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Biomedical subjects

S T Bogardus

Publications and source records attributed to S T Bogardus.

17 recordsLinked to original sources
PubMed2004

Patient preferences for treatment of rheumatoid arthritis.

OBJECTIVE: To elicit treatment preferences of patients with rheumatoid arthritis (RA) for disease modifying antirheumatic drugs (DMARDs) with varying risk profiles. METHODS: Patient values for 16 DMARD characteristics were ascertained using published data about side effects, effectiveness, and cost. Patient preferences were determined by Adaptive Conjoint Analysis, an interactive computer program that predicts preferences by asking patients to make trade-offs between specific treatment characteristics. Simulations were run to derive preferences for four drugs: methotrexate, gold, leflunomide, and etanercept, under different risk-benefit scenarios. Infliximab was not included because it is given with methotrexate, and we did not include preferences for combination therapy. Based on each patient's expressed preferences, and the characteristics of the treatments available at the time of the study, the option that best fitted each patient's perspective was identified. RESULTS: 120 patients (mean age 70 years) were interviewed. For the base case scenario (which assumed the maximum benefits reported in the literature, a low probability of adverse effects, and low equal monthly "co-pays" (out of pocket costs)), 95% of the respondents preferred etanercept over the other treatment options. When all four options were described as being equally effective, 88% continued to prefer etanercept owing to its safer short term adverse effect profile. Increasing etanercept's co-pay to $30.00 decreased the percentage of patients preferring this option to 80%. CONCLUSIONS: In this study, older patients with RA, when asked to consider trade-offs between specific risk and benefits, preferred etanercept over other treatment options. Preference for etanercept is explained by older patients' risk aversion for drug toxicity.

Adult↗
PubMed2003

Risk-attitude and patient treatment preferences.

Women's treatment preferences for lupus nephritis vary widely even after adjusting for sociodemographic factors and disease severity. Attitude toward risk may partially explain interpatient variability in treatment preference. The objective of this study was to examine the association between 'risk-attitude' and patient treatment preferences in lupus nephritis. Sixty-five premenopausal women with systemic lupus erythematosus were interviewed. Patient preferences for cyclophosphamide versus azathioprine for the treatment of lupus nephritis were ascertained using an Adaptive Conjoint Analysis questionnaire. Risk-attitude was ascertained by asking patients to choose between a pair of lotteries having the same expected value but differing in spread (the difference between the worst and best outcomes). Respondents preferring the wider spread were classified as relatively more risk-seeking and those preferring the narrower spread were classified as relatively more risk-averse. Twenty-eight percent of respondents were classified as relatively more risk-seeking. Risk-seeking women were more likely to prefer cyclophosphamide for the treatment of lupus nephritis compared with risk-averse women [least square mean (+/- SD) preference for cyclophosphamide 63 +/- 3 among risk-seeking women versus 55 +/- 2 among risk-averse women (P < 0.03)]. The association between risk attitude and treatment preference persisted asthe probabilities of adverse events were varied to reflect the range of risks reported in the literature. Our results suggest that patients' relative risk-attitudes, as measured by a lottery task, are related to their treatment preferences. Differences in risk-attitude may help explain the inter-patient variability in treatment preferences.

Adult↗
PubMed2001

Goals for the care of frail older adults: do caregivers and clinicians agree?

PURPOSE: Establishing shared treatment goals for patients may improve the quality of care by facilitating achievement of appropriate and desired outcomes. The purpose of this study was to describe types of family caregiver and physician treatment goals for frail elderly patients who had a high prevalence of cognitive impairment, and to ascertain the level of agreement between family caregivers and physicians on principal treatment goals. SUBJECTS AND METHODS: We surveyed family caregivers and physicians for 200 consecutive older adults who were initially evaluated at the outpatient geriatric assessment center of a major teaching hospital. Treatment goals for patients were measured after a comprehensive geriatric assessment. RESULTS: Goals commonly chosen as most important by family caregivers and physicians pertained to day-to-day functioning (61 [31%] family caregivers, 81 [41%] physicians), behavior and emotional health (56 [28%] family caregivers, 50 [25%] physicians), and safety (40 [20%] family caregivers, 29 [15%] physicians). Although a substantial proportion of family caregiver and physician pairs shared at least one goal (157 [79%] of 200), agreement on presence or absence of individual categories of goals was poor (kappas from -0.19 to 0.28), and agreement on the most important goal was also poor (kappa 0.20). CONCLUSIONS: Agreement on treatment goals between family caregivers and physicians for patients at the study site was low. These results suggest that encounters between family caregiver and physician may need improvement. Further research is needed to assess whether lack of agreement is found in other settings, persists over time, and affects achievement of goals and optimal health outcomes.

Activities of Daily Living↗
PubMed2001

Risk adjustment for older hospitalized persons: a comparison of two methods of data collection for the Charlson index.

To compare Charlson indices based on chart data and ICD-9 data for agreement overall and on rating specific comorbid conditions, and to compare mortality risks associated with these indices. Prospective cohort study. Six general medicine wards at Yale-New Haven Hospital. 524 consecutive patients who had no clinical evidence of delirium at enrollment, admitted between November 6, 1989 and July 31, 1991, aged 70 years or older. Death within 1 year of the index hospital admission date. Scores using the chart-based data were significantly higher than those using ICD-9 data. About half of the individual conditions showed fair-to-good agreement between the two scores, whereas the other half showed poor agreement. A comparison of mortality prediction indicated that the weightings assigned to individual comorbidities differed substantially from those used in Charlson's original index. While mortality prediction of each individual index was comparable, the ICD-9 and chart indices contributed independently to mortality prediction in the presence of the other. Low agreement between Charlson scores based on the two methods of data collection and their cumulative contribution to mortality prediction suggest that these indices may include different information. Our results suggest that the original Charlson index may not provide optimal risk adjustment for elderly general medicine samples. We suggest development of an empirically-derived index of comorbid conditions and weights may be warranted for older general medical patients.

Aged↗
PubMed2001

An algorithm for prospective individual matching in a non-randomized clinical trial.

A method is described to achieve balance across prognostic factors in intervention trials for which randomized allocation to treatment group is not possible. The method involves prospective individual matching of patients that have already been assigned to treatment groups. Data can be analyzed using methods appropriate for prospective matched cohort studies. Successful implementation depends on the number and complexity of factors to be matched, and on the number of available control patients. Simulation studies suggest that, in order to yield satisfactory match rates and to reduce costs associated with screening unmatched controls, no more than three prognostic factors should generally be considered. Baseline prognostic indices, incorporating information from multiple variables, provide effective matching factors. The implementation of the method in a successful clinical trial, the Delirium Prevention Trial, is discussed. In that study, treatment group was determined by hospital admission to either an intervention floor or to one of two usual care hospital floors. The ratio of available control to intervention patients was 1.3, and 95% of the eligible intervention floor patients were successfully matched to control floor patients. Excellent balance was demonstrated for non-matching factors, due in part to the use of a composite baseline risk score as a matching factor. In addition, external validity is enhanced because most eligible intervention patients are enrolled as they present. The methods outlined in this report provide a methodologically rigorous alternative for achieving balance across treatment groups, with respect to important prognostic factors, in non-randomized clinical trials, and will have broad applicability in the numerous situations in which randomization is not possible.

Aged↗
PubMed2001

Dementia and race: are there differences between African Americans and Caucasians?

This study provides an overview of racial differences in etiology and prevalence of dementia. Preliminary findings indicate that the clinical and molecular etiologies of dementia differ between races. African Americans have a higher prevalence of vascular dementia and a lower prevalence of Parkinsonian dementia than do Caucasians. The genetic etiologies of Alzheimer's-type dementia appear to differ between African Americans and Caucasians. The variations in dementia etiologies and in cognitive testing accuracy between races suggests the urgent need to develop racially appropriate cognitive assessment methods and to develop preventive and treatment etiologies differently according to racial background of individual patients.

Alzheimer Disease↗
PubMed2001

Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value?

INTRODUCTION: Delirium, or acute confusional state, is a common and serious occurrence among hospitalized older persons. Current estimates suggest that delirium complicates hospital stays for more than 2.3 million older persons each year, involving more than 17.5 million hospital days and accounting for more than $4 billion (1994 dollars) of Medicare expenditures. A 40% reduction was recently reported in the risk for delirium among hospitalized older persons receiving a multicomponent targeted risk factor intervention (MTI) strategy to prevent delirium, compared with subjects receiving usual hospital care.1 Before recommending that this preventive strategy be implemented in clinical practice, however, the cost implications must be thoroughly examined as well. METHODS: The present analysis performs net cost evaluations of the MTI for the prevention of delirium among hospitalized patients. Hospital charge and cost-to-charge ratio data are linked to a database of 852 subjects, who were treated with MTI or usual care. Multivariable regression methods were used to help isolate the impact of MTI on hospital costs. These results were then combined with our earlier work on the impact of the MTI on delirium prevention to assess the cost effectiveness of this intervention. RESULTS: The MTI significantly reduced nonintervention costs among subjects at intermediate risk for developing delirium, but not among subjects at high risk. When MTI intervention costs were included, MTI had no significant effect on overall health care costs in the intermediate risk cohort, but raised overall costs in the high risk group. CONCLUSIONS: Because the MTI prevented delirium in the intermediate risk group without raising costs, the conclusion reached is that it is a cost effective treatment option for patients at intermediate risk for developing delirium. In contrast, the results suggest that the MTI is not cost effective for subjects at high risk.

Aged↗
PubMed2001

What does the medical record reveal about functional status? A comparison of medical record and interview data.

OBJECTIVE: Functional status measures are potent independent predictors of hospital outcomes and mortality. The study objective was to compare medical record with interview data for functional status. SUBJECTS AND METHODS: Subjects were 525 medical patients, aged 70 years or older, hospitalized at an academic medical center. Patient interviews determined status for 7 basic activities of daily living (BADLs) and 7 instrumental activities of daily living (IADLs). Medical records were reviewed to assess documentation of BADLs and IADLs. RESULTS: Most medical records contained no documentation of individual BADLs and IADLs (61% to 98% of records lacking documentation), with the exception of walking (24% of medical records lacking documentation). Impairment prevalence was lower in medical records than at interview for all BADLs and IADLs, and agreement between interview and medical record was poor (kappa < 0.40 for individual BADLs and IADLs). Sensitivity of the medical record for BADL and IADL impairment was poor (range 95% to 44%), using the interview as a reference standard. Sensitivity and specificity of the medical record for detection of BADL and IADL impairment changed substantially when records with nondocumentation of functional status were excluded or were assumed to be equivalent to independence. CONCLUSIONS: The results suggest that the medical record is a poor source of data on many functional status measures, and that assuming that nondocumentation of functional status is equivalent to independence may be unwarranted. Given the prognostic importance of functional status measures, the results highlight the importance of developing reliable and efficient means of obtaining functional status information on hospitalized older patients.

Academic Medical Centers↗
PubMed2000

Goals in geriatric assessment: are we measuring the right outcomes?

Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.

Activities of Daily Living↗
PubMed2000

The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program.

OBJECTIVES: To describe the Hospital Elder Life Program, a new model of care designed to prevent functional and cognitive decline of older persons during hospitalization. PROGRAM STRUCTURE AND PROCESS: All patients aged > or =70 years on specified units are screened on admission for six risk factors (cognitive impairment, sleep deprivation, immobility, dehydration, vision or hearing impairment). Targeted interventions for these risk factors are implemented by an interdisciplinary team-including a geriatric nurse specialist, Elder Life Specialists, trained volunteers, and geriatricians--who work closely with primary nurses. Other experts provide consultation at twice-weekly interdisciplinary rounds. INTERVENTION: Adherence is carefully tracked. Quality assurance procedures and performance reviews are an integral part of the program. PROGRAM OUTCOMES: To date, 1,507 patients have been enrolled during 1,716 hospital admissions. The overall intervention adherence rate was 89% for at least partial adherence with all interventions during 37,131 patient-days. Our results indicate that only 8% of admissions involved patients who declined by 2 or more points on MMSE and only 14% involved patients who declined by 2 or more points on ADL score. Comparative results for the control group from the clinical trial were 26% and 33%, and from previous studies 14 to 56% and 34 to 50% for cognitive and functional decline, respectively. Effectiveness of the program for delirium prevention and of the program's nonpharmacologic sleep protocol have been demonstrated previously. CONCLUSIONS: These results suggest that the Hospital Elder Life Program successfully prevents cognitive and functional decline in at-risk older patients. The program is unique in its hospital-wide focus; in providing skilled staff and volunteers to implement interventions; and in targeting practical interventions toward evidence-based risk factors. Future studies are needed to evaluate cost-effectiveness and longterm outcomes of the program as well as its effectiveness in non-hospital settings.

Activities of Daily Living↗
PubMed1999

Clinical epidemiological quality in molecular genetic research: the need for methodological standards.

CONTEXT: A genetic basis has been identified for many medical conditions and some molecular tests have been commercialized. However, little attention has been given to the quality of clinical epidemiology in molecular studies. OBJECTIVE: To examine the clinical epidemiological quality of recent publications on molecular genetic analysis. DESIGN: Cross-sectional study of original research articles published in 1995, identified by manually searching 4 general clinical journals. Of 83 articles identified, 40 were selected for analysis; these 40 discussed molecular genetic techniques, studied 10 or more patients, and had inferential conclusions. MAIN OUTCOME MEASURE: Compliance of the selected articles with 7 methodological standards for clinical epidemiological science (reproducibility, objectivity, delineation of case group, adequacy of spectrum in case group, delineation of comparison group, adequacy of comparison group, and quantitative summary of results). RESULTS: Among the 40 inferential articles that studied 10 or more patients, only 5 (12.5%) complied with all 7 applicable standards, and 10 (25.0%) complied with all but 1 standard, whereas 25 articles (62.5%) failed to comply with 2 or more standards and 9 (22.5%) failed 4 or 5 standards. Most articles did not comply with standards for reproducibility (n = 25, 62.5%) or objectivity (n = 27, 67.5%); however, the majority of articles did comply with standards for adequacy of case group (n = 35, 87.5 %), adequacy of comparison group (n = 35, 87.5%), and quantitative summary of results (n = 36, 90%). CONCLUSIONS: Despite major laboratory advances in molecular genetic analysis, our data suggest that reported applications in clinical journals often have troubling omissions, deficiencies, and lack of attention to the different, but necessary, principles of clinical epidemiological science. Without suitable attention to fundamental methodological standards, the expected benefits of molecular genetic testing may not be achieved.

Clinical Medicine↗
PubMed1999

Perils, pitfalls, and possibilities in talking about medical risk.

Virtually every course of medical action is associated with some adverse risk to the patient. Discussing these risks with patients is a fundamental duty of physicians both to fulfill a role as trusted adviser and to promote the ethical principle of autonomy (particularly as embodied in the doctrine of informed consent). Discussing medical risk is a difficult task to accomplish appropriately. Challenges stem from gaps in the physician's knowledge about pertinent risks, uncertainty about how much and what kind of information to communicate, and difficulties in communicating risk information in a format that is clearly understood by most patients. For example, a discussion of the risk of undergoing a procedure should be accompanied by a discussion of the risk of not undergoing a procedure. This article describes basic characteristics of risk information, outlines major challenges in communicating risk information, and suggests several ways to communicate risk information to patients in an understandable format. Ultimately, a combination of formats (eg, qualitative, quantitative, and graphic) may best accommodate the widely varying needs, preferences, and abilities of patients. Such communication will help the physician accomplish the fundamental duty of teaching the patient the information necessary to make an informed and appropriate decision.

Comprehension↗
PubMed1999

A multicomponent intervention to prevent delirium in hospitalized older patients.

BACKGROUND: Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium. METHODS: We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge. RESULTS: Delirium developed in 9.9 percent of the intervention group as compared with 15.0 percent of the usual-care group, (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and a reduction in the rate of use of sleep medications among all patients. Among the other risk factors per patient there were trends toward improvement in immobility, visual impairment, and hearing impairment. CONCLUSIONS: The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy.

Aged↗
PubMed1999

Goal-setting in clinical medicine.

The process of setting goals for medical care in the context of chronic disease has received little attention in the medical literature, despite the importance of goal-setting in the achievement of desired outcomes. Using qualitative research methods, this paper develops a theory of goal-setting in the care of patients with dementia. The theory posits several propositions. First, goals are generated from embedded values but are distinct from values. Goals vary based on specific circumstances and alternatives whereas values are person-specific and relatively stable in the face of changing circumstances. Second, goals are hierarchical in nature, with complex mappings between general and specific goals. Third, there are a number of factors that modify the goal-setting process, by affecting the generation of goals from values or the translation of general goals to specific goals. Modifying factors related to individuals include their degree of risk-taking, perceived self-efficacy, and acceptance of the disease. Disease factors that modify the goal-setting process include the urgency and irreversibility of the medical condition. Pertinent characteristics of the patient-family-clinician interaction include the level of participation, control, and trust among patients, family members, and clinicians. The research suggests that the goal-setting process in clinical medicine is complex, and the potential for disagreements regarding goals substantial. The nature of the goal-setting process suggests that explicit discussion of goals for care may be necessary to promote effective patient-family-clinician communication and adequate care planning.

Aged↗
PubMed1998

A taxonomy for goal setting in the care of persons with dementia.

OBJECTIVE: Develop a taxonomy for understanding and classifying goals in the care of persons with dementia. DESIGN: Qualitative study using open-ended interviews with key informants and the constant comparative method of qualitative data analysis. SETTING: The geriatric assessment center at a large academic medical center in Connecticut. PARTICIPANTS: Key informant interviews with 36 subjects: consecutive patients receiving geriatric assessment at the center and their primary family caregivers, case managers, and physicians of patients. MEASUREMENTS AND MAIN RESULTS: Goals, or desired outcomes, for the patient's care as described by patients, primary family caregivers, case managers, and physicians were the main measurements. Participant interviews were conducted until the point of theoretical saturation, i.e., until further interviews no longer provided new concepts. All participants articulated at least one goal. Specific goals were characterized by a limited number of goal attributes resulting in a taxonomy, or consistent classification system, for reported goals. These attributes include domain (or content), specificity, time frame, and level of challenge. CONCLUSIONS: The findings suggested that patients, primary family caregivers, and clinicians can articulate goals of care and may bring differing perspectives to the goal-setting process. The research identified a taxonomy that may facilitate negotiation of goals by revealing important, and perhaps overlooked, aspects of goals and the goal-setting process.

Activities of Daily Living↗
PubMed1996

"Mother-baby" biliary endoscopy: the University of Chicago experience.

OBJECTIVE: The "mother-baby" technique of peroral cholangioscopy is a relatively recent development in biliary endoscopy and permits direct visualization of the biliary tree. This paper presents the experience of one institution with this new technique. METHODS: We used the Olympus mother-baby endoscopy system at the University of Chicago and at one of its affiliated hospitals to examine and treat selected lesions in the biliary tree that had eluded successful diagnosis or treatment by standard means. In addition, we used the baby endoscope alone through surgically created percutaneous tracts to treat selected patients with retained stones. RESULTS: From July 1990 to June 1993, peroral cholangioscopy was performed 18 times in 12 patients at the University of Chicago and affiliated hospitals. The baby endoscope was successfully passed into the bile duct in 15 of 18 cases (83.3%). Additionally, the baby endoscope alone was used through a T-tube or cholecystostomy tract 10 times in six patients. Complications occurred in two patients and were minor; there were no fatalities. With refinement of technique, successful passage of the baby endoscope was accomplished in 100% of patients undergoing peroral cholangioscopy. CONCLUSIONS: Direct visualization of the biliary tree with the ability to sample (brush, biopsy) or treat (basket removal, electrohydraulic or laser lithotripsy) lesions significantly aided in the care of all patients in whom the baby endoscope was successfully passed by providing the correct diagnosis and, when appropriate, by allowing definitive treatment of lesions. The eventual role of this technique in the current cost-conscious climate is unclear, but at present it should be limited to selected referral centers.

Adult↗