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Biomedical subjects

S J Spann

Publications and source records attributed to S J Spann.

At least 19 recordsLinked to original sources
PubMed2000

Controlling blood glucose levels in patients with type 2 diabetes mellitus. An evidence-based policy statement by the American Academy of Family Physicians and American Diabetes Association.

OBJECTIVE: To review evidence about the benefit of intensive glycemic control for patients with type 2 diabetes and to develop practice recommendations. PARTICIPANTS: A 9-member panel composed of family physicians, general internists, endocrinologists, and a practice guidelines methodologist was assembled by the American Academy of Family Physicians, the American Diabetes Association, and the American College of Physicians. EVIDENCE: Admissible evidence included published randomized controlled trials and observational studies regarding the effects of glycemic control on microvascular and macrovascular complications and on adverse effects. We followed systematic search and data abstraction procedures. Greater weight was given to clinical trials and to evidence about health outcomes. CONSENSUS PROCESS: Interpretations of evidence and approval of documents were finalized by unanimous vote, with recommendations linked to evidence and not expert opinion. The full report was prepared by the chair and 2 panel members, representing each of the 3 organizations. The initial draft underwent external review by 14 diabetologists and family physicians and changes consistent with the evidence were incorporated. CONCLUSIONS: The evidence demonstrates that the risk of microvascular and neuropathic complications is reduced by lowering glucose concentrations. Whether glycemic control affects macrovascular outcomes is less clear. The potential benefits of glycemic control must be balanced against factors that either preempt benefits (eg, limited life expectancy, comorbid disease) or increase risk (eg, severe hypoglycemia). The magnitude of benefit is a function of individual clinical variables (eg, baseline glycated hemoglobin level, presence of preexisting microvascular disease). Appropriate targets for treatment should be determined by considering these factors, patients' risk profiles, and personal preferences.

Aged↗
PubMed1999

Poliovirus vaccine options.

As a result of the success of immunization, indigenous wild poliomyelitis has disappeared from the United States. Of 142 confirmed cases of paralytic poliomyelitis reported in the United States from 1980 to 1996, 134 were classified as vaccine-associated paralytic poliomyelitis (VAPP). Persons with VAPP have a disabling illness, and this has caught the attention of the lay media. The risk of VAPP is one case per 750,000 doses distributed for the first dose of oral poliovirus vaccine (OPV) and one case per 2.4 million doses of OPV distributed overall. Because of this risk, most parents prefer a vaccine schedule that starts with inactivated poliovirus vaccine (IPV), even though extra injections are required. IPV does not cause VAPP. New studies show that high immunization rates can be achieved in disadvantaged populations with a schedule starting with IPV. The American Academy of Family Physicians now recommends that the first two doses of poliovirus vaccine should be IPV; that is, either an all-IPV schedule or a sequential schedule of two doses of IPV followed by two doses of OPV. OPV is no longer recommended for the first two doses and is acceptable only under special circumstances, such as when parents do not accept the recommended number of injections.

Family Practice↗
PubMed1999

Screening for prostate cancer with the prostate-specific antigen test: are patients making informed decisions?

BACKGROUND: The benefits of early detection of prostate cancer are uncertain, and the American College of Physicians and the American Academy of Family Physicians recommend individual decision making in prostate cancer screening. This study reports the knowledge of male primary care patients about prostate cancer and prostate-specific antigen (PSA) testing and examines how that knowledge is related to PSA testing, preferences for testing in the future, and desire for involvement in physician-patient decision making. METHODS: The sample included 160 men aged 45 to 70 years with no history of prostate cancer who presented for care at a university-based family medicine clinic. Before scheduled office visits, patients completed a questionnaire developed for this study that included a 10-question measure of prostate cancer knowledge, the Deber-Kraestchmer Problem-Solving Decision-Making Scale, sociodemographic indicators, and questions on PSA testing. RESULTS: In general, patients who were college graduates were more knowledgeable about prostate cancer and early detection than those with a high school education or less. Aside from college graduates, most patients could not identify the principle advantages and disadvantages of PSA testing. Patients indicating previous or future plans for PSA testing demonstrated greater knowledge than other patients. Desire for involvement in decision making varied by patient education but was not related to past PSA testing. CONCLUSIONS: Patients lack knowledge about prostate cancer and early detection. This knowledge deficit may impede the early detection of prostate cancer and is a barrier to making an informed decision about undergoing PSA testing.

Adult↗
PubMed1998

Aspirin for primary prevention of cardiovascular events.

OBJECTIVE: The use of aspirin for primary prevention of cardiovascular events in the general population is controversial. The purpose of this study was to create a versatile model to evaluate the effects of aspirin in the primary prevention of cardiovascular events in patients with different risk profiles. DESIGN: A Markov decision-analytic model evaluated the expected length and quality of life for the cohort's next 10 years as measured by quality-adjusted survival for the options of taking or not taking aspirin. SETTING: Hypothetical model of patients in a primary care setting. PATIENTS: Several cohorts of patients with a range of risk profiles typically seen in a primary care setting were considered. Risk factors considered included gender, age, cholesterol levels, systolic blood pressure, smoking status, diabetes, and presence of left ventricular hypertrophy. The cohorts were followed for 10 years. Outcomes were myocardial infarction, stroke, gastrointestinal bleed, ulcer, and death. MAIN RESULTS: For the cases considered, the effects of aspirin varied according to the cohort's risk profile. By taking aspirin, the lowest-risk cohort would be the most harmed with a loss of 1.8 quality-adjusted life days by taking aspirin; the highest risk cohort would achieve the most benefit with a gain of 11.3 quality-adjusted life days. Results without quality adjustment favored taking aspirin in all the cohorts, with a gain of 0.73 to 8.04 days. The decision was extremely sensitive to variations in the utility of taking aspirin and to aspirin's effects on cardiovascular mortality. The model was robust to other probability and utility changes within reasonable parameters. CONCLUSIONS: The decision of whether to take aspirin as primary prevention for cardiovascular events depends on patient risk. It is a harmful intervention for patients with no risk factors, and it is beneficial in moderate and high-risk patients. The benefits of aspirin in this population are comparable to those of other widely accepted preventive strategies. It is especially dependent on the patient's risk profile, patient preferences for the adverse effects of aspirin, and on the level of beneficial effects of aspirin on cardiovascular-related mortality.

Aspirin↗
PubMed1998

Care of adults with type 2 diabetes mellitus. A review of the evidence.

BACKGROUND: The purpose of this study was to provide primary care physicians with a concise review of the evidence that guides selected aspects of type 2 diabetes care, including glycemic control, macrovascular risk reduction, and screening for microvascular complications of diabetes. METHODS: We identified randomized clinical trials that addressed selected aspects of the care of adults with type 2 diabetes using systematic literature review, review of existing clinical guidelines, and other sources. The results of these trials were interpreted as absolute risk reduction, and the number of patients that need to be treated to obtain a specific clinical outcome was calculated. RESULTS: Good glycemic control with metformin may reduce overall mortality in obese patients with type 2 diabetes (number need to treat [NNT] = 14 for 10 years), and improved blood pressure control reduced diabetes-related mortality (NNT = 15 for 10 years); improved glycemic control with agents other than metformin, or with combinations including metformin, does not reduce diabetes-related or overall mortality. Major cardiovascular events (CVE) in type 2 diabetes can be prevented by control of blood pressure with low-dose diuretics, atenolol, or angiotensin-converting enzyme inhibitors (NNT = 10 to 20 for 5 to 10 years for primary prevention of one CVE); by use of aspirin (NNT = 45 for 5 years for primary prevention of one CVE); and by use of simvastatin to lower low-density lipoprotein (LDL) cholesterol (NNT = 6 for 5 years for secondary prevention of one CVE). Glycemic control (NNT = 19 for 10 years) and hypertension control (NNT = 6 for 10 years) slow the progression of complications in patients with type 2 diabetes. Retinopathy and nephropathy are more preventable than neuropathy. The benefits of glycemic control are less for patients with shorter life expectancy and are greater for those with the highest levels of Hb A1c because larger Hb A1c improvements can be achieved in such patients. Periodic screening of patients for eye, kidney, and foot complications is supported because effective early treatment of these complications is available. CONCLUSIONS: In patients with type 2 diabetes, control of hypertension reduces microvascular and macrovascular complications more than glycemic control does. Control of LDL cholesterol with statins, aspirin, and smoking cessation reduce major cardiovascular events. Metformin reduces overall mortality in obese patients with creatinine levels < 1.5 mg/dL. Glycemic control reduces microvascular complications. The evidence supports angiotensin-converting enzyme inhibitors, atenolol, or low-dose diuretics for blood pressure control. Effective treatment of eye, kidney, and foot complications is available, and regular screening for these complications is justified.

Adult↗
PubMed1997

Faculty development for foreign teachers of family medicine.

BACKGROUND: The development of family medicine in Latin America is inhibited by limited resources. Successful strategies to promote the specialty include academic exchanges between countries. Short-term faculty development opportunities are needed for foreign academic family physicians. METHODS: After 2 years of unstructured visits by Latin American physicians planning to teach family medicine, we designed a faculty development course, in Spanish, that continues to evolve through constructive feedback. This includes workshops in project planning, computer training, clinical decision making, family systems, clinical teaching, problem-based learning, and clinical epidemiology. Each fellow designs a project to be implemented subsequently in the country of origin. RESULTS: Since 1991, we have trained 37 physicians from nine Latin American countries, 27 since 1993 in the structured course. A full schedule encourages fellow to complete course objectives within 8 weeks. All participating physicians have rated highly the course content and quality. Twenty-five of the 27 course participants are or will soon begin teaching in family practice residency programs in their home countries. CONCLUSIONS: This faculty development course for Latin American physicians is perceived as an effective way to enhance academic skills. Ongoing evaluation will show how the fellowship impacts the physicians' teaching effectiveness and the development of family medicine in their countries.

Faculty, Medical↗
PubMed1995

The medical school without walls: who will be the faculty?

To involve community physicians as medical school faculty, a survey was completed to establish the needs of 64 community physicians participating in a third-year family medicine clerkship. We received 48 responses that indicated issues of practice regulation, training office staff, and local continuing medical education were highest priority needs. The 27 respondents in rural areas placed more emphasis on issues of referral/consultation, recruiting of physician associates, and faculty development. As a result of the survey, The University of Texas Medical Branch at Galveston has implemented a comprehensive strategy to address the stated needs, with special emphasis on a rural health initiative. This strategy includes a special program for faculty to provide rural practice coverage technical assistance for practice management, a rural communications network, faculty development, and provider recruitment. The goal of this strategy is to continue developing the "medical school without walls."

Clinical Clerkship↗
PubMed1995

Prostate cancer screening: a decision analysis.

BACKGROUND: The issue of whether to screen men for prostate cancer is controversial. No randomized clinical trials have been completed to confirm the efficacy of screening for prostate cancer. We created a mathematical model of the clinical risks and benefits of screening for prostate cancer. METHODS: A Markov decision-analytic model evaluated the outcomes of annually screening asymptomatic men for prostate cancer beginning at age 50 years. The screening and testing algorithm included the digital rectal examination, transrectal ultrasound, and prostate-specific antigen test. A sample of 10 male patients with no history of prostate disease were interviewed to assess their utilities (preferences) regarding the various adverse outcomes of prostate cancer treatment. RESULTS: The model indicated that no screening was preferred to screening when patients' utilities were considered (24.14 vs 23.47 quality-adjusted life years expected). The optimal decision was sensitive to the utilities of impotence and urethral stricture, the most common adverse outcomes for patients under the age of 65 years. When adverse outcomes of treatment were ignored, screening was favored (24.86 vs 24.22 years of life expectancy. CONCLUSIONS: When quality-of-life preferences of men are considered, the annual screening of asymptomatic patients for prostate cancer is not recommended.

Aged↗
PubMed1994

Cost-effectiveness analysis of screening health care workers for HIV.

BACKGROUND: Because of the public's concern regarding the possibility of human immunodeficiency virus (HIV) transmission from health care worker to patient, this study evaluated the cost-effectiveness of screening health care workers for HIV. METHODS: The study examined a screening protocol that would include a sequence of antibody tests (enzyme-linked immunosorbent assay and the Western blot) and culture for HIV. The incremental cost-effectiveness of applying this protocol as opposed to the status quo for the prevention of transmission of HIV from health care worker to patient was evaluated. Sensitivity analysis was performed on appropriate variables. The incremental cost-effectiveness ratio was then compared with that of other interventions. RESULTS: The expected annual cost of screening to a large hospital was found to be $244,382 to prevent 0.02663 transmissions. The incremental cost-effectiveness ratio was $9,177,615 per transmission prevented. Sensitivity analysis revealed that the incremental cost-effectiveness ratio is relatively insensitive to the variability in the performance characteristics of the individual tests but highly sensitive to variance in HIV prevalence, estimated risk of transmission, and the number of exposure-prone procedures performed annually. Cost-effectiveness ratios ranged from $917,762 to $91,776,156 per transmission prevented. CONCLUSIONS: Screening health care workers for prevention of potential HIV transmission to patients is an expensive use of health care resources.

AIDS Serodiagnosis↗
PubMed1993

A cost-effectiveness analysis of epoetin usage for patients with AIDS.

Epoetin (recombinant human erythropoietin) therapy for patients with AIDS may reduce the need for blood transfusion; however, it is expensive. We conducted a cost-effectiveness analysis of the use of epoetin for AIDS patients from a healthcare system perspective. We constructed a decision analysis model using probability, outcome and cost data from the literature and hospital sources. The incremental cost-effectiveness ratio was measured in dollars per unit of blood saved. In AIDS patients undergoing transfusion with serum epoetin concentrations less than or equal to 500 U/L treatment with epoetin cost $US1007 per unit of blood saved compared with treatment without epoetin. One-way sensitivity analysis revealed that the incremental cost-effectiveness ratio was sensitive to the efficacy and unit price of epoetin, but less sensitive to the current price cap determined by the distributor.

Acquired Immunodeficiency Syndrome↗
PubMed1992

The evaluation and treatment of men with asymptomatic prostate nodules in primary care: a decision analysis.

BACKGROUND: Whether to perform periodic rectal examinations in asymptomatic men as a screening test for prostatic cancer remains controversial. A randomized clinical trial that tests the efficacy of further evaluation and treatment of men who have been found to have asymptomatic prostate nodules may never be carried out. Decision analysis was therefore used to further investigate this clinical issue. METHODS: A decision tree was developed to model the decision of whether to biopsy an asymptomatic prostate nodule found by digital rectal examination in a 65-year-old man by his primary care physician. Test operating characteristics, probabilities of disease at different stages, probabilities of side effects from various treatments, and average life expectancies were obtained from the medical literature. Utilities for the various possible health outcome states were obtained from ratings by two experienced primary care physicians using the Kaplan-Anderson Quality of Well-Being Scale. These were used to adjust the quality-of-life expectancies for each outcome state. Multiple sensitivity analyses were performed to assess the robustness of the conclusions. RESULTS: Disregarding patient utilities, the average survival benefit of evaluation and treatment is 1.1 months. When quality-of-life adjustments are included in the analysis, evaluation and treatment results in an average loss of 3.5 quality-adjusted months of life. Factors that shift the decision toward evaluation and treatment include a positive predictive value of a prostate nodule for cancer of 49% or greater, specificity of prostate biopsy of 98.3% or greater, and the availability of much more effective treatment for stage D cancers. Factors that do not substantially affect the decision are cancer-free life expectancy, the percentage of cancers that are stage B at time of discovery, the sensitivity of prostate biopsy, and more effective treatment for stage C cancer, assuming the same rate of adverse consequences from treatment. CONCLUSIONS: The evaluation and treatment of prostatic nodules found by digital rectal examination in asymptomatic men in the primary care setting does not lead to significant improvement in life expectancy and adversely affects quality of life. Digital rectal examination should not be performed by primary care physicians as a screening test for prostate cancer.

Aged↗
PubMed1990

Documentation of referrals: recording bias due to patient insurance type.

This study explores a possible association between the propensity of primary care physicians to record referrals on special referral forms and the source/mechanism of payment for services. Using a randomly selected sample of visits to University faculty family physicians over a 12-month period, referrals were identified from three sources: progress notes, a special form that was included in the patient's chart, and a computerized list that was generated from the special referral form. A notation in one or more of these sources constituted a referral. Using all three sources, the referral rates were 13.8 referrals per 100 patient encounters for Health Maintenance Organization (HMO) patients, compared with 14.1 for Preferred Provider Organization (PPO) patients and 10.4 for patients with other insurance (p = .83). The progress note in the patient chart was the best source for determining whether a referral had been requested, with approximately 85% documentation. Special forms were not likely to be completed for referrals, especially for non-HMO patients (less than 30% documentation). Thus, reliance on a special form for documentation of referrals would have led to the erroneous conclusion of higher referral rates for HMO patients. The tendency of providers to be more complete in recording referrals of HMO patients (a recording bias) may account for the observed higher rate of referral of such patients in other studies.

Adult↗