational factors such as staff layoffs and reorganizations competed for the teams' attention. Team leaders differed in their ability to inspire members to "run with" ideas and to motivate personnel outside the team to implement interventions. SUMMARY AND CONCLUSIONS: Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that resulted in varied implementation across the different organizations. Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques.

Academic Medical Centers↗
PubMed1995

Development and evaluation of the Seattle Angina Questionnaire: a new functional status measure for coronary artery disease.

OBJECTIVES: This study sought to establish the validity, reproducibility and responsiveness of the Seattle Angina Questionnaire, a 19-item self-administered questionnaire measuring five dimensions of coronary artery disease: physical limitation, anginal stability, anginal frequency, treatment satisfaction and disease perception. BACKGROUND: Assessing the functional status of patients is becoming increasingly important in both clinical research and quality assurance programs. No current functional status measure quantifies all of the important domains affected by coronary artery disease. METHODS: Cross-sectional or serial administration of the Seattle Angina Questionnaire was carried out in four groups of patients: 70 undergoing exercise treadmill testing, 58 undergoing coronary angioplasty, 160 with initially stable coronary artery disease and an additional 84 with coronary artery disease. Evidence of validity was sought by comparing the questionnaire's five scales with the duration of exercise treadmill tests, physician diagnoses, nitroglycerin refills and other validated instruments. Reproducibility and responsiveness were assessed by comparing serial responses over a 3-month interval. RESULTS: All five scales correlated significantly with other measures of diagnosis and patient function (r = 0.31 to 0.70, p < or = 0.001). Questionnaire responses of patients with stable coronary artery disease did not change over 3 months. The questionnaire was sensitive to both dramatic clinical change, as seen after successful coronary angioplasty, and to more subtle clinical change, as seen among outpatients with initially stable coronary artery disease. CONCLUSIONS: The Seattle Angina Questionnaire is a valid and reliable instrument that measures five clinically important dimensions of health in patients with coronary artery disease. It is sensitive to clinical change and should be a valuable measure of outcome in cardiovascular research.

Activities of Daily Living↗
PubMed1995

Resource utilization in treatment of acute myocardial infarction: staff-model health maintenance organization versus fee-for-service hospitals. The MITI Investigators. Myocardial Infarction Triage and Intervention.

OBJECTIVES: This study sought to compare the use of invasive procedures and length of stay for patients admitted with acute myocardial infarction to health maintenance organization (HMO) and fee-for-service hospitals. BACKGROUND: The HMOs have reduced costs compared with fee-for-service systems by reducing discretionary admissions and decreasing hospital length of stay. It has not been established whether staff-model HMO hospitals also reduce the rate of procedure utilization. METHODS: Using data from a retrospective cohort, we performed univariate and multivariate comparisons of the use of cardiac procedures, length of stay and hospital mortality in 998 patients admitted to two staff-model HMO hospitals and 7,036 patients admitted to 13 fee-for-service hospitals between January 1988 and December 1992. RESULTS: The odds of undergoing coronary angiography were 1.5 times as great for patients admitted to fee-for-service hospitals than for those admitted to HMO hospitals (odds ratio 1.5, 95% confidence interval [CI] 1.3 to 1.9). Similarly, the odds of undergoing coronary revascularization were two times greater in fee-for-service hospitals (odds ratio 2.0, 95% CI 1.6 to 2.5). However, higher utilization was strongly associated with the greater availability of on-site cardiac catheterization facilities in fee-for-service hospitals. The length of hospital stay, by contrast, was approximately 1 day shorter in the fee-for-service cohort (7.3 vs. 8.0 days, p < 0.05). CONCLUSIONS: Physicians in staff-model HMO hospitals use fewer invasive procedures and longer lengths of stay to treat patients with acute myocardial infarction than physicians in fee-for-service hospitals. This finding, however, appears to be associated with the lack of on-site catheterization facilities at HMO hospitals.

Aged↗
PubMed1995

A comprehensive system for quality improvement in ambulatory care: assessing the quality of diabetes care.

A comprehensive state-of-the-art system for quality improvement in ambulatory care has been designed to test (1) whether patients at 8 intervention sites demonstrate improved health status and satisfaction with their care as compared to patients at 8 control sites and (2) the extent to which timely patient self-reported data influences provider practice patterns. During the study pilot period, several investigators developed, tested and analyzed disease-specific questionnaires for 7 common chronic conditions. An advanced automated information system was designed to link hospital computer information and patient questionnaire data in order to provide timely communication between patients and providers about important health problems. This report briefly describes the 3-year quality of ambulatory care clinical trial and details the development and pilot testing of the disease specific questionnaire for diabetes. Reliability testing showed correlations were higher for fixed events such as foot ulcers than for subjective judgments such as satisfaction with providers. Responsiveness testing indicated that this questionnaire could measure behavior and care modifications in patients 6 months following an outpatient education course, compared to the baseline pre-education values. Diabetes severity information has been collected from self-administered questionnaires and laboratory data to assist providers in assessing the patients' likelihood of 4-year mortality. It is anticipated that the rapid identification of important patient issues will assist patients and clinicians in mutually addressing and resolving health care problems, thereby improving the quality of outpatient care.

Ambulatory Care↗
PubMed1994

Monitoring the quality of life in patients with coronary artery disease.

Monitoring the outcomes of treatment and quantifying patients' functional status have assumed a prominent role in both clinical trials and quality assurance programs. Because patients with coronary artery disease (CAD) may have comorbid illnesses, and because generic health status questionnaires may not focus on symptoms and impairments unique to coronary disease, a generic measure of health status may not be sufficient to detect important changes in patients' CAD. The responsiveness to clinical change of the Seattle Angina Questionnaire (SAQ), a disease-specific measure for CAD, was compared with that of the Short Form-36, a generic measure of health status. Both questionnaires were serially administered, 3 months apart, to 45 patients undergoing coronary angioplasty and to 130 patients with stable CAD. Most scales of both questionnaires improved significantly after coronary angioplasty. The responsiveness statistics of the SAQ exceeded those of the Short Form-36. Among 130 patients with initially stable angina, 33 deteriorated, 79 remained stable, and 18 improved over 3 months of observation. Mean SAQ scores changed significantly and appropriately in each of these groups. In contrast, none of the Short Form-36 scales detected these more subtle changes. Although useful in assessing overall function, a generic health status measure, such as the Short Form-36, may not be responsive enough to detect important clinical changes in patients' CAD. A disease-specific instrument, such as the SAQ, can be an important and relevant outcome measure in clinical trials or quality assurance programs.

Activities of Daily Living↗
PubMed1994

Attitudes toward assisted suicide and euthanasia among physicians in Washington State.

BACKGROUND: Despite considerable public interest in legalizing physician-assisted suicide and euthanasia, little is known about physicians' attitudes toward these practices. METHODS: We sent questionnaires to 1355 randomly selected physicians in the state of Washington, including all hematologists and oncologists and a disproportionately high number of internists, family practitioners, psychiatrists, and general surgeons. To avoid ambiguity in our survey, instead of "physician-assisted suicide," we used the phrase "prescription of medication [e.g., narcotics or barbiturates] or the counseling of an ill patient so he or she may use an overdose to end his or her own life." Instead of "euthanasia," we used the phrase "deliberate administration of an overdose of medication to an ill patient at his or her request with the primary intent to end his or her life." RESULTS: Of the 1355 eligible physicians who received our questionnaire, 938 (69 percent) responded. Forty-eight percent of the respondents agreed with the statement that euthanasia is never ethically justified, and 42 percent disagreed. Fifty-four percent thought euthanasia should be legal in some situations, but only 33 percent stated that they would be willing to perform euthanasia. Thirty-nine percent of respondents agreed with the statement that physician-assisted suicide is never ethically justified, and 50 percent disagreed. Fifty-three percent thought assisted suicide should be legal in some situations, but only 40 percent stated that they would be willing to assist a patient in committing suicide. Of the groups surveyed, hematologists and oncologists were most likely to oppose euthanasia and assisted suicide, and psychiatrists were most likely to support these practices. CONCLUSIONS: The attitudes toward physician-assisted suicide and euthanasia of physicians in Washington State are polarized. A slight majority favors legalizing physician-assisted suicide and euthanasia in at least some situations, but most would be unwilling to participate in these practices themselves.

Attitude of Health Personnel↗
PubMed1994

How residents spend their time in clinic and the effects of clerical support.

The authors conducted a time study of residents in clinic to determine the effects of providing clerical assistance. The residents recorded their activities at 5-minute intervals at baseline and six months after hiring three clerical assistants. Before and after introduction of the clerical assistants, approximately 40% of the time was devoted to direct interaction with patients. Statistically significant improvements were observed in the availability of medical records (89% vs 100%) and the time spent looking up test results (5% vs 3% of the clinic time). The residents felt the clerical assistants greatly improved their clinic experience and the quality of patient care.

Allied Health Personnel↗
PubMed1994

Anticoagulation therapy and primary care internal medicine: a nurse practitioner model for combined clinical science.

The anticoagulation clinics at the University of Virginia Health Sciences Center and the University of California at Davis Medical Center are nurse-practitioner-operated, are affiliated with the general medicine clinic, and rely on portable prothrombin time (PT) monitors that use whole blood and provide timely as well as accurate results reported in PT seconds or as the international normalized ratio (INR). On-site PT/INR testing at these clinics simplifies anticoagulation, mandates direct patient contact, and facilitates primary as well as comprehensive care for patients requiring multispecialty services in large tertiary care centers. Encounters are relatively brief, averaging 19 minutes; 72% of the encounter time involves anticoagulation care and 28% involves primary care. Anticoagulation results using portable PT/INR monitors are safe and accurate based on comparisons with results from clinics relying on standard instruments.

Academic Medical Centers↗
PubMed1994

A computerized intervention to improve timing of outpatient follow-up: a multicenter randomized trial in patients treated with warfarin. National Consortium of Anticoagulation Clinics.

OBJECTIVE: To evaluate a computerized scheduling model that employs nonlinear optimization to recommend optimal follow-up intervals for patients taking warfarin. DESIGN: Randomized trial. SETTING: 5 anticoagulation clinics. PATIENTS/PARTICIPANTS: 620 patients expected to receive warfarin for > or = 6 weeks. INTERVENTIONS: Computer-generated recommendations for scheduling the next visit were presented to or withheld from practitioners. MEASUREMENTS AND MAIN RESULTS: The main outcome measures were the follow-up interval scheduled by the provider, the interval at which the patient actually returned to clinic, and the quality of anticoagulation control (computed as the absolute difference between the measured and target prothrombin times [PTRs] or international normalized ratios [INRs]). Follow-up intervals scheduled for the patients whose practitioners received computer-generated recommendations were significantly longer than those for control patients (mean, 4.4 vs 3.5 weeks, p < 0.001), despite the fact that the practitioners modified the suggested return interval by > 1 week on 40% of the visits. The interval at which the intervention group actually returned to clinic was also longer (mean, 4.4 vs 4.1 weeks, p < 0.05), even though the control patients tended to return at longer intervals than were scheduled by their practitioners. Control of anticoagulation was nearly the same among experimental and control patients. Life-threatening complications occurred in the care of three experimental patients and one control patient, while other serious complications occurred in the care of 16 experimental patients and 17 control patients. CONCLUSIONS: Recommendations based on nonlinear optimization prompted clinicians to schedule less frequent follow-up for patients taking warfarin, with no deterioration in anticoagulation control. This approach to scheduling can potentially reduce utilization while maintaining quality of care for patients who require long-term monitoring.

Appointments and Schedules↗
PubMed1993

The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. Myocardial Infarction Triage and Intervention Project Investigators.

BACKGROUND: During the past decade the use of coronary angiography after acute myocardial infarction has substantially increased. Among the possible contributing factors, the increasing availability of cardiac catheterization facilities was the focus of our investigation. METHODS: We investigated whether the availability of cardiac catheterization facilities at an admitting hospital was associated with the likelihood that a patient would undergo coronary angiography. After adjusting for age, sex, cardiac history, and cardiac complications during hospitalization, we evaluated this association in 5867 consecutive patients with acute myocardial infarction admitted to 19 Seattle-area hospitals. We also assessed the association between the presence of on-site cardiac catheterization facilities and in-hospital mortality. RESULTS: Patients admitted to hospitals with on-site cardiac catheterization facilities were far more likely to undergo coronary angiography (odds ratio, 3.21; 95 percent confidence interval, 2.81 to 3.67) than patients admitted to hospitals where transfer to another institution would be required to perform cardiac catheterization. Admission to a hospital with on-site facilities was more strongly associated with the use of coronary angiography than any characteristic of the patient. Although our study had limited power to detect differences in mortality, the availability of coronary angiography had no discernible association with in-hospital mortality rates (odds ratio for mortality among patients admitted to hospitals with on-site facilities vs. patients admitted to hospitals without such facilities, 0.88; 95 percent confidence interval, 0.71 to 1.09). CONCLUSIONS: In this community-wide study, the availability of on-site cardiac catheterization facilities was associated with a higher likelihood that a patient would undergo coronary angiography. However, admission to hospitals with these facilities did not appear to be associated with lower short-term mortality.

Aged↗
PubMed1993

Risk factors for complications of chronic anticoagulation. A multicenter study. Warfarin Optimized Outpatient Follow-up Study Group.

OBJECTIVE: To define risk factors for complications that occur during warfarin therapy. DESIGN: Retrospective cohort study. SETTING: Five anticoagulation clinics. PATIENTS: Nine hundred twenty-eight consecutive patients receiving 1103 courses of warfarin. MAIN OUTCOME MEASURES: Hemorrhagic and thromboembolic complications. RESULTS: In 1950 patient-years of follow-up, there were 1332 bleeding events (4 were classified as fatal, 31 as life-threatening, 226 as serious, and 1071 as minor). The cumulative incidence of fatal bleeding was 1% at 1 year and 2% at 3 years. The cumulative incidences of first episodes of life-threatening and serious bleeding at 1, 2, 4, and 8 years were 1%, 2%, 5%, and 9% and 12%, 20%, 28%, and 40%, respectively. Of 156 patients who had a serious or life-threatening hemorrhage, 32% suffered a recurrence, typically within 1 year. Independent predictors of a first episode of serious bleeding included a mean prothrombin time ratio (PTR) of 2.0 or more during the course of treatment (relative risk, 3.0; 95% CI, 1.9 to 4.7); recent initiation of warfarin therapy (relative risk during the first 3 months compared with the rest of the first year, the second year, and anytime thereafter, 1.9 [CI, 1.3 to 3.0], 3.0 [CI, 1.8 to 4.8], and 5.9 [CI, 3.8 to 9.3], respectively); variability of the PTR over time (relative risk for the highest compared with the lowest tertile, 1.6 [CI, 1.2 to 2.7]); and the presence of 3 or more comorbid conditions (RR, 1.4 [CI, 1.1 to 2.5]). Age, reason for anticoagulation, use of interfering drugs, and hypertension were not associated with risk for bleeding. The risk for a thromboembolic complication at a PTR of less than 1.3 was 3.6 (CI, 2.1 to 6.4) times higher than at a PTR of 1.3 to 1.5. CONCLUSIONS: The incidence of warfarin-associated bleeding may be reduced by attending to modifiable risk factors (that is, highly variable PTRs and values greater than 2.0), frequent monitoring early in treatment, and careful patient selection. Older age, in and of itself, is not a risk factor.

Adult↗
PubMed1993

Infection of an arterial prosthesis as the presenting manifestation of disseminated coccidioidomycosis: control of disease with fluconazole.

We describe an elderly man whose presenting manifestation of disseminated coccidioidomycosis was bilateral infection of femoral arterial prosthetic grafts. After the patient failed to respond to both ketoconazole and amphotericin B, treatment with fluconazole brought about clinical resolution of meningitis and pulmonary disease and, in combination with repeated percutaneous aspiration, control of the arterial infection. The unusual clinical features of this case, along with the incidence and management of prosthetic arterial infections caused by fungi, are discussed.

Aged↗
PubMed1993

Variation in the rate of cervical spine surgery in Washington State.

Lack of consensus about the treatment of low back pain is reflected by wide regional variations in lumbar spine surgery rates. Neck pain may be as common as low back pain, but there has been no similar evaluation of regional variation for the surgical treatment of neck pain. This report examines the geographic variation and temporal trends in the rate of cervical spine surgery in Washington state from 1986 through 1989. Using diagnosis and procedure codes from the International Classification of Diseases (ICD-9 CM), the authors retrospectively identified cervical spine surgery cases from a statewide hospital discharge registry for Washington. After excluding cases associated with trauma, infection, or malignancy, 5,173 incident cervical spine surgery cases were analyzed. Cervical spine surgery was performed at approximately 25% the rate of lumbar spine surgery, and from 1986 to 1989, the age- and gender-adjusted rate increased 20%. Small area analysis demonstrated a sevenfold variation among counties in the rate of cervical spine surgery (P < 0.001), with variation of fourfold to 13-fold for specific surgical procedures. These data demonstrate that cervical spine surgery for neck pain is an increasingly common procedure with wide geographic variability. Rational treatment of neck pain requires further definition of indications for cervical spine surgery, preferably based on firm data concerning the outcomes of surgical and nonsurgical care.

Cervical Vertebrae↗
PubMed1992

Lower urinary tract infection in women.

Infections of the lower urinary tract affect 10% to 20% of all women, among whom a substantial proportion go on to experience recurrent infections. Bacterial virulence factors, particularly those enhancing mucosal adherence, are important in the pathogenesis of urinary tract infection. The use of a diaphragm with spermicides predisposes to urinary tract infection, most likely through alterations of the normal vaginal flora. Urine microscopy is the most accurate rapid office test for urinary tract infection. Automated and dipstick techniques yield slightly lower sensitivity and specificity. Recent treatment trials indicate that 3-day therapy for uncomplicated lower urinary tract infection provides an optimal balance between efficacy and adverse effects when compared with single-dose therapy or treatment for 7 to 10 days. Antibiotic prophylaxis is an important strategy in treating recurrent infections and is effective for periods as long as 5 years without undue emergence of resistant bacterial strains. Interstitial cystitis remains an elusive entity without definite diagnostic criteria or clearly effective therapy.

Anti-Bacterial Agents↗
PubMed1991

Appropriate reductions in compliance among well-controlled hypertensive patients.

Physicians have traditionally viewed partial compliance with medications as a concern only in hypertensive patients whose blood pressure (BP) is poorly controlled. However, partial compliance also occurs in patients whose BP has become normal on medications; in them, reduced compliance may indicate that they have been prescribed more medication than they need. During enrollment for a study of medication reduction in hypertensive patients, we identified 118 male veterans who were eligible for the study because their diastolic BP had been less than 95 mmHg for more than 6 months. Fifty-nine of these patients (50.0%) agreed to participate in the study, of whom 71% successfully reduced or stopped ("stepped down") one or more of their antihypertensive drugs over a 1-year period. The 59 patients who did not enroll continued to receive routine care for hypertension in the clinic without intensive efforts at stepdown. Nevertheless, 24% of these patients reduced or stopped at least one medication over the same time period. In the year prior to the study, 29 of the 118 eligible patients (24.6%) had obtained less than 80% of their medications, measured by pharmacy refill records. Compliance in obtaining antihypertensive medications prior to the study was lower among eligible patients who stepped down medications during the study year (90.4% +/- 18.7%) than in those who did not (102.1% +/- 26.1%, p = 0.006). After adjustment for other predictors of stepdown (number of medications, duration of clinic enrollment, and pre-reduction systolic BP), each 10% increase in compliance among all eligible patients was associated with a reduction in the odds ratio for successful stepdown of 0.8 (95% CI 0.5-1.0, p = 0.01). We conclude that many well-controlled hypertensives appropriately obtain less medications than they are prescribed. Such patients should be considered for reduction of antihypertensive drugs.

Aged↗