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Biomedical subjects

S G Pauker

Publications and source records attributed to S G Pauker.

At least 19 recordsLinked to original sources
PubMed1992

DecisionNET: database/network support for clinical decision analysts.

DecisionNET is a proposed remote database/wide-area computer network that should cultivate quantitative approaches to medicine by providing rapid access to medical facts, literature citations, decision models, and commentary of specific use to those involved with quantitative clinical decision making. Increasing accessibility to data and providing a forum for exchange of ideas should prove to be a significant asset to clinicians, either as modelers or as clients. Further work will address specific database implementation, development of a query engine, and coordination of the communications infrastructure. DecisionNET provides a unique model for the growth and maintenance of other medical knowledge bases.

Archives↗
PubMed1992

Direct angioplasty for acute myocardial infarction. A review of outcomes in clinical subsets.

PURPOSE: To review the usefulness of angioplasty done early in the course of an acute myocardial infarction without preceding thrombolytic therapy. DATA SOURCES: The English-language literature was searched from 1983 through October 1991 using MEDLINE; bibliographies from selected articles were searched by hand. STUDY SELECTION: Series reporting results for direct angioplasty without preceding thrombolytic therapy were reviewed. Twenty-three articles describing a total of 4368 patients were found. DATA EXTRACTION: After duplicate patient series were eliminated, weighted average short- and long-term mortality rates were calculated for the remaining 2073 patients in 10 series and for selected clinical subsets. RESULTS OF DATA SYNTHESIS: Average hospital mortality for patients with acute myocardial infarction having direct angioplasty was 8.3% (95% Cl, 7.1% to 9.5%). Patients in cardiogenic shock had the highest mortality (44.2%; Cl, 35.9% to 52.5%); patients with one-vessel disease had the lowest (1%; Cl, 0% to 2.3%). For patients in cardiogenic shock, data on direct angioplasty appeared superior to data for similar patients receiving thrombolytic therapy. Although few data exist, a survival advantage was also suggested for patients with a history of previous bypass surgery (hospital mortality, 11.1% [Cl, 4.4% to 17.8%]). CONCLUSIONS: Direct angioplasty has an overall mortality similar to that of thrombolytic therapy. Patients who may benefit more from mechanical revascularization than from thrombolytic therapy include those at increased risk for thrombolytic therapy (uncontrolled hypertension, recent major surgery, cerebrovascular accident, prolonged cardiopulmonary resuscitation, or bleeding diathesis), and those with cardiogenic shock. The efficacy in several other patient subsets (age greater than 65 years, previous coronary artery bypass grafting, prolonged delay before reperfusion) warrants further study.

Angioplasty, Balloon, Coronary↗
PubMed1992

Risky business.

Explore the source record for details and available documents.

Adult↗
PubMed1992

Cost-effectiveness of the implantable cardioverter-defibrillator: effect of improved battery life and comparison with amiodarone therapy.

The implantable cardioverter-defibrillator (ICD) greatly reduces the incidence of sudden cardiac death among patients with recurrent sustained ventricular tachycardia and fibrillation who do not respond to conventional antiarrhythmic therapy. A cost-effectiveness analysis was performed, comparing the ICD, amiodarone and conventional agents. Actual variable costs of hospitalization and follow-up care were used for 21 ICD- and 43 amiodarone-treated patients. Life expectancy and total variable costs were predicted with use of a Markov decision analytic model. Clinical event rates and probabilities were based on published reports or expert opinion. Life expectancy with an ICD (6.1 years) was 50% greater than that associated with treatment with amiodarone (3.9 years) and 2.5 times that associated with conventional treatment (2.5 years). Assuming replacement every 24 months, ICD lifetime treatment costs (in 1989 dollars) for a 55-year old patient are expected to be $89,600 compared with $24,800 for amiodarone and $16,100 for conventional therapy, yielding a marginal cost/effectiveness ratio for ICD versus amiodarone therapy of 1f429,200/year of life saved, which is comparable to that of other accepted medical treatments. If technologic improvements extend average battery life to 36 months, the marginal cost/effectiveness ratio would be $21,800/year of life saved, and at 96 months it would be $13,800/year of life saved. Patient age at implantation did not significantly affect these results. If quality of life on amiodarone therapy is 30% lower than that with the ICD, the marginal cost/effectiveness ratio decreases by 35%. If the quality of life for patients receiving drugs is 40% lower than that of patients treated with an ICD, use of the defibrillator becomes the dominant strategy.

Amiodarone↗
PubMed1992

Decision making and the principles of screening for breast cancer.

This position paper raises issues central to the screening process and how it relates to breast cancer in the elderly. These comments reflect neither a formal model developed specifically for breast cancer screening nor detailed data about this disease. Such information is available elsewhere in these Forum proceedings. Rather, this discussion develops the general principles of screening as they impact on breast cancer in elderly women.

Aged↗
PubMed1991

Variations in length of stay and outcomes for six medical and surgical conditions in Massachusetts and California.

OBJECTIVES: --To determine the extent to which interinstitutional variations in length of stay are explained by differences in patient characteristics and to determine whether patients in hospitals with shorter lengths of stay had worse outcomes. DESIGN: --We reviewed patients' medical records and surveyed patients between 3 and 12 months after hospital discharge using a questionnaire. SETTING: --Six teaching hospitals in California and Massachusetts. PATIENTS: --A cohort of 2484 selected patients who had been hospitalized for acute myocardial infarction or to rule out acute myocardial infarction, coronary artery bypass graft surgery, total hip replacement, cholecystectomy, or transurethral prostatectomy. Between 73% and 84% of the patients with each condition completed a follow-up questionnaire. OUTCOME MEASURES: --In-hospital complications, deaths, length of stay, functional status after hospital discharge, readmission, and patient satisfaction with hospital care were analyzed. RESULTS: --Significant interinstitutional differences in length of stay were noted for all conditions except rule-out acute myocardial infarction. Statistical adjustment for case-mix differences accounted for most of the interinstitutional differences in length of stay for total hip replacement but explained little of the differences in the other conditions. When we controlled statistically for other predictors, length of stay did not have a significant impact on deaths, functional status after hospital discharge, the probability of readmission, or patient satisfaction with hospital care. CONCLUSION: --More research is needed to determine the medical practices that are related to variations in lengths of stay. Routinely available outcome data may help preserve quality in the face of efforts to decrease costs by effecting more standardized practices of care.

Adult↗
PubMed1991

Neonatal screening for sickle cell disease: a cost-effectiveness analysis.

PURPOSE: To determine the cost-effectiveness of screening newborn infants for sickle cell disease. DESIGN: We developed a decision model that examined two strategies: (1) screening neonates and administering penicillin to infants found to have sickle cell disease in the hope of preventing pneumococcal sepsis, and (2) not screening but administering penicillin to infants after symptoms of sickle cell disease develop. The model calculates the cost-effectiveness of these strategies during the first 3 years of life. We applied the model to three prototypic populations of neonates--black, nonblack with a relatively high prevalence of hemoglobin S genes, and nonblack with a low prevalence of hemoglobin S genes. DATA IDENTIFICATION: We obtained from the published literature the effectiveness and risk of penicillin prophylaxis, the risk of pneumococcal sepsis, and the probability that in infants not screened the development of symptoms would lead to the discovery of sickle cell disease within the first 3 years of life; we used the published literature and the Hardy-Weinberg law to determine the prevalence of sickle cell disease. We used actual variable costs of screening, antibiotic prophylaxis, and hospitalization for pneumococcal sepsis or anaphylaxis. RESULTS: Screening and then treating affected black infants costs only $3100 more per life saved than not screening. Screening nonblack populations with a high prevalence of hemoglobin S genes would cost $1.4 million per life saved, and screening low prevalence populations would cost $450 billion per life saved. CONCLUSIONS: Screening black infants is very worthwhile, but screening populations in which the hemoglobin S gene is rare is unjustified.

Anaphylaxis↗
PubMed1991

Which renal transplant patients should receive cytomegalovirus immune globulin? A cost-effectiveness analysis.

Our study objective was to determine the cost-effectiveness of prophylaxis with cytomegalovirus immune globulin for preventing CMV-associated disease in renal transplant patients. We used a decision analytic model applied to 5 groups of renal transplant recipients at varying risks of developing CMV-associated disease. We obtained the rates of developing CMV-associated disease, graft rejection, and mortality, and the effectiveness of CMV-IG from the published literature. We used actual variable costs of CMV-IG, hospitalization, dialysis, and outpatient follow-up. The incremental cost of administering CMV-IG compared with withholding it ranged from $29,800 per life saved for the highest risk group, CMV-seronegative recipients of kidneys from CMV-seropositive cadaveric donors, to $1.68 million per additional life saved for the lowest risk group, CMV-seronegative recipients of grafts from CMV-seronegative donors. The outcome was somewhat sensitive to the effectiveness of CMV-IG in preventing CMV-associated disease but not sensitive to wide variations in CMV-IG costs, dialysis costs, outpatient costs, and the probability of graft rejection. Our conclusion is that prophylaxis with CMV-IG is very worthwhile for renal transplant recipients at high risk of CMV-associated disease and is possibly worthwhile for some patients at lower risk. The cost-effectiveness of other strategies for preventing CMV-associated disease, such as prophylaxis with acyclovir, CMV vaccine, or unselected immune globulin, should be compared with CMV-IG.

Cost-Benefit Analysis↗
PubMed1990

Myocardial revascularization for chronic stable angina. Analysis of the role of percutaneous transluminal coronary angioplasty based on data available in 1989.

No prospective, randomized clinical trial comparing coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, and conservative therapy has been reported. To address when revascularization is indicated, we constructed a decision analytic model. Our model incorporates procedure-related mortality and morbidity, coronary artery disease-related mortality, and the benefit of revascularization. We determined the quality-adjusted life expectancy and expected costs for each strategy. Our model suggests that angioplasty is a reasonable alternative to bypass surgery in patients with favorable lesions if angioplasty would provide a comparable degree of revascularization. Our model predicts that patients treated with angioplasty will have more revascularization procedures than will patients treated with bypass surgery but predicts that both treatments will cost the same over the typical patient's lifetime. In many patients with severe angina or documented ischemia, angioplasty is indicated for stenosis of a single artery. In patients with two vessel disease that is amenable to angioplasty, angioplasty may be a reasonable alternative to bypass surgery. Even in patients whose three vessel disease can be completely revascularized by angioplasty, bypass surgery, although relatively expensive, is slightly better than angioplasty. In patients with three vessel disease and comorbidities that increase operative risk, angioplasty may be a reasonable alternative to either bypass surgery or medical therapy.

Angina Pectoris↗