Biomedical subjects

T G Tape

Publications and source records attributed to T G Tape.

14 recordsLinked to original sources

PubMed1992

The influence of treatment descriptions on advance medical directive decisions.

OBJECTIVE: To determine whether the wording of the descriptions of life-sustaining interventions would affect the choices elderly patients make when completing advance directives. METHODS: Survey. SETTING: General community in Omaha, Nebraska. PATIENTS: Two hundred one community-dwelling elderly were selected from a population-based sample. MAIN OUTCOME MEASURES: Subjects were asked whether they would accept or reject three life-sustaining interventions: cardiopulmonary resuscitation, mechanical ventilation, or tube feeding in three separate hypothetical case scenarios. The three life-sustaining interventions were each described positively, negatively, and exactly as they are worded in a widely used advance directive. Subjects reviewed each scenario three times with three different descriptions of the three interventions. RESULTS: For the three interventions presented in three scenarios, subjects opted for the intervention 12 percent of the time when it was presented negatively, 18 percent of the time when it was phrased as in an advance directive already in use and 30 percent of the time it was phrased positively. One hundred fifty-five of the 201 subjects (77 percent) changed their minds at least once when given the same scenario but a different description of the intervention. Of these 155, 33 percent changed decisions one to three times, 33 percent changed decisions four to seven times, and another 34 percent changed decisions eight to seventeen times based solely on the description of the intervention. CONCLUSION: The decisions patients make about whether to accept or reject life-sustaining treatments are affected by the descriptions of the treatments. These findings emphasize the critical importance of doctor-patient consultation when patients execute advance directives.

Advance Directives↗

PubMed1992

Implementing guidelines in ambulatory practice.

As we understand the process of ambulatory care better, the need to effectively implement standards of practice becomes more apparent. To facilitate successful use of practice guidelines, we have integrated an artificial intelligence system of Medical Logic Modules into our computerized medical record. A rule shell allows rapid development and prototyping of rules which can be practice reminders, information gathering utilities, or standing orders. A set of utilities allows non-programmer clinicians to develop and maintain the rule set. We will demonstrate these enhancements in the context of the comprehensive patient record.

Ambulatory Care↗

PubMed1991

Increasing physician acceptance and use of the computerized ambulatory medical record.

Because physicians have been reluctant to accept computerized medical records systems, we sought to identify the barriers to acceptance and redesigned our ambulatory records system accordingly. We identified several problems physicians encounter in using our computerized medical record system (COSTAR), including physicians' hesitation to use a computer in front of their patients, physicians' poor keyboard skills, and the structural organization of the computerized medical record. We formed a users group to educate users and the group has helped identify solutions to these problems. We equipped the exam room terminals with a user-friendly, patient-specific menu. We created a new physician interface for COSTAR that was organized to function similarly to a patient's chart and features user-friendly menus that provide cues to the unsophisticated user. Physician use of exam room terminals tripled after the installation of the exam room menu. The new physician interface doubled physician use of COSTAR's scheduling features. Acceptance of the new interface as gauged by a user survey was excellent, with the majority stating it improved their patient care.

Academic Medical Centers↗

PubMed1990

Clinical prediction rule for pulmonary infiltrates.

OBJECTIVE: To derive and validate a clinical rule for predicting pneumonic infiltrates in adult patients with acute respiratory illness. DESIGN: Prevalence studies in three settings. SETTING: Emergency departments of the University of Illinois Hospital at Chicago, the University of Nebraska Medical Center at Omaha, and the Medical College of Virginia at Richmond. PATIENTS: Symptoms, signs, comorbidity data, and chest roentgenogram results were recorded for 1134 patients from Illinois (the derivation set), 150 patients from Nebraska, and 152 patients from Virginia (the validation sets). All patients presented to the emergency department and had a chest roentgenogram to evaluate fever or respiratory complaints. MEASUREMENTS AND MAIN RESULTS: Within the training set, temperature greater than 37.8 degrees C, pulse greater than 100 beats/min, rales, decreased breath sounds, and the absence of asthma were identified as significant predictors of radiographically proved pneumonia in a stepwise logistic regression model (P = 0.001). The logistic rule discriminated patients with and without pneumonia in the training set with a receiver operating characteristic (ROC) area of 0.82. In the validation sets, the rule discriminated pneumonia and nonpneumonia with ROC areas of 0.82 and 0.76 after adjusting for differences in disease prevalence (P greater than 0.2 compared with the training set). The predicted probability of having pneumonia for patients with different clinical findings corresponded closely with the incidence of pneumonia among patients with such findings in the three settings. CONCLUSIONS: Among adults presenting with acute respiratory illness, a prediction rule based on clinical findings accurately discriminated patients with and without radiographic pneumonia, and was used in two other samples of patients without significant decrement in discriminatory ability. This rule can be used by physicians to develop more effective strategies for detecting pneumonia and for helping to determine the need for radiologic study among patients with acute respiratory disease.

Acute Disease↗

PubMed1990

Procedural skills of practicing nephrologists. A national survey of 700 members of the American College of Physicians.

OBJECTIVE: To determine which procedures nephrologists do in practice, where they learned the procedures, and how much training they recommend to achieve and maintain clinical competence in each. DESIGN: Mailed survey. PARTICIPANTS: A random sample of 700 members of the American College of Physicians who were identified as practicing nephrologists; 516 (74%) responded. RESULTS: Acute peritoneal dialysis, acute hemodialysis, continuous arteriovenous hemofiltration, and percutaneous renal biopsy were done by 95%, 97%, 87%, and 91% of the respondents, respectively. Except for hemofiltration, procedures were learned by most respondents during fellowship training. Compared with general internists, fewer nephrologists did most of the 19 general procedures included in the survey. The number of nephrology procedures done during the past year varied considerably among respondents, as did the minimum number of procedures they recommended for achieving and maintaining competence. Neither the variation in number of procedures done nor recommendations regarding certification were explained by differences in practice characteristics. Median recommendations remained relatively constant among subgroups. CONCLUSIONS: Nearly all nephrologists do the four nephrology procedures included in the survey. Their opinions about the training needed for competence help to better define requirements for training programs. More attention should be focused on training and certifying practicing nephrologists in procedures learned after formal fellowship training.

Biopsy, Needle↗

PubMed1989

Procedural skills training in internal medicine residencies. A survey of program directors.

STUDY OBJECTIVE: To obtain the opinions of internal medicine residency program directors about which procedural skills residents master during training and the amount of training needed to attain and maintain competence in each procedure. DESIGN: A mailed survey to all program directors in the United States. RESPONDENTS: Program directors or their designees from 389 of 431 (90%) internal medicine residency programs. RESULTS: For several procedures, 40% more respondents said all residents should master the procedure than said all their residents do master the procedure. Some procedures commonly done in practice were perceived as mastered by all residents in fewer than half of the programs. There were few differences in procedures learned by size or type of program. A fellowship program did affect exposure to some procedures in the field covered by the program. Median recommendations of training needed to master each procedure were similar to those of practicing internists for most procedures. CONCLUSIONS: Current residency training does not assure competency in all of the procedures the general internist does in practice. Program directors should examine which skills are adequately taught, test competence, and ways to improve residents' skills. Practicing general internists should have access to supervised training in procedural skills.

Clinical Competence↗

PubMed1986

The utility of routine chest radiographs.

Although admission and preoperative chest radiography has been done for many years in various settings, existing data do not support its utility in enhancing patient care. Calculations based on estimates of the accuracy of chest radiographs and the likelihood of disease suggest that routine chest radiography may result in many more misleading than helpful results. Patients in whom chest radiographs are likely to improve outcome are best identified by a careful history and physical examination. We recommend that the practice of doing routine chest radiographs on admission and preoperatively be stopped and that the procedure be reserved for patients with clinical evidence of chest disease and patients having intrathoracic surgery.

Adult↗

PubMedDate not supplied

How useful are routine chest x-rays of preoperative patients at risk for postoperative chest disease?

The authors studied the value of routine chest x-rays in the management of patients admitted for vascular surgery, a population likely to have comorbid chest disease. Patient records from 341 admissions were reviewed to determine the relationship between chest x-ray results and postoperative chest complications. Patients who had major abnormalities had a 40% postoperative complication rate, compared with 9% for those with normal x-rays; but only 13% of the complications occurred in patients with major abnormalities. Nine patients had x-ray findings that led to clinical action: three with potentially beneficial management changes (congestive heart failure in 2, fibrosis in 1) and six with potentially detrimental clinical action (false diagnosis of tuberculosis in 2, false diagnosis of nodules in 2, falsely normal chest x-ray in 2). None of 50 surgical cancellations occurred as a result of an abnormal x-ray. All the beneficial effects attributable to preoperative chest x-rays accrued to patients who had clinical evidence of chest disease. The authors conclude that routine chest x-rays were not helpful in improving patient outcomes. They recommend ordering preoperative chest x-rays based on clinical indications so that the likelihood of false positives and false negatives and their associated detrimental effects can be minimized.

Adult↗

PubMedDate not supplied

Echocardiography, endocarditis, and clinical information bias.

Although clinical information provided to the interpreter of imaging tests may improve disease detection, it may also bias the interpreter towards certain diagnoses, increasing the chance of false positives. To determine the possibility of this bias, the authors studied patients who were referred for echocardiography with a clinical suspicion of endocarditis. Hospital charts from a two-year period were reviewed to determine clinical data available to the echocardiographer, echocardiogram results, and the final diagnosis. Four clinical features, when present at the time of echocardiography, were associated with increased numbers of false-positive results. Test specificity was 97% (34/35) for patients without any of these features, but dropped to 80% (16/20) when two or more features were present. The authors conclude that clinical information may bias echocardiogram interpretations such that both test specificity and the posttest probability of disease may be overestimated when tests are used in clinical practice.

Echocardiography↗

PubMedDate not supplied

Medical students' and residents' estimates of cardiac risk.

Resident physicians' and medical students' perceptions of atherosclerotic heart disease (ASHD) risks and their understanding of risk appraisal concepts were studied. Subjects estimated the average risks of death from ASHD, from motor vehicle accidents, and from all causes for men in three age groups. Given a patient with severe hypertension, they then estimated relative risk and used their estimates to calculate individual patient risks. Risk estimates varied widely. Only 36% of the subjects were consistently accurate estimators of ASHD and all-causes risks. Subjects who had family histories of heart disease performed significantly better than others. Only about half the subjects were able to compute the hypertensive patient's risk correctly. Thus, residents and students were not adept at estimating the average risks of death from various causes or using the estimates to assess a patient's risk. Better physician understanding of these concepts might lead to improved patient counseling in risk factor reduction.

Accidents, Traffic↗

PubMedDate not supplied

Use of clinical judgment analysis to explain regional variations in physicians' accuracies in diagnosing pneumonia.

The authors sought to explain regional differences in physicians' accuracies in diagnosing pneumonia by prospectively studying emergency department patients at three sites and analyzing differences in physicians' diagnostic strategies and patient characteristics. They enrolled 1,119 Illinois patients, 150 Nebraska patients, and 142 Virginia patients presenting with fever or respiratory symptoms for whom physicians ordered a chest radiograph because of suspicion of pneumonia. Emergency department physicians recorded patients' clinical findings and estimated the probability that a chest radiograph would show pneumonia. A measure of accuracy, the correlation between physicians' probability estimates and actual outcomes, was 0.41 (95% CI 0.36-0.46) at Illinois, 0.66 (95% CI 0.54-0.75) at Nebraska, and 0.55 (95% CI 0.42-0.65) at Virginia. Physicians' strategies at the three sites differed markedly in their weightings of asthma, signs of consolidation, cough, tachypnea, age, and gender. These differences in weighting paralleled differences in the optimal clinical strategies derived from patient data at the three sites. Differences in diagnostic accuracy were best explained by differences in the difficulties of diagnosing pneumonia in the populations. Physicians at each site used clinical findings in a way that was close to optimal for their location. This type of analysis provides a new tool for understanding the sources of regional variations in clinical practice.

Adult↗

PubMedDate not supplied

Relation of physicians' predicted probabilities of pneumonia to their utilities for ordering chest x-rays to detect pneumonia.

To investigate the relation between physicians' predicted probabilities of pneumonia and their utilities for ordering chest x-rays to detect pneumonia, the authors studied 52 physicians who ordered chest x-rays of 886 patients presenting to an emergency department with fever or respiratory complaints. Physicians estimated the probability of pneumonia prior to obtaining the results of the chest x-ray. Utilities were assessed by asking physicians to consider a hypothetical patient presenting with acute respiratory symptoms, with unknown chest x-ray status, and to rank on a scale from +50 ("best thing I could do") to -50 ("worst thing I could do") their rating scale utilities for not diagnosing pneumonia and not ordering a chest x-ray when the patient had pneumonia (i.e., missing a pneumonia), and for diagnosing pneumonia and ordering a chest x-ray when the patient did not have pneumonia (i.e., ordering an unnecessary x-ray). The utility for ordering an unnecessary x-ray was negatively correlated with average predicted probability (r = -0.1495, p = 0.29), whereas the utility for missing a pneumonia was positively correlated with average predicted probability (r = 0.2254, p = 0.11), although the correlations were not statistically significant. Relative chagrin, defined as the difference in these utilities, was significantly inversely correlated with average predicted probability (r = -0.2992, p less than 0.035), even after adjusting for the prevalence of pneumonia seen by each physician (partial r = -0.42, p less than 0.0027). It is concluded that physicians who experienced greater regret over missing a pneumonia than over ordering an unnecessary x-ray estimated lower probabilities of pneumonia for patients for whom they ordered x-rays.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-Benefit Analysis↗

PubMedDate not supplied

Comparing methods of learning clinical prediction from case simulations.

Feedback to physicians about how they use information in making judgments can improve the quality of their judgments, but questions remain about which types of feedback are most effective. The authors conducted a controlled study of feedback in 60 medical students learning to predict the risk of cardiovascular death based on the presence or absence of five risk factors. After a pretest of 40 cases abstracted from patient records, the students worked through 173 computer-simulated cases and a posttest of 40 patient cases. The students received no feedback, probability feedback (correct probability of cardiac death for each case), cognitive feedback (the correct cue weights compared with their own weights derived from the previous set of cases), or both types of feedback. Students who received probability feedback markedly improved both base rate calibration and discrimination. Those who received only cognitive feedback showed no improvement over control on any of the measures of learning. All subjects were highly consistent in their weightings. The superiority of probability feedback differed from previous findings that cognitive feedback was essential for mastery of multiple-cue-probability learning tasks. The information on cue-outcome relationships given by cognitive feedback may be more useful when these relationships are complex and the combining rule is not known, while the precise outcome information provided by probabilistic feedback is more useful when the combining rule is known and the cue-outcome relationships are straightforward. Thus, the optimal method of learning depends on the nature of the task.

Adult↗

PubMedDate not supplied

Reproducibility of predictor variables from a validated clinical rule.

It has been suggested that clinical prediction rules are not reproducible, and that the most important variables frequently do not appear in replicate models. The authors studied the reproducibility of a validated rule for predicting radiographic evidence of pneumonia (ROC areas for the training and validation cohorts, 0.816 and 0.821, respectively). Two hundred replicate samples of size 250 and size 500 were generated by sampling without replacement from the original training cohort of 905 patients with a 14.6% prevalence of pneumonia. Forward selection was performed among 31 candidate variables by stepwise logistic regression. Using as reproducibility criteria: 1) inclusion of all five variables from the original model in the original order; 2) inclusion of all five variables in any order; 3) inclusion of the first three variables; 4) inclusion of the first two variables; 5) inclusion of the first variable; and 6) inclusion of any of the five variables: 2.5%, 13.5%, 48.5%, 85.5%, 98.0%, and 100% of replicate models of sample size 500, respectively, met the criteria, whereas 0%, 0%, 16.5%, 49.0%, 71.5%, and 97.5% of models of sample size 250 met the criteria (all comparisons by sample size p < .0001 except for criteria 1 and 6, p = 0.07). Mean ROC areas in the training and validation samples were 0.829 and 0.791 for replicate models of sample size 500, and 0.831 and 0.779 for models of sample size 250. There was no significant difference in ROC areas between training and validation cohorts for 80.5% of models of sample size 500, and for 75.3% of models of sample size 250.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Care↗