PubMed Health⌕ Search

Biomedical subjects

Steven H Woolf

Publications and source records attributed to Steven H Woolf.

At least 19 recordsLinked to original sources
PubMed2006

A sense of priorities for the healthcare commons.

Limited resources make it impossible to deliver all healthcare services to all people. Therefore, it is vital for the nation to adopt rational methods for setting priorities. The work of the National Commission on Prevention Priorities takes such an approach in ranking the relative importance of effective preventive services, and it carries important implications for policymakers, clinicians, and patients. The crisis facing health care requires society to function as a community to use limited resources in ways that maximize the public good.

Health Policy↗
PubMed2006

The rising prevalence of severe poverty in America: a growing threat to public health.

BACKGROUND: The U.S. poverty rate has increased since 2000, but the depth of poverty experienced by Americans has been inadequately studied. Of particular concern is whether severe poverty is increasing, a trend that would carry important public health implications. METHODS: Income-to-poverty (I/P) ratios and income deficits/surpluses were examined for the 1990-2004 period. The severely poor, moderately poor, and near-poor were classified as those with I/P ratios of less than 0.5, 0.5 to 1.0, or 1.0 to 2.0, respectively. Income deficits/surpluses were classified relative to the poverty threshold as Tier I (deficit Dollars 8000 or more), Tier II (deficit or surplus less than Dollars 8000), or Tier III (surplus more than Dollars 8000). Odds ratios for severe poverty and Tier I were also calculated. RESULTS: Severe poverty increased between 2000 and 2004-those with I/P ratios of less than 0.5 grew by 20%, and Tier I grew by 45% to 55%-while the prevalence of higher levels of income diminished. The population in severe poverty was over-represented by children (odds ratio [OR] = 1.69, confidence interval [CI] = 1.63-1.75), African Americans (OR = 2.84, CI = 2.74-2.95), and Hispanics (OR = 1.64, CI = 1.58-1.71). CONCLUSIONS: From 2000 to 2004, the prevalence of severe poverty increased sharply while the proportion of Americans in higher income tiers diminished. These trends have broad societal implications. Likely health consequences include a higher prevalence of chronic illnesses, more frequent and severe disease complications, and increased demands and costs for healthcare services. Adverse effects on children warrant special concern. The growth in the number of Americans living in poverty calls for the re-examination of policies enacted in recent years to foster economic progress.

Adolescent↗
PubMed2006

Weighing the evidence to formulate dietary guidelines.

Dietary guidelines have broad implications for the health of individuals and populations. Increasingly, government agencies and medical organization that issue guidelines have pursued evidence-based approaches. These approaches emphasize a comprehensive, critical, and explicit examination of the scientific evidence that the proposed dietary practice will improve health. Evidence-based guidelines typically feature an explicit methodology, include as their foundation a systematic review of the evidence, provide graded recommendations that are linked directly to the supporting evidence, and state explicitly when recommendations are based on opinion. Guideline development usually involves some combination of six steps: (1) specification of the topic and the guideline development methodology, (2) systematic review of the evidence, (3) consideration of expert opinion, (4) public policy analysis, (5) drafting of the document, and (6) peer review. The supporting evidence undergoes critical appraisal, including an assessment of the magnitude of the effect on outcomes observed in studies, the quality of the studies reporting the effect, or both. Dietary guidelines should also consider untoward effects, potential harms, and economic implications to society, the food industry, and others. A hallmark of evidence-based guidelines is making explicit the strength of recommendations and the quality of the evidence on which they are based. Grading systems are commonly used to rate the quality of the supporting evidence.

Diet↗
PubMed2006

Use of beryllium lymphocyte proliferation testing for screening of asymptomatic individuals: an evidence-based assessment.

OBJECTIVE: We reviewed published data describing use of beryllium lymphocyte proliferation testing (BeLPT) to determine the appropriateness of BeLPT for screening asymptomatic individuals. METHODS: Published studies were identified by computerized literature searches and hand searches of relevant bibliographies and cited references. Critical assessment of evidence focused on five elements essential to judging effectiveness of preventive services: 1) burden of suffering, 2) accuracy and reliability of screening tests, 3) effectiveness of early detection, 4) harms of screening, and 5) benefits outweighing harms. RESULTS: Important gaps and deficiencies in the evidence were found. The prevalence of beryllium sensitization and chronic beryllium disease in asymptomatic individuals are unknown. The accuracy and reliability of BeLPT are uncertain. Marked intra- and interlaboratory variability has been reported. The clinical benefits of early intervention have not been confirmed or quantified in asymptomatic individuals. CONCLUSIONS: There is currently insufficient scientific evidence to support the use of BeLPT for routine screening of asymptomatic individuals.

Berylliosis↗
PubMed2005

Promoting informed choice: transforming health care to dispense knowledge for decision making.

Ours is an era in which patients seek greater engagement in health care choices, increasing the demand for high-quality information about clinical options. Providing support for informed choice is not straightforward, however, because of challenges faced by clinicians, health systems, and consumers. Greater use of written or electronic tools can help to clarify choices for patients, but decision aids cannot replace the human element in facilitating informed choice. The ideal solution is to couple information with high-quality decision counseling to help patients understand the potential risks, benefits, and uncertainties of clinical options and to assist them in selecting the option that best accommodates their personal preferences. Decision counseling can be offered by 3 types of providers: clinicians who lack formal informed-choice training ("usual care"), clinicians with formal informed-choice training, or trained third parties who function as impartial decision counselors. Controlled studies are needed to determine which model is best, but none appears to be ideal. The health care system cannot truly support informed decision making without correcting the underlying obstacles that impede patient access to needed information. New information technology solutions, training programs, and reimbursement schemes are necessary. Patient demand for guidance will only increase as clinical options multiply and the world of information continues its rapid growth. Today's health care system is unprepared for the convergence of these 2 burgeoning domains, and the need to address systemic deficiencies will grow more urgent over time.

Choice Behavior↗
PubMed2005

Unwanted control: how patients in the primary care setting decide about screening for prostate cancer.

Current guidelines recommend shared decision-making to determine whether the prostate-specific antigen (PSA) test should be performed. At a large family medicine practice in suburban Washington, DC, we administered a sequence of patient and physician surveys to examine the desired and actual level of patient control over PSA screening decisions and the circumstances in which they occur. Both before and after visits, patients expressed a preference for a shared approach to the PSA decision, but the actual decision involved a significant shift toward greater patient control. Almost 25% of patients reported greater decisional control than they desired. Fully 30% of the men who wanted a shared approach made the actual decision themselves. Patients prefer a shared approach to the PSA decision but report greater personal control when the decision is actually made. Further research is needed to understand this phenomenon and to better accommodate patients' desire for shared decision-making.

Aged↗
PubMed2005

Title VII funding and physician practice in rural or low-income areas.

CONTEXT: Whether Title VII funding enhances physician supply in underserved areas has not clearly been established. PURPOSE: To determine the relation between Title VII funding in medical school, residency, or both, and the number of family physicians practicing in rural or low-income communities. METHODS: A retrospective cross sectional analysis was carried out using the 2000 American Academy of Family Physicians physician database, Title VII funding records, and 1990 U.S. Census data. Included were 9,107 family physicians practicing in 9 nationally representative states in the year 2000. FINDINGS: Physicians exposed to Title VII funding through medical school and residency were more likely to have their current practice in low-income communities (11.9% vs 9.9%, P< or =.02) and rural areas (24.5% vs 21.8%, P< or =.02). Physicians were more likely to practice in rural communities if they attended medical schools (24.2% vs 21.4%; P =.009) and residencies (24.0% vs 20.3%; P =.011) after the school or program had at least 5 years of Title VII funding vs before. Similar increases were not observed for practice in low-income communities. In a multivariate analysis, exposure to funding and attending an institution with more years of funding independently increased the odds of practicing in rural or low-income communities. CONCLUSIONS: Title VII funding is associated with an increase in the family physician workforce in rural and low-income communities. This effect is temporally related to initiation of funding and independently associated with effect in a multivariate analysis, suggesting a potential causal relationship. Whereas the absolute 2% increase in family physicians in these underserved communities may seem modest, it can represent a substantial increase in access to health care for community members.

Career Choice↗
PubMed2004

Informed decision making: what is its role in cancer screening?

Interest in informed decision making (IDM) has grown in recent years. Greater patient involvement in decision making is consistent with recommendations to improve health care quality. This report provides an overview of IDM; clarifies the differences between IDM, shared decision making (SDM), and informed consent; and reviews the evidence to date about IDM for cancer screening. The authors also make recommendations for research. We define IDM as occurring when an individual understands the disease or condition being addressed and comprehends what the clinical service involves, including its benefits, risks, limitations, alternatives, and uncertainties; has considered his or her preferences and makes a decision consistent with them; and believes he or she has participated in decision making at the level desired. IDM interventions are used to facilitate informed decisions. The authors reviewed the evidence to date for IDM and cancer screening based primarily on published meta-analyses and a recent report for the Centers for Disease Control and Prevention's Guide to Community Preventive Services. IDM and SDM interventions, such as decision aids, result in improved knowledge, beliefs, risk perceptions, and combinations of these. Little or no evidence exists, however, regarding whether these interventions result in 1) participation in decision making at a level consistent with patient preferences or 2) effects on patient satisfaction with the decision-making process. These variables generally either were not assessed or were not reported in the articles reviewed. Results of interventions on uptake of screening were variable. After exposure to IDM/SDM interventions, most studies showed small decreases in prostate cancer screening, whereas four studies on breast and colorectal cancer screening showed small increases. Few data are available by which to evaluate current practices in cancer screening IDM. Patient participation in IDM should be facilitated for those who prefer it. More research is needed to assess the benefits of IDM/SDM interventions and to tailor interventions to individuals who are most likely to desire and benefit from them. There are many system barriers to IDM/SDM and few tools. More work is needed in this area as well. In addition, research is needed to learn how to incorporate IDM into ongoing clinical practice and to determine whether there are unintended negative consequences of IDM.

Community Health Services↗
PubMed2004

Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature.

A large number of taxonomies are used to rate the quality of an individual study and the strength of a recommendation based on a body of evidence. We have developed a new grading scale that will be used by several family medicine and primary care journals (required or optional), with the goal of allowing readers to learn one taxonomy that will apply to many sources of evidence. Our scale is called the Strength of Recommendation Taxonomy. It addresses the quality, quantity, and consistency of evidence and allows authors to rate individual studies or bodies of evidence. The taxonomy is built around the information mastery framework, which emphasizes the use of patient-oriented outcomes that measure changes in morbidity or mortality. An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening. Levels of evidence from 1 to 3 for individual studies also are defined. We hope that consistent use of this taxonomy will improve the ability of authors and readers to communicate about the translation of research into practice.

Algorithms↗
PubMed2004

Patient safety is not enough: targeting quality improvements to optimize the health of the population.

Ensuring patient safety is essential for better health care, but preoccupation with niches of medicine, such as patient safety, can inadvertently compromise outcomes if it distracts from other problems that pose a greater threat to health. The greatest benefit for the population comes from a comprehensive view of population needs and making improvements in proportion with their potential effect on public health; anything less subjects an excess of people to morbidity and death. Patient safety, in context, is a subset of health problems affecting Americans. Safety is a subcategory of medical errors, which also includes mistakes in health promotion and chronic disease management that cost lives but do not affect "safety." These errors are a subset of lapses in quality, which result not only from errors but also from systemic problems, such as lack of access, inequity, and flawed system designs. Lapses in quality are a subset of deficient caring, which encompasses gaps in therapeutics, respect, and compassion that are undetected by normative quality indicators. These larger problems arguably cost hundreds of thousands more lives than do lapses in safety, and the system redesigns to correct them should receive proportionately greater emphasis. Ensuring such rational prioritization requires policy and medical leaders to eschew parochialism and take a global perspective in gauging health problems. The public's well-being requires policymakers to view the system as a whole and consider the potential effect on overall population health when prioritizing care improvements and system redesigns.

Health Priorities↗
PubMed2004

Shared decision making about screening and chemoprevention. a suggested approach from the U.S. Preventive Services Task Force.

Shared decision making is a process in which patients are involved as active partners with the clinician in clarifying acceptable medical options and in choosing a preferred course of clinical care. Shared decision making offers a way of individualizing recommendations, according to patients' special needs and preferences, when some patients may benefit from an intervention but others may not. This paper clarifies how the U.S. Preventive Services Task Force (USPSTF) envisions the application of shared decision making in the execution of screening and chemoprevention. Unlike conventional USPSTF reports, this paper is neither a systematic review nor a formal recommendation. Instead, it is a concept paper that includes a commentary on the current thinking and evidence regarding shared decision making. Although the USPSTF does not endorse a specific style of decision making, it does encourage informed and joint decisions. This means that patients should be informed about preventive services before they are performed, and that the patient-clinician partnership is central to decision making. The USPSTF suggests that clinicians inform patients about preventive services for which there is clear evidence of net benefit, and, if time permits, about other services with high visibility or special individual importance. Clinicians should make sure that balanced, evidence-based information about the service (including the potential benefits and harms, alternatives, and uncertainties) is available to the patient if needed. For preventive services for which the balance of potential benefits and harms is a close call, or for which the evidence is insufficient to guide a decision for or against screening, clinicians should additionally assist patients in determining whether individual characteristics and personal preferences favor performing or not performing the preventive service. The USPSTF believes that clinicians generally have no obligation to initiate discussion about services that have either no benefit or net harm. Nonetheless, clinicians should be prepared to explain why these services are discouraged and should consider a proactive discussion for services with high visibility or special individual importance or for services for which new evidence has prompted withdrawal of previous recommendations.

Chemoprevention↗
PubMed2004

Society's choice: the tradeoff between efficacy and equity and the lives at stake.

Society understands that racial and ethnic minorities experience inferior medical care and health status, but may not appreciate the seriousness of the problem. Each year the nation spends billions of dollars to perfect the "technology" of health care (e.g., development of new drugs) and modernize delivery systems, thereby saving thousands of lives. Correcting disparities in care, however, would avert five times as many deaths. If policymakers adhered to the goal of optimizing population health, greater priority would go to resolving disparities than to refining technology, but reverse priorities prevail. Adverse socioeconomic conditions-chief among the many causes of disparities-could be eased through bold socioeconomic reforms. Society has the resources to enable the disadvantaged to attain better health but pursues other priorities.

Delivery of Health Care↗
PubMed2004

The health impact of resolving racial disparities: an analysis of US mortality data.

The US health system spends far more on the "technology" of care (e.g., drugs, devices) than on achieving equity in its delivery. For 1991 to 2000, we contrasted the number of lives saved by medical advances with the number of deaths attributable to excess mortality among African Americans. Medical advances averted 176,633 deaths, but equalizing the mortality rates of Whites and African Americans would have averted 886,202 deaths. Achieving equity may do more for health than perfecting the technology of care.

Black or African American↗
PubMed2004

Simplifying the language of evidence to improve patient care: Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in medical literature.

Several taxonomies exist for rating individual studies and the strength of recommendations, making the analysis of evidence confusing for practitioners. A new grading scale-the Strength of Recommendation Taxonomy (SORT)-will be used by several family medicine and primary care journals (required or optional), allowing readers to learn 1 consistently applied taxonomy of evidence. SORT is built around the information mastery framework, which emphasizes the use of patient-oriented outcomes that measure changes in morbidity or mortality. Levels of evidence from 1 to 3 for individual studies also are defined. An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening.

Algorithms↗
PubMed2003

Screening adults for type 2 diabetes: a review of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Type 2 diabetes mellitus is associated with a heavy burden of suffering. Screening for diabetes is controversial. PURPOSE: To examine the evidence that screening and earlier treatment are effective in reducing morbidity and mortality associated with diabetes. DATA SOURCES: MEDLINE, the Cochrane Library, reviews, and experts, all of which addressed key questions about screening. STUDY SELECTION: Studies that provided information about the existence and length of an asymptomatic phase of diabetes; studies that addressed the accuracy and reliability of screening tests; and randomized, controlled trials with health outcomes for various treatment strategies were selected. DATA EXTRACTION: Two reviewers abstracted relevant information using standardized abstraction forms and graded articles according to U.S. Preventive Services Task Force criteria. DATA SYNTHESIS: No randomized, controlled trial of screening for diabetes has been performed. Type 2 diabetes mellitus includes an asymptomatic preclinical phase; the length of this phase is unknown. Screening tests can detect diabetes in its preclinical phase. Over the 10 to 15 years after clinical diagnosis, tight glycemic control probably reduces the risk for blindness and end-stage renal disease, and aggressive control of hypertension, lipid therapy, and aspirin use reduce cardiovascular events. The magnitude of the benefit is larger for cardiovascular risk reduction than for tight glycemic control. The additional benefit of starting these treatments in the preclinical phase, after detection by screening, is uncertain but is probably also greater for cardiovascular risk reduction. CONCLUSIONS: The interventions that are most clearly beneficial during the preclinical phase are those that affect the risk for cardiovascular disease. The magnitude of additional benefit of initiating tight glycemic control during the preclinical phase is uncertain but probably small.

Adult↗