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S R Majumdar

Publications and source records attributed to S R Majumdar.

7 recordsLinked to original sources
PubMed2001

Designing an intervention to improve the management of Helicobacter pylori infection.

BACKGROUND: An intervention to improve the testing and treatment of Helicobacter pylori (HP) in patients receiving chronic acid suppression (AS) therapy was developed at Harvard Pilgrim Health Care (HPHC), a mixed-model not-for-profit health maintenance organization. METHODS: Ten full-time primary care physicians (4 staff model and 6 group practice) were interviewed in 1999 about their knowledge, attitudes, and practice regarding dyspepsia, the use of chronic AS drugs, and approaches to HP infection, as well as about the feasibility and acceptability of various potential interventions that might be used in a quality improvement program. RESULTS: Self-reported practice regarding dyspepsia and HP infection were relatively uniform, and physicians were generally aware of current recommendations. Three common misperceptions acted as barriers to optimal HP management: Untreated HP was not considered an important problem; patients who used drugs for chronic AS rarely had HP infection; and chronic use of AS drugs was considered effective and without adverse consequence. All physicians wanted brief educational materials with explicit guidelines, preferably locally adapted and endorsed by local experts. All informants agreed that the main barrier to successful QI interventions was the requirement for any extra time or effort, particularly when directed at populations of patients who do not have symptomatic complaints. DISCUSSION: The interviews revealed the many barriers to improving the management of HP infection and to targeting educational messages and tailoring different methods for facilitating practice change across different managed care settings. Evidence-based components of the intervention program include physician education, a notification/reminder system, and practice-based tools to facilitate change and minimize workload.

Boston↗
PubMed2001

Influence of physician specialty on adoption and relinquishment of calcium channel blockers and other treatments for myocardial infarction.

OBJECTIVE: Recent reports have linked calcium channel blockers (CCBs) with an increased risk of acute myocardial infarction (AMI). We sought to determine to what extent physicians relinquished CCBs following these adverse reports and if there were differences in the use of CCBs and other AMI therapies across 3 levels of specialist involvement: generalist attendings, collaborative care (generalist with cardiologist consultation), and cardiologist attendings. DESIGN: We measured use of CCBs during hospitalization for AMI before (1992--1993) and after (1995--1996) the adverse CCB reports, controlling for hospital-, physician-, and patient-level variables. We also examined use of effective medications (aspirin, beta-blockers, thrombolytic therapy) and ineffective AMI treatments (lidocaine). SETTING: Thirty-seven community-based hospitals in Minnesota. PATIENTS: Population-based sample of 5,347 patients admitted with AMI. MEASUREMENTS: The primary outcome was prescription of a CCB at the time of discharge from hospital. Secondary outcomes included use of other effective and ineffective AMI therapies during hospitalization and at discharge. MAIN RESULTS: Compared with cardiologists, generalist attendings were less likely to use aspirin (37% vs 68%; adjusted odds ratio [OR], 0.58; 95% confidence interval [95% CI], 0.42 to 0.80) and thrombolytics (29% vs 64%; adjusted OR, 0.18; 95% CI, 0.13 to 0.25), but not beta-blockers (20% vs 46%; adjusted OR, 0.93; 95% CI, 0.66 to 1.31). From 1992--1993 to 1995--1996, the use of CCBs in patients with AMI decreased from 24% to 10%, the net result of physicians starting CCBs less often and discontinuing them more often. In multivariate models, the odds of CCB relinquishment after the adverse reports (adjusted OR, 0.33; 95% CI, 0.27 to 0.39) were independent of, and not modified by, the involvement of a cardiologist. CONCLUSIONS: Compared with cardiologists, generalist physicians were less likely to adopt some effective AMI therapies, particularly those associated with risk such as thrombolytic therapy. However, generalists were as likely as cardiologists to relinquish CCBs after the adverse reports. This pattern of practice may be the generalist physicians' response to an expanding, but increasingly risky and uncertain, pharmacopoeia.

Adrenergic beta-Antagonists↗
PubMed1999

Beta-blockers for the treatment of hypertension in patients with diabetes: exploring the contraindication myth.

PURPOSE: To review the evidence supporting the "contraindications" (hypoglycemic unawareness, insulin resistance, and dyslipidemia) usually given as the reasons for not using beta blockers for treating hypertension in patients with diabetes mellitus. METHODS: A research synthesis based on MEDLINE (January 1966 through January 1999), hand searches of pertinent references and textbooks, and consultation with experts. RESULTS: There is little evidence to support the assertion that beta blockers should be routinely contraindicated in diabetes. Beta blockers have few clinically important effects on hypoglycemic awareness and recovery, insulin resistance and hyperglycemia, or lipid profiles. Moreover, when diabetics have been treated with beta blockers for hypertension or for the secondary prevention of myocardial infarction, they benefit as much, if not more, than nondiabetic patients. There may be circumstances (e.g., hypertensive patients with coronary disease) under which beta blockers are the drugs of first choice for diabetic patients. Recommendations to use agents other than beta blockers for the treatment of hypertension in diabetes are based on these agents' effectiveness against surrogate endpoints, and not their proven benefit in preventing important clinical endpoints. CONCLUSIONS: Except for patients with brittle glycemic control, manifest hypoglycemic unawareness, renal parenchymal disease, or documented intolerance, beta blockers should no longer be considered routinely contraindicated in the presence of diabetes.

Adrenergic beta-Antagonists↗
PubMed1999

Undertreatment of hyperlipidemia in the secondary prevention of coronary artery disease.

OBJECTIVES: To determine adherence to national guidelines for the secondary prevention of coronary artery disease (CAD) using lipid-lowering drugs (LLDs), by studying the rate of use of LLDs, predictors of use, and the rate of achieving lipid goals, among eligible patients recently hospitalized with acute myocardial infarction. DESIGN: Cross-sectional analysis of 2,938 medical records, collected from July 1995 to May 1996. SETTING: Thirty-seven community-based hospitals in Minnesota. PATIENTS: The 622 patients had previously established CAD and hyperlipidemia (total cholesterol> 200 mg/dL or currently using LLDs), and were eligible for LLDs according to the National Cholesterol Education Program II (NCEP II) Guidelines. MEASUREMENTS: The use of LLDs in eligible patients (primary outcome) and successful achievement of NCEP II goals (total cholesterol <160 mg/dL) among treated patients (secondary outcome). MAIN RESULTS: Only 230 (37%) of 622 eligible patients received LLDs. In multivariate logistic regression, factors independently related to LLD use included age greater than 74 years (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.35, 0.88) and severe comorbidity (AOR 0.60; 95% CI 0.38, 0.95), managed care enrollee (AOR 1.56; 95% CI 1.02, 2.39), past smoker (AOR 1.72; 95% CI 0.98, 3.01), prior revascularization (AOR 2.31; 95% CI 1.51, 3.53), and the use of aspirin (AOR 1.59; 95% CI 1.07, 2.38) or >/=4 medications (AOR 2.89; 95% CI 2.19, 3.84). Of the treated patients who had lipid levels measured (n = 149), 15% achieved the recommended goal of a total cholesterol below 160 mg/dL. Of the untreated patients (n = 392), 89% were discharged from hospital without a LLD prescription. CONCLUSIONS: Lipid-lowering drugs, although proven effective for the secondary prevention of CAD, were used by only one third of eligible patients. Among patients receiving LLDs, few achieved recommended lipid goals. Directed quality improvement interventions, such as starting LLDs during hospitalization, may have the potential to substantially reduce CAD morbidity and mortality in this vulnerable population.

Adult↗
PubMed1999

How does colorectal cancer present? Symptoms, duration, and clues to location.

OBJECTIVE: Most colorectal cancers still present with symptoms because screening, although effective, is not yet widely practiced. A careful history and physical examination are still the usual methods for suspecting colorectal cancer and ordering appropriate investigation. Therefore, we studied the symptoms, duration, and clues to location of colorectal cancer. METHODS: We reviewed both hospital and office records for 204 consecutive patients with colorectal cancer, first diagnosed after symptoms, at one regional referral center from 1983-87. We abstracted data on demographic characteristics, presence and duration of 15 symptoms, and characteristics of the tumors. RESULTS: The 194 patients included in the study were similar to those with colorectal cancer described elsewhere in terms of age, gender, and tumor location (58% distal to the splenic flexure), and stage (56% stage A or B). The most common symptoms were rectal bleeding (58%), abdominal pain (52%), and change in bowel habits (51%); the majority had anemia (57%) and occult bleeding (77%). The median duration of symptoms (from onset to diagnosis) was 14 wk (interquartile range 5-43). We found no association between overall duration of symptoms and the stage of the tumor. Patient age, gender, and proximal cancer location were also not associated with a longer duration of symptoms before diagnosis. We developed a rule for predicting a distal location of cancer using multiple logistic regression. Independent predictors were (odds ratio [95% CI]): Hb (1.34 for each g/dl [1.16-1.54]); rectal bleeding (3.45 [1.71-6.95]); constipation (3.16 [1.38-7.24]); and proximal symptoms (at least one of anorexia, nausea, vomiting, abdominal pain, or fatigue) (0.48 [0.20-1.02]). The rule had sensitivity of 93% and a specificity of 47%, with an area under the ROC curve of 0.79. CONCLUSIONS: Until prevention of colorectal cancer is more common, we must continue to rely on clinical findings for detecting this cancer. Our results will remind physicians to keep colorectal cancer on the differential diagnosis of "chronic" gastrointestinal symptoms, and our decision rule may prompt earlier investigation with colonoscopy.

Adenocarcinoma↗