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Biomedical subjects

S Shea

Publications and source records attributed to S Shea.

125 records · Page 7Linked to original sources
PubMedDate not supplied

Management of high blood cholesterol by primary care physicians: diffusion of the National Cholesterol Education Program Adult Treatment Panel guidelines.

OBJECTIVE: To study knowledge of and adherence to National Cholesterol Education Program Adult Treatment Panel (ATP) guidelines among primary care physicians. DESIGN: Cross-sectional telephone survey. SETTING: New York State primary care practitioners; survey conducted November 1988-January 1989. PARTICIPANTS: Physicians in general practice, family practice, internal medicine without subspecialty, and cardiology who reported greater than or equal to 10 hours/week of clinical practice (n = 329; response rate = 63%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: While 84% of physicians had heard of the ATP guidelines, gaps in knowledge and inconsistencies between ATP recommendations and clinical practices were found. Although the ATP guidelines recommend six months of dietary therapy before starting drug treatment, 41% of physicians would initiate drug treatment for a healthy 40-year-old man with total cholesterol of 7.8 mmol/L (300 mg/dl) either at the initial visit or after one month of lipid-lowering diet. Multivariate analysis of a 24-item knowledge scale revealed that less knowledgeable physicians were more likely to be older, lack board certification, and have a specialty other than cardiology (p less than 0.01). Less knowledgeable physicians were also more likely to consider drug company literature and drug company representatives very useful sources of information about cholesterol (p = 0.02). CONCLUSION: This study suggests that hard-to-reach physician groups may require special efforts to communicate consensus guidelines of major importance to clinical practice.

Adult↗
PubMedDate not supplied

Explaining diagnostic complexity in an intake setting.

A one patient-one illness paradigm is implicit in the history and theory of psychiatry, and in basic research. Yet, in clinical practice and treatment populations in general, more than one diagnosis per patient is frequently encountered. How clinicians formulate comorbidity by means of DSM-III has rarely been investigated. In this study, the ideas of clinical condition and that of its diagnostic complexity are used to analyze descriptive features of a large number of patients seen in an intake setting. Axis I of DSM-III is used to measure diagnostic complexity. Complexity is analyzed in relation to demographic variables, to ratings entered in the remaining axes of DSM-III formulations, to symptom levels of patients, and to decisions involving disposition. Results indicate that analysis of diagnostic complexity by means of DSM-III yields a definable structure and that it can be related meaningfully to clinical factors. The idea of information uncertainty in diagnosis, i.e., the opacity versus transparency of a clinical condition, is also used to explain results. The ideas introduced and studied are shown to have value for social psychiatric research.

Adaptation, Psychological↗
PubMedDate not supplied

Computer-generated informational messages directed to physicians: effect on length of hospital stay.

OBJECTIVE: With the advent of hospital payment by diagnosis-related group (DRG), length of stay (LOS) has become a major issue in hospital efforts to control costs. Because the Columbia-Presbyterian Medical Center (CPMC) has had above-average LOSs for many DRGs, the authors tested the hypothesis that a computer-generated informational message directed to physicians would shorten LOS. DESIGN: Randomized clinical trial with the patient as the unit of randomization. SETTING AND STUDY POPULATION: From June 1991 to April 1993, at CPMC in New York, 7,109 patient admissions were randomly assigned to an intervention (informational message) group and 6,990 to a control (no message) group. INTERVENTION: A message giving the average LOS for the patient's admission or provisional DRG, as assigned by hospital utilization review, and the current LOS, in days, was included in the main menu for review of test results in the hospital's clinical information system, available at all nursing stations in the hospital. MAIN OUTCOME MEASURE: Hospital LOS. RESULTS: The median LOS for study patients was 7 days. After adjustment for covariates including age, sex, payor, patient care unit, and time trends, the mean LOS in the intervention group was 3.2% shorter than that in the control group (p = 0.022). CONCLUSION: Computer-generated patient-specific LOS information directed to physicians was associated with a reduction in hospital LOS.

Analysis of Variance↗
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A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting.

OBJECTIVE: Computer-based reminder systems have the potential to change physician and patient behaviors and to improve patient outcomes. We performed a meta-analysis of published randomized controlled trials to assess the overall effectiveness of computer-based reminder systems in ambulatory settings directed at preventive care. DESIGN: Meta-analysis. SEARCH STRATEGY: Searches of the Medline (1966-1994), Nursing and Allied Health (1982-1994), and Health Planning and Administration (1975-1994) databases identified 16 randomized, controlled trials of computer-based reminder systems in ambulatory settings. STATISTICAL METHODS: A weighted mixed effects model regression analysis was used to estimate intervention effects for computer and manual reminder systems for six classes of preventive practices. MAIN OUTCOME MEASURE: Adjusted odds ratio for preventive practices. RESULTS: Computer reminders improved preventive practices compared with the control condition for vaccinations (adjusted odds ratio [OR] 3.09; 95% confidence interval [CI] 2.39-4.00), breast cancer screening (OR 1.88; 95% CI 1.44-2.45), colorectal cancer screening (OR 2.25; 95% CI 1.74-2.91), and cardiovascular risk reduction (OR 2.01; 95% CI 1.55-2.61) but not cervical cancer screening (OR 1.15; 95% CI 0.89-1.49) or other preventive care (OR 1.02; 95% CI 0.79-1.32). For all six classes of preventive practices combined the adjusted OR was 1.77 (95% CI 1.38-2.27). CONCLUSION: Evidence from randomized controlled studies supports the effectiveness of data-driven computer-based reminder systems to improve prevention services in the ambulatory care setting.

Ambulatory Care↗
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Adjusting for confounding due to population admixture when estimating the effect of candidate genes on quantitative traits.

When analyzing the relationship between allelic variability and traits, a potential source of confounding is population admixture. An approach to adjusting for potential confounding due to population admixture when estimating the influence of allelic variability at a candidate gene is presented. The approach involves augmenting linear regression models with additional regressors. Family genotype data are used to define the regressors, and inclusion of the regressors ensures that, even in the presence of population admixture, the estimates of the regression coefficients that parameterize the influence of allelic variability on the trait are unbiased. The approach is illustrated through an analysis of the influence of apolipoprotein E genotype on plasma low density lipoprotein cholesterol concentrations.

Alleles↗
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Medically unexplained symptoms in an urban general medicine practice.

The authors investigated the prevalence of multiple medically unexplained symptoms (MMUS) as identified by primary care physicians (PCPs) in a systematic sample of 172 patients. Patients were from a university-affiliated urban primary care practice serving a low-income population. Patients with a history of MMUS were older (mean: 57.2 vs. 53.0 years), more likely to be female (90.5% vs. 72.3%), and less likely to be married or living with a partner (14.4% vs. 36.2%) than those without MMUS. Patients with MMUS had over twice the rate of any current psychiatric disorder, almost two-and-a-half times the rate of any current anxiety disorder, and greater functional impairment. These data suggest that patients with MMUS are as common in urban primary care clinics as in more affluent clinics and reinforce the need for PCPs to screen these patients for common and treatable psychiatric conditions.

Adolescent↗
PubMedDate not supplied

Preventable hospitalizations and socioeconomic status.

"Preventable" hospitalizations have been proposed as indicators of poor health plan performance. In this study of elderly Medicare beneficiaries, however, we found that preventable hospitalizations are also more common among elders of lower socioeconomic status (SES). The relationship persisted even when an up-to-date severity-of-illness adjustment system was used. To the extent that indicators of health plan "performance" reflect enrollees' characteristics, plans will be rewarded for marketing their services to wealthier, healthier, and better-educated patients. Further work is needed to clarify issues of accountability for preventable hospitalizations and other putative indices of health plan performance.

Aged↗
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The impact of occupation on self-reported cardiovascular morbidity in western Germany: gender differences.

BACKGROUND: In Germany, research is sparse on the associations between occupation and cardiovascular risk factors and disease or whether such associations differ for men and women. METHODS: We analyzed the data from 12,093 males and 12,125 females aged 40-69 years, who participated in three regional and national health surveys that were conducted in western Germany between 1984-1991 as part of the German Cardiovascular Prevention Study. Hypertension, total and HDL cholesterol levels, and obesity were based on standardized measurements, whereas smoking, diabetes, and history of myocardial infarction, stroke, and angina pectoris were based on self-report, using standardized questionnaires. Occupations were categorized into 13 (males) or 12 (females) groups as proposed by Blossfeld, as well as according to the 30 most frequent specific occupations. Multiple logistic regression analyses were used to adjust for age, cardiovascular risk factors, and socio-economic status (SES). RESULTS: Among males, after adjusting for age, cardiovascular risk factors and SES, all 12 occupational groups had significantly elevated odds rations for the prevalence of cardiovascular disease when compared with the reference category of professionals. Among females, no significant increase in cardiovascular disease was found in any of the 11 main occupational groups. Teachers were used as the reference category for the 30 most frequent occupations. In males, five occupations (carpenter, locksmith, warehouse clerk, doorman, and driver) yielded significantly elevated age-adjusted odds ratios for the prevalence of self-reported cardiovascular disease. In females, we found significant associations with cardiovascular disease only for two occupations (kindergarten-teacher and cook). CONCLUSION: The findings suggest that certain aspects of the workplace and its culture, particularly in blue-collar occupations, influence the cardiovascular risk in men to a greater extent than in women.

Adult↗
PubMedDate not supplied

Relation between body height and self-reported myocardial infarction in Germany.

BACKGROUND: Several studies have reported an association between body height and the incidence of myocardial infarction. METHODS: We analyzed data from regional and national health surveys that were conducted from 1984-1992 within the framework of the German Cardiovascular Prevention Study. Eligible survey candidates were males and females with German nationality in the age group 25-69 years. The total number of subjects in our study comprised 12,447 males and 13,355 females. The assessment of whether a respondent had ever undergone a myocardial infarction was based on self-reporting by the subject. Multiple logistic regression analyses, controlling for several confounding factors, were carried to calculate odds ratios to estimate th effect of body height on the prevalence of self-reported myocardial infarction, comparing each body-height quintile with the shortest group, which served as the reference group. RESULTS: Without adjusting for confounding variables, a strong association between body height and self-reported myocardial infarction was found in both genders (trend test: p < 0.001), with an unadjusted odds ratio (OR) of 0.41 for males and 0.33 for females. After adjusting for age, the ORs increased to 0.67 (p < 0.05) in males and 0.58 (p < 0.05) in females for quintile 5 (tallest) compared with quintile 1 (shortest). After an additional adjustment for community size, region, social class, and number of CVD risk factors, the ORs of myocardial infarction for quintile 5 (males OR = 0.78, females OR = 0.68) were higher than those for quintile 1, but the results were no longer statistically significant. CONCLUSIONS: Despite the lack of statistical significance, we suggest that the differences in the prevalence of myocardial infarction for the five height quintiles cannot be explained by confounding factors alone. The underlying causes for such height-specific differences remain unknown.

Adult↗
PubMedDate not supplied

Poverty, health, and nutrition in Germany.

OBJECTIVE: To investigate the relation between poverty and several variables describing health and nutrition behavior in East Germany and West Germany. METHODS: Data are from the third National Health Survey in West Germany and the first Health Survey for the new federal states of Germany (1991/92). Both health surveys included a self-administered questionnaire ascertaining sociodemographic variables, smoking history, nutritional behavior (using a food-frequency list), physical activity, and a medical examination comprising measurements of height, weight, blood pressure, and blood sampling for serum cholesterol determination. Participants included 4958 subjects in the West Survey and 2186 subjects in the East Survey aged 25-69 years, with a respective net response rate of 69.0% and 70.2%. Poverty was defined as a household equivalence income of 62.5% or less of the median income of the general population. RESULTS: The lowest income group (poverty or near poverty) comprised 11.6% of East German versus 15.9% of West German males and 14.8% of East German versus 19.3% of West German females. For most but not all health and nutrition parameters, less favorable results were obtained for subjects with an equivalence income below or near poverty. The most striking poverty-related differences regarding cardiovascular disease risk factors were found for lack of regular exercise for both genders and obesity in females. No poverty-related differences were found for the prevalence of hypercholesterolemia, despite a much higher prevalence of obesity in persons with an income below the poverty line. Current nutritional behavior and changes in nutritional behavior during the last three years was strongly related to income status, with a more unhealthy status for low-income population groups in both East and West Germany. CONCLUSIONS: In Germany, poverty has strong effects on individual health status and nutritional behavior. Because of rising unemployment rates and reductions in social security payments for low-income groups, it is likely that the negative consequences of poverty on health are increasing.

Adult↗
PubMedDate not supplied

Antihypertensive treatment and serum cholesterol: results of population-based surveys in the German Cardiovascular Prevention Study.

We analyzed the data from three cross-sectional, population-based surveys in West Germany to evaluate the effect of antihypertensive drug therapy on the level of serum cholesterol in German residents (18,344 males; 19,137 females) aged 25-69 years, after excluding persons with missing values (N = 5529) for any study variable. The data were obtained from the national and regional health surveys that were conducted during the years 1984-1992, within the framework of the German Cardiovascular Prevention Study (GCP). The response rates were between 66.0% and 71.4% for the national surveys and between 65.9% and 83.3% for the regional surveys. Blood-pressure and non-fasting cholesterol measurements were carried out under strictly standardized conditions. Multiple linear regression analysis was used to compare the age-adjusted mean value and prevalence for each of the following study variables: total serum cholesterol, HDL-cholesterol, non-HDL cholesterol, and the ratio of HDL cholesterol/total cholesterol for users and non-users of antihypertensive medications. Antihypertensive medications were reportedly taken during the seven days preceding the survey examination by 7.8% of all males and 10.4% of all females. The beta-blocker type of medication was prescribed most frequently for lowering high blood pressure. In both genders, the strongest age-adjusted effect of an increase in cholesterol level was found for beta-blockers. The difference in the age-adjusted means for non-HDL cholesterol values between users and non-users of beta-blockers was 9.2 mg/dL (p < 0.001) in males and 9.0 mg/dL (p < 0.001) in females. Regression analysis carried out to control for several potential confounders confirmed the results. The findings suggest that mass treatment of hypertension with beta-blockers may be associated with reductions in benefit because of an increase in non-HDL and a decrease in HDL cholesterol levels.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

Social correlates of cigarette smoking cessation: findings from the 1995 microcensus survey in Germany.

BACKGROUND: An increasing percentage of smokers are quitting this unhealthy behavior during their life course. The aim of this study is to analyze which social factors play an important role regarding ex-smoking in Germany. METHODS: Data were derived from the 1995 German Microcensus, which is a representative survey for the population in Germany. Included in the analysis were 44,553 current smokers and 23,780 ex-smokers. The independent variables were education, occupational status, family status, unemployment/social welfare, household income, and community size. A two-stage statistical modeling procedure was used, initially to assess the most important effects of the independent variables on smoking cessation and secondly, to analyze the cumulative effects of the independent variables. RESULTS: The most striking effects observed for smoking cessation were family status and education. For example, in males aged 30 to 49 years, the percentages of ex-smokers of all ever smokers were 44.7% for married males with high education compared with only 14.6% for males with low education. The corresponding percentages for females were 44.0% and 17.6%. CONCLUSIONS: Such striking differences in the social polarization of smoking cessation in Germany demonstrate the importance of anti-smoking policies and new strategies that avoid a further increase in the social inequality of smoking behavior.

Adolescent↗
PubMedDate not supplied

A review of five major community-based cardiovascular disease prevention programs. Part I: Rationale, design, and theoretical framework.

Major community-based cardiovascular disease prevention programs have been conducted in North Karelia, Finland; the state of Minnesota; Pawtucket, Rhode Island; and in three communities and more recently in five cities near Stanford, California. These primary prevention programs aim to reduce cardiovascular disease incidence by reducing risk factors in whole communities. These risk factors are smoking, high blood cholesterol, diet high in cholesterol and saturated fat, hypertension, sedentary lifestyle, and obesity. This strategy may be contrasted with secondary prevention programs directed at patients who already have symptomatic cardiovascular disease and "high risk" primary prevention programs directed at individuals found through screening to have one or more risk factors. The design of the five major programs is similar in that intervention communities are matched for purposes of evaluation with nearby comparison communities. Underlying these programs are theories of community health education, social learning, communication, social marketing, and community activation, as well as more traditional biomedical and public health disciplines. This is Part I of a two-part article.

California↗
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A review of five major community-based cardiovascular disease prevention programs. Part II: Intervention strategies, evaluation methods, and results.

Major community-based cardiovascular disease prevention programs have been conducted in North Karelia, Finland; the state of Minnesota; Pawtucket, Rhode Island; and in three communities and more recently in five cities near Stanford, California. The main hypothesis is that community intervention will reduce the prevalence of cardiovascular disease risk factors and consequently reduce cardiovascular disease incidence, morbidity, and mortality. Intervention strategies include community mobilization, social marketing, school-based health education, worksite health promotion, screening and referral of those at high risk, education of health professionals, direct education of adults, and modification of physical environments. Formative evaluation provides short-term feedback to program managers about immediate effects of intervention strategies. Outcome evaluation examines the effects of intervention on longitudinally sampled cohorts and compares cardiovascular risk status and morbidity and mortality in intervention and comparison communities. Results from North Karelia and the Stanford Three Community Study indicate that this model is efficacious and cost-effective. The National Heart, Lung, and Blood Institute biomedical research spectrum envisions research in knowledge transfer and innovation diffusion as the last link in the causal chain whereby research affects the health of the population, but research in this area remains undeveloped compared to other aspects of cardiovascular disease prevention. This is Part II of a two part article; Part I appeared in Volume 4, Number 3.

California↗
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The integrated academic information management system at Columbia-Presbyterian Medical Center.

Over the past seven years, Columbia-Presbyterian Medical Center has been planning and implementing an integrated academic information management system. Accomplishments to date include establishing an institutional information architecture, installing a campus-wide network of workstations, recruiting the staff needed to develop and implement the system, and developing various applications. This paper presents the rationale and steps involved in these accomplishments, as well as data on use of the system so far.

Academic Medical Centers↗