Mary Kane Goldstein

Abstract

When given a choice, how do people decide which physician to select? Although significant research has demonstrated that how people actually feel (their "actual affect") influences their health care preferences, how people ideally want to feel (their "ideal affect") may play an even greater role. Specifically, we predicted that people trust physicians whose affective characteristics match their ideal affect, which leads people to prefer those physicians more. Consistent with this prediction, the more participants wanted to feel high arousal positive states on average (ideal HAP; e.g., excited), the more likely they were to select a HAP-focused physician. Similarly, the more people wanted to feel low arousal positive states on average (ideal LAP; e.g., calm), the more likely they were to select a LAP-focused physician. Also as predicted, these links were mediated by perceived physician trustworthiness. Notably, while participants' ideal affect predicted physician preference, actual affect (how much people actually felt HAP and LAP on average) did not. These findings suggest that people base serious decisions on how they want to feel, and highlight the importance of considering ideal affect in models of decision making preferences. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

View details for DOI 10.1037/a0034372

View details for PubMedID 24188062

Abstract

Willingness to pay (WTP) is a monetary, preference-based, burden-of-disease measure with a potential role in dermatology, where many conditions are temporary and/or mild, and many treatments are inexpensive and one might be able to imagine paying out of pocket. We assessed construct validity by interviewing 254 consecutive dermatology patients at Stanford Medical Center, Grady Hospital, and Parkland Hospital. Instruments asked about an individual's own health status and elicited WTP, time-trade-off (TTO) utilities, and health status quality of life (QOL). We measured WTP cure (short treatment course to eliminate disease) and WTP control (lifelong medication). Our data indicate greater construct validity in non-Medicaid (n=163) than Medicaid (n=91) patients. Non-Medicaid subjects had greater WTP as percent of income for cure (median: 2%) than control (median: 1.6%), P<0.01; Medicaid WTP amounts for control and cure did not differ. Non-Medicaid subjects with verrucae had little QOL impact, no measurable burden by TTO, and a correspondingly low WTP. Medicaid subjects with basal cell carcinoma had a strong, negative QOL impact and high burden by TTO, but had relatively moderate WTP. WTP appears promising in certain income categories. More studies are needed for conclusions about specific diagnoses.

View details for DOI 10.1038/jid.2012.50

View details for Web of Science ID 000305492900009

View details for PubMedID 22418874

Abstract

At times, caregivers make life-and-death decisions for loved ones. Yet very little is known about the factors that make caregivers more or less accurate as surrogate decision makers for their loved ones. Previous research suggests that in low stress situations, individuals with high attachment-related anxiety are attentive to their relationship partners' wishes and concerns, but get overwhelmed by stressful situations. Individuals with high attachment-related avoidance are likely to avoid intimacy and stressful situations altogether. We hypothesized that both of these insecure attachment patterns limit surrogates' ability to process distressing information and should therefore be associated with lower accuracy in the stressful task of predicting their loved ones' end-of-life health care wishes.Older patients visiting a medical clinic stated their preferences toward end-of-life health care in different health contexts, and surrogate decision makers independently predicted those preferences. For comparison purposes, surrogates also predicted patients' perceptions of everyday living conditions so that surrogates' accuracy of their loved ones' perceptions in nonstressful situations could be assessed.Surrogates high on either type of insecure attachment dimension were less accurate in predicting their loved ones' end-of-life health care wishes. It is interesting to note that even though surrogates' attachment-related anxiety was associated with lower accuracy of end-of-life health care wishes of their loved ones, it was associated with higher accuracy in the nonstressful task of predicting their loved ones' everyday living conditions.Attachment orientation plays an important role in accuracy about loved ones' end-of-life health care wishes. Interventions may target emotion regulation strategies associated with insecure attachment orientations.

View details for DOI 10.1037/a0025664

View details for Web of Science ID 000297029200020

View details for PubMedID 22081941

Abstract

BACKGROUND- The majority of current implantable cardioverter-defibrillator (ICD) recipients are significantly older than those in the ICD trials. Data on periprocedural complications among the elderly are insufficient. We evaluated the influence of age on perioperative complications among primary prevention ICD recipients in the United States. METHODS AND RESULTS- Using the National Cardiovascular Data's ICD Registry, we identified 150 264 primary prevention patients who received ICDs from January 2006 to December 2008. The primary end point was any adverse event or in-hospital mortality. Secondary end points included major adverse events, minor adverse events, and length of stay. Of 150 264 patients, 61% (n=91 863) were 65 years and older. A higher proportion of patients ?65 years had diabetes, congestive heart failure, atrial fibrillation, renal disease, and coronary artery disease. Approximately 3.4% of the entire cohort had any complication, including death, after ICD implant. Any adverse event or death occurred in 2.8% of patients under 65 years old; 3.1% of 65- to 69-year-olds; 3.5% of 70- to 74-year-olds; 3.9% of 75- to 79-year-olds, 4.5% of 80- to 84-year-olds; and 4.5% of patients 85 years and older. After adjustment for clinical covariates, multivariate analysis found an increased odds of any adverse event or death among 75- to 79-year-olds (1.14 [95% confidence interval, 1.03 to 1.25], 80-to 84-year-olds (1.22 [95% confidence interval, 1.10 to 1.36], and patients 85 years and older (1.15 [95% confidence interval, 1.01 to 1.32], compared with patients under 65 years old. CONCLUSIONS- Older patients had a modestly increased-but acceptably safe-risk of periprocedural complications and in-hospital mortality, driven mostly by increased comorbidity.

View details for DOI 10.1161/CIRCOUTCOMES.110.959205

View details for Web of Science ID 000295028800012

View details for PubMedID 21878667

Abstract

To estimate the potentially inappropriate use of implantable cardioverter-defibrillator ICDs in older U.S. adults.Retrospective study.The National Cardiovascular Data ICD Registry.Forty-four thousand eight hundred five individuals in the National Cardiovascular Data's ICD Registry(™) who had received ICDs for primary prevention from January 2006 to December 2008. Individuals with a prior myocardial infarction and ejection fraction less than 30% were included.Mortality risk was categorized using the Multicenter Automatic Defibrillator Implantation (MADIT) II risk-stratification system. Low-risk and very-high-risk individuals were considered potentially inappropriate recipients.Of 44,805 individuals, 67% (n = 29,893) were aged 65 and older, of whom 51% were aged 75 and older. A significant proportion of ICD recipients had a low risk of death (16%, n = 6,969) or very high risk of nonarrhythmic death (8%, n = 3,693). Potentially inappropriate ICD use was 10% in those aged 75 and older, much less than in younger groups (40%, <65; 21%, 65-74, P < .001). Although age was associated with a high risk of nonarrhythmic death, its influence was markedly attenuated after adjusting for comorbidities and timing of ICD implantation (odds ratio = 1.02, 95% confidence interval = 1.02-1.03, P < .001).Potentially inappropriate ICD use appears significantly less--and at modest rates--in older Americans than in younger age groups. Overall, almost one-quarter of individuals may have received ICDs inappropriately based on their risk of death. Physicians appear to be conservatively referring older adults and wisely deferring those with high comorbid burden.

View details for DOI 10.1111/j.1532-5415.2011.03542.x

View details for Web of Science ID 000295615000003

View details for PubMedID 21883101

Abstract

Development of clinical decision support systems (CDSs) has tended to focus on facilitating medication management. An understanding of behavioral medicine perspectives on the usefulness of a CDS for patient care can expand CDSs to improve management of chronic disease. The purpose of this study is to explore feedback from behavioral medicine providers regarding the potential for CDSs to improve decision-making, care coordination, and guideline adherence in pain management. Qualitative methods were used to analyze semi-structured interview responses from behavioral medicine stakeholders following demonstration of an existing CDS for opioid prescribing, ATHENA-OT. Participants suggested that a CDS could assist with decision-making by educating providers, providing recommendations about behavioral therapy, facilitating risk assessment, and improving referral decisions. They suggested that a CDS could improve care coordination by facilitating division of workload, improving patient education, and increasing consideration and knowledge of options in other disciplines. Clinical decision support systems are promising tools for improving behavioral medicine care for chronic pain.

View details for DOI 10.1007/s13142-011-0022-6

View details for PubMedID 24073031

Abstract

Research on aging has indicated that whereas deliberative cognitive processes decline with age, emotional processes are relatively spared. To examine the implications of these divergent trajectories in the context of health care choices, we investigated whether instructional manipulations emphasizing a focus on feelings or details would have differential effects on decision quality among younger and older adults. We presented 60 younger and 60 older adults with health care choices that required them to hold in mind and consider multiple pieces of information. Instructional manipulations in the emotion-focus condition asked participants to focus on their emotional reactions to the options, report their feelings about the options, and then make a choice. In the information-focus condition, participants were instructed to focus on the specific attributes, report the details about the options, and then make a choice. In a control condition, no directives were given. Manipulation checks indicated that the instructions were successful in eliciting different modes of processing. Decision quality data indicate that younger adults performed better in the information-focus than in the control condition whereas older adults performed better in the emotion-focus and control conditions than in the information-focus condition. Findings support and extend extant theorizing on aging and decision making as well as suggest that interventions to improve decision-making quality should take the age of the decision maker into account.

View details for DOI 10.1037/a0018500

View details for Web of Science ID 000276369400007

View details for PubMedID 20350046

Abstract

The Morningside Initiative is a public-private activity that has evolved from an August, 2007, meeting at the Morningside Inn, in Frederick, MD, sponsored by the Telemedicine and Advanced Technology Research Center (TATRC) of the US Army Medical Research Materiel Command. Participants were subject matter experts in clinical decision support (CDS) and included representatives from the Department of Defense, Veterans Health Administration, Kaiser Permanente, Partners Healthcare System, Henry Ford Health System, Arizona State University, and the American Medical Informatics Association (AMIA). The Morningside Initiative was convened in response to the AMIA Roadmap for National Action on Clinical Decision Support and on the basis of other considerations and experiences of the participants. Its formation was the unanimous recommendation of participants at the 2007 meeting which called for creating a shared repository of executable knowledge for diverse health care organizations and practices, as well as health care system vendors. The rationale is based on the recognition that sharing of clinical knowledge needed for CDS across organizations is currently virtually non-existent, and that, given the considerable investment needed for creating, maintaining and updating authoritative knowledge, which only larger organizations have been able to undertake, this is an impediment to widespread adoption and use of CDS. The Morningside Initiative intends to develop and refine (1) an organizational framework, (2) a technical approach, and (3) CDS content acquisition and management processes for sharing CDS knowledge content, tools, and experience that will scale with growing numbers of participants and can be expanded in scope of content and capabilities. Intermountain Healthcare joined the initial set of participants shortly after its formation. The efforts of the Morningside Initiative are intended to serve as the basis for a series of next steps in a national agenda for CDS. It is based on the belief that sharing of knowledge can be highly effective as is the case in other competitive domains such as genomics. Participants in the Morningside Initiative believe that a coordinated effort between the private and public sectors is needed to accomplish this goal and that a small number of highly visible and respected health care organizations in the public and private sector can lead by example. Ultimately, a future collaborative knowledge sharing organization must have a sustainable long-term business model for financial support.

View details for DOI 10.2174/1874431101004010278

View details for PubMedID 21603282

Abstract

Rates of dialysis withdrawal are higher among the elderly and lower among Blacks, yet it is unknown whether preferences for withdrawal and engagement in advance care planning also vary by age and race or ethnicity. DESIGN, SETTING, PARTICIPANTS AND METHODS: We recruited 61 participants from two dialysis clinics to complete questionnaires regarding dialysis withdrawal preferences in five different health states. Engagement in advance care planning (end-of-life discussions), completion of advance directives and 'do not resuscitate' or 'do not intubate' (DNR/DNI) orders were ascertained by a questionnaire and from dialysis unit records.The mean age was 62 +/- 15 years; 38% were Black, 11% were Latino, 34% were White and 16% of participants were Asian. Blacks were less likely to prefer dialysis withdrawal as compared with Whites (odds ratio 0.16, 95% confidence interval 0.03-0.88) and other race/ethnicity groups, and this difference was not explained by age, education, comorbidity and other confounders. In contrast, older age was not associated with preferences for withdrawal. Rates of engagement in end-of-life discussions were higher than for documentation of advance care planning for all age and most race/ethnicity groups. Although younger participants and minorities were generally less likely to document treatment preferences as compared with older patients and Whites, they were not less likely to engage in end-of-life discussions.Preferences for withdrawal vary by race/ ethnicity, whereas the pattern of engagement in advance care planning varies by age and race/ethnicity. Knowledge of these differences may be useful for improving communication about end-of-life preferences and in implementing effective advance care planning strategies among diverse haemodialysis patients.

View details for DOI 10.1093/ndt/gfp430

View details for Web of Science ID 000273113100039

View details for PubMedID 19734137

Abstract

Radiology reports are unstructured free text documents that describe abnormalities in patients that are visible via imaging modalities such as X-ray. The number of imaging examinations performed in clinical care is enormous, and mining large repositories of radiology reports connected with clinical data such as patient outcomes could enable epidemiological studies, such as correlating the frequency of infections to the presence or length of time medical devices are present in patients. We developed a natural language processing (NLP) system to recognize device mentions in radiology reports and information about their state (insertion or removal) to enable epidemiological research. We tested our system using a reference standard of reports that were annotated to indicate this information. Our system performed with high accuracy (recall and precision of 97% and 99% for device mentions and 91-96% for device insertion status). Our methods are generalizable to other types of radiology reports as well as to other information extraction tasks and could provide the foundation for tools that enable epidemiological research exploration based on mining radiology reports.

View details for PubMedID 21347067

Abstract

Structuring Textual Clinical Guidelines (GLs) into a formal representation is a necessary prerequisite for supporting their automated application. We had developed a collaborative guideline-structuring methodology that involves expert physicians, clinical editors and knowledge engineers, to produce a machine-comprehensible representation for automated support of evidence-based, guideline-based care. Our goals in the current study were: (1) to investigate the perceptions of the expert physicians and clinical editors as to the relative importance, for the structuring process, of different aspects of the methodology; (2) to assess, for the clinical editors, the inter-correlations among (i) the reported level of understanding of the guideline structuring ontology's (knowledge scheme's) features, (ii) the reported ease of structuring each feature and (iii) the actual objective quality of structuring.A clinical consensus regarding the contents of three guidelines was prepared by an expert in the domain of each guideline. For each guideline, two clinical editors independently structured the guideline into a semi-formal representation, using the Asbru guideline ontology's features. The quality of the resulting structuring was assessed quantitatively. Each expert physician was asked which aspects were most useful for formation of the consensus. Each clinical editor filled questionnaires relating to: (1) the level of understanding of the ontology's features (before the structuring process); (2) the usefulness of various aspects in the structuring process (after the structuring process); (3) the ease of structuring each ontological feature (after the structuring process). Subjective reports were compared with objective quantitative measures of structuring correctness.Expert physicians considered having medical expertise and understanding the ontological features as the aspects most useful for creation of a consensus. Clinical editors considered understanding the ontological features and the use of the structuring tools as the aspects most useful for structuring guidelines. There was a positive correlation (R = 0.87, P < 0.001) between the reported ease of understanding ontological features and the reported ease of structuring those features. However, there was no significant correlation between the reported level of understanding the features - or the reported ease of structuring by using those features - and the objective quality of the structuring of these features in actual guidelines.Aspects considered important for formation of a clinical consensus differ from those for structuring of guidelines. Understanding the features of a structuring ontology is positively correlated with the reported ease of using these features, but neither of these subjective reports correlated with the actual objective quality of the structuring using these features.

View details for DOI 10.1111/j.1365-2753.2009.01241.x

View details for Web of Science ID 000273067800026

View details for PubMedID 20367704

Abstract

Less than one third of the 65 million Americans with hypertension have adequate blood pressure (BP) control. This study examined the effectiveness of 2 interventions for improving patient BP control.This was a 2-level (primary care provider and patient) cluster randomized trial with 2-year follow-up occurring among patients with hypertension enrolled from a Veterans Affairs Medical Center primary care clinic. Primary care providers (n = 17) in the intervention received computer-generated decision support designed to improve guideline concordant medical therapy at each visit; control providers (n = 15) received a reminder at each visit. Patients received usual care or a bimonthly tailored nurse-delivered behavioral telephone intervention to improve hypertension treatment. The primary outcome was proportion of patients who achieved a BP <140/90 mm Hg (<130/85 for diabetic patients) over the 24-month intervention.Of the 816 eligible patients contacted, 190 refused and 38 were excluded. The 588 enrolled patients had a mean age of 63 years, 43% had adequate baseline BP control, and 482 (82%) completed the 24-month follow-up. There were no significant differences in amount of change in BP control in the 3 intervention groups as compared to the hypertension reminder control group. In secondary analyses, rates of BP control for all patients receiving the patient behavioral intervention (n = 294) improved from 40.1% to 54.4% at 24 months (P = .03); patients in the nonbehavioral intervention group improved from 38.2% to 43.9% (P = .38), but there was no between-group differences at the end of the study.The brief behavioral intervention showed improved outcomes over time, but there were not significant between group differences.

View details for DOI 10.1016/j.ahj.2008.11.003

View details for Web of Science ID 000264214700008

View details for PubMedID 19249414

View details for Web of Science ID 000270024300006

Abstract

We introduce a three-phase, nine-step methodology for specification of clinical guidelines (GLs) by expert physicians, clinical editors, and knowledge engineers and for quantitative evaluation of the specification's quality. We applied this methodology to a particular framework for incremental GL structuring (mark-up) and to GLs in three clinical domains. A gold-standard mark-up was created, including 196 plans and subplans, and 326 instances of ontological knowledge roles (KRs). A completeness measure of the acquired knowledge revealed that 97% of the plans and 91% of the KR instances of the GLs were recreated by the clinical editors. A correctness measure often revealed high variability within clinical editor pairs structuring each GL, but for all GLs and clinical editors the specification quality was significantly higher than random (p<0.01). Procedural KRs were more difficult to mark-up than declarative KRs. We conclude that given an ontology-specific consensus, clinical editors with mark-up training can structure GL knowledge with high completeness, whereas the main demand for correct structuring is training in the ontology's semantics.

View details for DOI 10.1016/j.jbi.2008.04.009

View details for Web of Science ID 000261220500004

View details for PubMedID 18550447

Abstract

Determine the relative impact of chronic hepatitis C (CHC) and co-morbid illnesses on health-related quality of life (HRQoL) in 3023 randomly selected veterans with known hepatitis C virus antibody (anti-HCV) status who previously completed a veteran-specific HRQoL questionnaire (SF-36V).Multiple regression analyses were performed to measure the relative contribution of anti-HCV status, four demographic variables, and ten common medical and six psychiatric co-morbidities to HRQoL between 303 anti-HCV(+) and 2720 anti-HCV(-) patients.Anti-HCV(+) veterans were younger, reported a lower HRQoL on seven of eight 36-Item Short Form Health Survey for Veterans (SF-36V) subscales (P < or = 0.001) and the mental component summary (MCS) scale (P < 0.001). The ten medical and six psychiatric co-morbidities had variable impact on predicting lower HRQoL in both groups. After adjusting for demographic variables and co-morbid illnesses, we found that anti-HCV(+) patients reported a significantly lower MCS score (P < 0.001) and a trend toward a lower physical component summary (PCS) score (P < 0.07) compared to anti-HCV(-) veterans. Among the anti-HCV(+) veterans, co-morbid medical illnesses contributed to impaired PCS but not to MCS.Veterans with CHC were younger than HCV(-) veterans and hence less likely to have other co-morbid medical illnesses. Medical co-morbidities seen in those veterans with CHC contribute to impaired PCS but not MCS. Anti-HCV(+) status negatively affects HRQoL, particularly MCS, independently of medical and psychiatric co-morbidities.

View details for DOI 10.1007/s11136-008-9344-3

View details for Web of Science ID 000256522600007

View details for PubMedID 18427949

Abstract

Evaluate KNAVE-II, a knowledge-based framework for visualization, interpretation, and exploration of longitudinal clinical data, clinical concepts and patterns. KNAVE-II mediates queries to a distributed temporal-abstraction architecture (IDAN), which uses a knowledge-based problem-solving method specializing in on-the-fly computation of clinical queries.A two-phase, balanced cross-over study to compare efficiency and satisfaction of a group of clinicians when answering queries of variable complexity about time-oriented clinical data, typical for oncology protocols, using KNAVE-II, versus standard methods: both paper charts and a popular electronic spreadsheet (ESS) in Phase I; an ESS in Phase II. The measurements included the time required to answer and the correctness of answer for each query and each complexity category, and for all queries, assessed versus a predetermined gold standard set by a domain expert. User satisfaction was assessed by the Standard Usability Score (SUS) tool-specific questionnaire and by a "Usability of Tool Comparison" comparative questionnaire developed for this study.In both evaluations, subjects answered higher-complexity queries significantly faster using KNAVE-II than when using paper charts or an ESS up to a mean of 255 s difference per query versus the ESS for hard queries (p=0.0003) in the second evaluation. Average correctness scores when using KNAVE-II versus paper charts, in the first phase, and the ESS, in the second phase, were significantly higher over all queries. In the second evaluation, 91.6% (110/120) of all of the questions asked within queries of all levels produced correct answers using KNAVE-II, opposed to only 57.5% (69/120) using the ESS (p<0.0001). User satisfaction with KNAVE-II was significantly superior compared to using either a paper chart or the ESS (p=0.006). Clinicians ranked KNAVE-II superior to both paper and the ESS.An evaluation of the functionality and usability of KNAVE-II and its supporting knowledge-based temporal-mediation architecture has produced highly encouraging results regarding saving of physician time, enhancement of accuracy of clinical assessment, and user satisfaction.

View details for DOI 10.1016/j.artmed.2008.03.006

View details for Web of Science ID 000256327300002

View details for PubMedID 18442899

Abstract

In populations with chronic illness, outcomes improve with the use of care models that integrate clinical information, evidence-based treatments, and proactive management of care. Health information technology is believed to be critical for efficient implementation of these chronic care models. Health care organizations have implemented information technologies, such as electronic medical records, to varying degrees. However, considerable uncertainty remains regarding the relative impact of specific informatics technologies on chronic illness care.To summarize knowledge and increase expert consensus regarding informatics components that support improvement in chronic illness care.A systematic review of the literature was performed. "Use case" models were then developed, based on the literature review, and guidance from clinicians and national quality improvement projects. A national expert panel process was conducted to increase consensus regarding information system components that can be used to improve chronic illness care.The expert panel agreed that informatics should be patient-centered, focused on improving outcomes, and provide support for illness self-management. They concurred that outcomes should be routinely assessed, provided to clinicians during the clinical encounter, and used for population-based care management. It was recommended that interactive, sequential, disorder-specific treatment pathways be implemented to quickly provide clinicians with patient clinical status, treatment history, and decision support.Specific informatics strategies have the potential to improve care for chronic illness. Software to implement these strategies should be developed, and rigorously evaluated within the context of organizational efforts to improve care.

View details for DOI 10.1007/s116O6-007-0303-4

View details for Web of Science ID 000251543500010

View details for PubMedID 18026812

Abstract

Clinical guidelines are a major tool in improving the quality of medical care. However, to support the automation of guideline-based care, several requirements must be filled, such as specification of the guidelines in a machine-interpretable format and a connection to an Electronic Patient Record (EPR). For several different reasons, it is beneficial to convert free-text guidelines gradually, through several intermediate representations, to a machine-interpretable format. It is also realistic to consider the case when an EPR is unavailable. We propose an innovative approach to the runtime application of intermediate-represented Hybrid-Asbru guidelines, with or without an available EPR. The new approach capitalizes on our extensive work on developing the Digital electronic Guideline Library (DeGeL) framework. The new approach was implemented as the Spock system. For evaluation, three guidelines were specified in an intermediate format and were applied to a set of simulated patient records designed to cover prototypical cases. In all cases, the Spock system produced the expected output, and did not produce an unexpected one. Thus, we have demonstrated the capability of the Spock system to apply guidelines encoded in the Hybrid-Asbru intermediate representation, when an EPR is not available.

View details for DOI 10.1016/j.jbi.2006.12.004

View details for Web of Science ID 000249876200006

View details for PubMedID 17276145

Abstract

Although beta-blockers are known to prolong survival for patients with reduced left ventricular ejection fraction, they are often underused. We hypothesized that a reminder attached to the echocardiography report would increase the use of beta-blockers for patients with reduced left ventricular ejection fraction.We randomized 1546 consecutive patients with a left ventricular ejection fraction <45% found on echocardiography at 1 of 3 laboratories to a reminder for use of beta-blockers or no reminder. Patients were excluded from analysis if they died within 30 days of randomization (n=89), did not receive medications through the Veterans Affairs system after 30 days (n=180), or underwent echocardiography at >1 laboratory (n=6). The primary outcome was a prescription for an oral beta-blocker between 1 and 9 months after randomization. The mean age of the 1271 included patients was 69 years; 60% had a history of heart failure, and 51% were receiving treatment with beta-blockers at the time of echocardiography. More patients randomized to the reminder had a subsequent beta-blocker prescription (74%, 458 of 621) compared with those randomized to no reminder (66%, 428 of 650; P=0.002). The effect of the reminder was not significantly different for subgroups based on patient location (inpatient versus outpatient) or prior use of beta-blockers.A reminder attached to the echocardiography report increased the use of beta-blockers in patients with depressed left ventricular systolic function.

View details for DOI 10.1161/CIRCULATIONAHA.106.684753

View details for Web of Science ID 000246972600008

View details for PubMedID 17515459

Abstract

Only 31% of Americans with hypertension have their blood pressure (BP) under effective control. We describe a study that tests 3 different interventions in a randomized controlled trial using home BP telemedicine monitoring.A sample of hypertensive patients with poor BP control at baseline (N = 600) are randomized to 1 of 4 arms: (1) control group--a group of hypertensive patients who receive usual care; (2) nurse-administered tailored behavioral intervention; (3) nurse-administered medication management according to a hypertension decision support system; (4) combination of the 2 interventions. The interventions are triggered based on home BP values transmitted via telemonitoring devices over standard telephone lines. The tailored behavioral intervention involves promoting adherence with medication and health behaviors. Patients randomized to the medication management or the combined arm have their hypertension regimen changed by the study team using a validated hypertension decision support system based on evidence-based hypertension treatment guidelines and individualized to patients' comorbid illnesses. The primary outcome is BP control: < or = 140/90 mm Hg (nondiabetic) and < or = 130/80 mm Hg (diabetics) measured at 6-month intervals over 18 months (4 total measurements).Given the increasing prevalence of hypertension and our inability to achieve adequate BP control using traditional models of care, testing novel interventions in patients' homes may improve access, quality, and outcomes.

View details for DOI 10.1016/j.ahj.2007.03.004

View details for Web of Science ID 000247540600005

View details for PubMedID 17540191

Abstract

Health-related quality of life is decreased in patients with GERD and Barrett's esophagus (BE).To determine whether time-tradeoff (TTO) values would differ in patients with BE when patients were asked to trade away the potential risk of esophageal adenocarcinoma rather than chronic heartburn symptoms.A prospective clinical trial.Subjects with biopsy-proven BE.Custom-designed computer program to elicit health-state utility values, quality of life in reflux and dyspepsia (QOLRAD), and Medical Outcomes Survey short form-36 surveys.TTO utility values for the annual cancer-risk-associated current health state and for hypothetical scenarios of dysplasia and esophageal cancer.We studied 60 patients in the cancer-risk cohort (57 men, 92% veteran; mean age [standard deviation; SD], 65 years [11 years], mean GERD duration 17 years [12 years]). The heartburn cohort included 40 patients with GERD and BE with TTO values derived for GERD symptoms. The mean (SD) utility for nondysplastic BE was 0.91 (0.13) compared with 0.90 (0.12) for the heartburn cohort (P = .7). The mean utility values were significantly lower for scenarios of low-grade dysplasia (0.85 [0.12], P = .02) and high-grade dysplasia (0.77 [0.14], P < .005). The mean TTO was 0.67 (0.19) for the scenario of esophageal cancer. There was no correlation between the utility scores and the disease-specific survey scores.TTO values were hypothetical for states of dysplasia and cancer.TTO utility values based on heartburn symptoms or annual risk of cancer in patients with nondysplastic BE are roughly equivalent. However, TTO utility values are significantly lower for health states with increasing cancer risks.

View details for DOI 10.1016/j.gie.2006.05.018

View details for Web of Science ID 000243361000005

View details for PubMedID 17185075

Abstract

To determine the relative impact of chronic hepatitis C (CHC) and comorbid psychiatric illness on the health-related quality of life (HRQoL).Psychiatric conditions are more common among patients with CHC but their relative influence on HRQoL is not well understood.We identified 864 veterans who had previously completed a veteran-specific HRQoL questionnaire (SF-36V) as part of the 1999 VA Large Health Survey with known HCV antibody (anti-HCV) status before the survey. For 201 anti-HCV(+) and 663 anti-HCV(-) patients, we compared the HRQoL status and the prevalence of 6 major psychiatric diagnoses. We conducted multiple regression analyses to measure the effect of anti-HCV status and psychiatric comorbidity.Compared with the anti-HCV(-) group, anti-HCV(+) veterans were more likely to have alcohol dependence (P<0.001), depression (P=0.01), or posttraumatic stress disorder (PTSD) (P<0.004). The anti-HCV(+) group also reported lower HRQoL on 4 of the 8 SF-36V subscales (P<0.01) and the mental component summary scale (P<0.001). Even after adjusting for demographic variables and comorbid psychiatric illness, anti-HCV(+) patients reported a significantly lower mental component summary score (P<0.01) than did anti-HCV(-) patients. Multiple regression analysis found that depression and PTSD predicted lower HRQoL scores for all 8 HRQoL subscales (P<0.01) and both the physical (P<0.001) and mental component (P<0.03) summary scales independent of anti-HCV status.The HRQoL is significantly impaired in veterans with CHC, particularly the mental health components of HRQoL. In contrast, comorbid depression and PTSD are associated with both lower physical and mental components of HRQol, independent of CHC.

View details for Web of Science ID 000239136700012

View details for PubMedID 16825936

Abstract

Poor blood pressure control remains a common problem that contributes to significant cardiovascular morbidity and mortality, particularly among African Americans. We explored antihypertensive medication adherence and other factors that may explain racial differences in blood pressure control.Baseline data were obtained from the Veteran's Study to Improve The Control of Hypertension, a randomized controlled trial designed to improve blood pressure control. Clinical, demographic, and psychosocial factors relating to blood pressure control were examined.A total of 569 patients who were African American (41%) or white (59%) were enrolled in the study. African Americans were more likely to have inadequate baseline blood pressure control than whites (63% vs 50%; odds ratio = 1.70; 95% confidence interval [CI] 1.20-2.41). Among 20 factors related to blood pressure control, African Americans also had a higher odds ratio of being nonadherent to their medication, being more functionally illiterate, and having a family member with hypertension compared with whites. Compared with whites, African Americans also were more likely to perceive high blood pressure as serious and to experience the side effect of increased urination compared with whites. Adjusting for these differences reduced the odds ratio of African Americans having adequate blood pressure control to 1.59 (95% confidence interval 1.09-2.29).In this sample of hypertensive patients who have good access to health care and medication benefits, African Americans continued to have lower levels of blood pressure control despite considering more than 20 factors related to blood pressure control. Interventions designed to improve medication adherence need to take race into account. Patients' self-reports of failure to take medications provide an opportunity for clinicians to explore reasons for medication nonadherence, thereby improving adherence and potentially blood pressure control.

View details for PubMedID 16431192

Abstract

Developing computer-interpretable clinical practice guidelines (CPGs) to provide decision support for guideline-based care is an extremely labor-intensive task. In the EON/ATHENA and SAGE projects, we formulated substantial portions of CPGs as computable statements that express declarative relationships between patient conditions and possible interventions. We developed query and expression languages that allow a decision-support system (DSS) to evaluate these statements in specific patient situations. A DSS can use these guideline statements in multiple ways, including: (1) as inputs for determining preferred alternatives in decision-making, and (2) as a way to provide targeted commentaries in the clinical information system. The use of these declarative statements significantly reduces the modeling expertise and effort required to create and maintain computer-interpretable knowledge bases for decision-support purpose. We discuss possible implications for sharing of such knowledge bases.

View details for PubMedID 17238448

Abstract

The Geriatric Evaluation and Management study was developed to assess the impact of a comprehensive geriatric assessment service on the care of the elderly.We sought to evaluate the cost and clinical impact of inpatient units and outpatient clinics for geriatric evaluation and management.We undertook a prospective, randomized, controlled trial using a 2x2 factorial design, with 1-year follow-up.A total of 1388 participants hospitalized on either a medical or surgical ward at 11 participating Veterans Affairs medical centers were randomized to receive either inpatient geriatric unit (GEMU) or usual inpatient care (UCIP), followed by either outpatient care from a geriatric clinic (GEMC) versus usual outpatient care (UCOP).We measured health care utilization and costs.Patients assigned to the GEMU had a significantly decreased rate of nursing home placement (odds ratio=0.65; P=0.001). Neither the GEMU nor GEMC had any statistically significant improvement effects on survival and only modest effects on health status. There were statistically insignificant mean cost savings of $1027 (P=0.29) per patient for the GEMU and $1665 (P=0.69) per patient for the GEMC.Inpatient or outpatient geriatric evaluation and management units didn't increase the costs of care. Although there was no effect on survival and only modest effects on SF-36 scores at 1-year follow-up, there was a statistically significant reduction in nursing home admissions for patients treated in the GEMU.

View details for Web of Science ID 000234342600013

View details for PubMedID 16365618

View details for DOI 10.1016/j.amjmed.2004.12.028

View details for Web of Science ID 000231807300018

View details for PubMedID 16164891

Abstract

Among the 60 million Americans with hypertension, only approximately 31% have their blood pressure (BP) under control (<140/90 mm Hg). Despite the damaging impact of hypertension and the availability of evidence-based target values for BP, interventions to improve BP control have had limited success.A randomized controlled health services intervention trial with a split-plot design is being conducted to improve BP control. This 4-year trial evaluates both a patient and a provider intervention in a primary care setting among diagnosed hypertensive veterans.In a cluster-randomization, 30 primary care providers in the Durham VAMC Primary Care Clinic were randomly assigned to receive the provider intervention or control. The provider intervention is a patient-specific electronically generated hypertension decision support system (DSS) delivering guideline-based recommendations to the provider at each patient's visit, designed to improve guideline-concordant therapy. For these providers, a sample of their hypertensive patients (n=588) was randomly assigned to receive a telephone-administered patient intervention or usual care. The patient intervention incorporates patients' need assessments and involves tailored behavioral and education modules to promote medication adherence and improve specific health behaviors. All modules are delivered over the telephone bi-monthly for 24 months. In this trial, the primary outcome is the proportion of patients who achieve a BP < or =140/90 mm Hg at each outpatient clinic visit over 24 months.Despite the known risk of poor BP control, a majority of adults still do not have their BP controlled. This study is an important step in testing the effectiveness of a patient and provider intervention to improve BP control among veterans in the primary care setting.

View details for DOI 10.1016/j.cct.2004.12.006

View details for Web of Science ID 000229144700005

View details for PubMedID 15837438

Abstract

Gastroesophageal reflux disease is a chronic disease that adversely affects health-related quality of life. The purpose of this study was to derive health state utilities for patients with chronic heartburn symptoms.We used a custom-designed computer program in order to elicit utilities with the time-tradeoff and standard-gamble techniques. Patients with chronic (more than 6 months) symptoms of gastroesophageal reflux disease entered the study. Two interviews were performed in random sequence either initially on medications for heartburn that adequately controlled symptoms, or off of medications for 1 wk while the patient was symptomatic. We also collected data using visual-analog scales, quality of life in reflux and dyspepsia (QOLRAD), and Gastrointestinal Symptom Rating Scale (GSRS) scores.We invited 222 patients to participate; 158 (71%) patients (129 men, 29 women) completed the study. Barrett's esophagus was present in 40 (25%), erosive disease in 17 (11%), and 118 (74%) had comorbid conditions. The mean (+/-SD) utility ratings were 0.94 +/- 0.09 on medical therapy and 0.90 +/- 0.12 off medications for patients with reflux alone using time tradeoff (p= 0.004), and 0.94 +/- 8.0 both on and off of antireflux medications with standard-gamble assessment (p= 0.96). Mean time-tradeoff scores were also significantly lower off of medications for patients with other comorbid conditions (p= 0.002). There was no significant difference between mean utility scores for patients with or without Barrett's esophagus or erosive disease.Gastroesophageal reflux disease adversely affects health-related quality of life. Time-tradeoff utility for patients with reflux disease is substantially higher when patients are on medication than off medications.

View details for DOI 10.1111/j.1572-0241.40588.x

View details for Web of Science ID 000227697900005

View details for PubMedID 15743346

Abstract

Studies of barriers to guideline adherence have generally surveyed clinicians temporally remote from the clinical scenario in which recommendations were delivered, potentially adversely biasing clinician observations. The user interface of ATHENA DSS, a guideline-based decision support system for hypertension, includes a point-of-care feedback window that accepts clinician-user comments during the display of recommendations. Analysis of this feedback has revealed a number of intriguing patient, provider, and technical barriers to adherence collected during real-time system use.

View details for PubMedID 16779202

Abstract

Behavioral health interventions are often gauged with a dichotomous outcome, "success" or "failure." Hidden by this dichotomy is a series of behavior changes that can be followed with the Transtheoretical Model (stages of change). There has been little consideration, however, about whether this information can and should be used in cost-effectiveness analysis. We review the stages of change model and its applications to behavioral health interventions. We then discuss analytical methods for including stages of change, or similar behavior change models, in cost-effectiveness analysis (CEA). This is typically not done but it may be critical for study design and for interpreting CEA results.

View details for DOI 10.1016/j.ypmed.2004.04.052

View details for Web of Science ID 000225496200021

View details for PubMedID 15539057

Abstract

Patients with pulmonary arterial hypertension (PAH) often present with dyspnea and severe functional limitations, but their health-related quality of life (HRQOL) has not been studied extensively. This study describes HRQOL in a cohort of patients with PAH.Cross-sectional study.A tertiary care, university hospital-based, pulmonary hypertension (PH) clinic.We studied HRQOL in 53 patients with PAH (mean age, 47 years; median duration of disease, 559 days). Eighty-three percent were women, 53% received epoprostenol, and 72% reported moderate-to-severe functional limitations with a New York Heart Association class 3 or 4 at enrollment.We examined HRQOL by administering the Nottingham Health Profile, Congestive Heart Failure Questionnaire, and Hospital Anxiety and Depression Scale. We used the Visual Analog Scale and standard gamble (SG) techniques to measure preferences for current health (utilities). Compared with population norms, participants reported moderate-to-severe impairment in multiple domains of HRQOL, including physical mobility, emotional reaction, pain, energy, sleep, and social isolation. Mean SG utilities were 0.71, suggesting that, on average, participants were willing to accept a 29% risk of death in order to be cured of PH.PAH is a devastating condition that affects predominately young women in the prime of their life. Understanding HRQOL and preferences are important in the care and management of these patients. Compared with population norms, patients with PAH have substantial functional and emotional limitations that adversely affect their HRQOL.

View details for Web of Science ID 000225214700016

View details for PubMedID 15539712

Abstract

Utilities are measures of quality of life that reflect the strength of individuals' preferences or values for a particular health outcome. As such, utilities represent a measure of disease burden. The aim of this article is to introduce the concept of utilities to the dermatology community and to present a catalog of dermatology utilities obtained from direct patient interviews. Our data are based on 236 total subjects from Grady Hospital (Atlanta, GA), Stanford Medical Center (Palo Alto, CA), and Parkland Hospital (Dallas, TX). The mean time trade-off utilities ranged from 0.640 for blistering disorders to 1.000 for alopecia, cosmetic, and urticaria. The mean utility across all diagnoses was 0.943. We present utilities for 17 diagnostic categories and discuss the underlying reasons for the significant disease burden that these utilities represent. We also present these dermatology categories relative to noncutaneous diseases to place the cutaneous utilities in perspective and to compare the burden of disease. We have demonstrated that skin diseases have considerable burden of disease and provided a preliminary repository of utility data for future researchers and policy makers.

View details for Web of Science ID 000220652200014

View details for PubMedID 15083784

Abstract

The success of clinical decision-support systems requires that they are seamlessly integrated into clinical workflow. In the SAGE project, which aims to create the technological infra-structure for implementing computable clinical practice guide-lines in enterprise settings, we created a deployment-driven methodology for developing guideline knowledge bases. It involves (1) identification of usage scenarios of guideline-based care in clinical workflow, (2) distillation and disambiguation of guideline knowledge relevant to these usage scenarios, (3) formalization of data elements and vocabulary used in the guideline, and (4) encoding of usage scenarios and guideline knowledge using an executable guideline model. This methodology makes explicit the points in the care process where guideline-based decision aids are appropriate and the roles of clinicians for whom the guideline-based assistance is intended. We have evaluated the methodology by simulating the deployment of an immunization guideline in a real clinical information system and by reconstructing the workflow context of a deployed decision-support system for guideline-based care. We discuss the implication of deployment-driven guideline encoding for sharability of executable guidelines.

View details for Web of Science ID 000226723300036

View details for PubMedID 15360798

Abstract

We develop a method and algorithm for deciding the optimal approach to creating quality-auditing protocols for guideline-based clinical performance measures. An important element of the audit protocol design problem is deciding which guide-line elements to audit. Specifically, the problem is how and when to aggregate individual patient case-specific guideline elements into population-based quality measures. The key statistical issue involved is the trade-off between increased reliability with more general population-based quality measures versus increased validity from individually case-adjusted but more restricted measures done at a greater audit cost. Our intelligent algorithm for auditing protocol design is based on hierarchically modeling incrementally case-adjusted quality constraints. We select quality constraints to measure using an optimization criterion based on statistical generalizability coefficients. We present results of the approach from a deployed decision support system for a hypertension guideline.

View details for Web of Science ID 000226723300202

View details for PubMedID 15360963

Abstract

Measurement of provider adherence to a guideline-based decision support system (DSS) presents a number of important challenges. Establishing a causal relationship between the DSS and change in concordance requires consideration of both the primary intention of the guideline and different ways providers attempt to satisfy the guideline. During our work with a guideline-based decision support system for hypertension, ATHENA DSS, we document a number of subtle deviations from the strict hypertension guideline recommendations that ultimately demonstrate provider adherence. We believe that understanding these complexities is crucial to any valid evaluation of provider adherence. We also describe the development of an advisory evaluation engine that automates the interpretation of clinician adherence with the DSS on multiple levels, facilitating the high volume of complex data analysis that is created in a clinical trial of a guideline-based DSS.

View details for Web of Science ID 000226723300026

View details for PubMedID 15360788

Abstract

Several studies indicate that treatment of hypertension in the United States does not follow recommendations from expert bodies. We thus implemented a program using academic detailers to increase practitioner compliance with antihypertensive treatment guidelines. Five Veterans Affairs medical facilities including academic medical centers and community based outpatient clinics were chosen for the intervention. Pharmacists were trained as academic detailers, and the intervention included lectures, educational materials, provider profiling, and meetings with 25 to 50 providers each. After intervention, the proportion of hypertensives receiving calcium antagonists decreased from 43% to 38% (P <.001), whereas the proportion receiving a beta blocker or thiazide diuretic increased from 58% to 64% (P <.001). For hypertensive subjects with diabetes mellitus or congestive heart failure, the proportion receiving an angiotensin converting enzyme inhibitor or angiotensin receptor blocker increased from 72% to 76% for the former and from 74% to 78% for the latter (P <.001 for both). Among hypertensive subjects with coronary artery disease an increase in beta blocker use was noted after intervention (P <.001 for change from baseline). Prescribing patterns after academic detailing more closely followed national recommendations.

View details for DOI 10.1016/S0895-7061(03)00060-8

View details for Web of Science ID 000183356400015

View details for PubMedID 12799103

Abstract

The Digital Electronic Guideline Library (DeGeL) is a Web-based framework and a set of distributed tools that facilitate gradual conversion of clinical guidelines from free text, through semi-structured text, to a fully structured, executable representation. Thus, guidelines exist in a hybrid, multiple-format representation The three formats support increasingly sophisticated computational tasks. The tools perform semantic markup, classification, search, and browsing, and support computational modules that we are developing, for run-time application and retrospective quality assessment. We describe the DeGeL architecture and its collaborative-authoring authorization model, which is based on (1) multiple medical-specialty authoring groups, each including a group manager who controls group authorizations, and (2) a hierarchical authorization model based on the different functions involved in the hybrid guideline-specification process. We have implemented the core modules of the DeGeL architecture and demonstrated distributed markup and retrieval using the knowledge roles of two guidelines ontologies (Asbru and GEM). We are currently evaluating several of the DeGeL tools.

View details for PubMedID 14728241

Abstract

In this theater-style demonstration, the speakers will demonstrate KNAVE-II, a Web-based distributed system for interactive visualization and exploration of large amounts of time-oriented clinical data from multiple sources, and of clinically meaningful concepts (abstractions) derivable from these data. The KNAVE-II system and its complete underlying architecture provide a solution to the data overload problem.

View details for PubMedID 14728576

Abstract

KNAVE-II is a system for visualization and exploration of large amounts of time-oriented clinical data and of multiple levels of clinically meaningful abstractions derivable from these data. KNAVE-II uses a distributed temporal-abstraction architecture that integrates a set of knowledge services, each interacting with a domain-specific knowledge source, a set of data-access services, each interacting with a clinical data source, and a computational service for deriving knowledge-based abstractions of the data.

View details for PubMedID 14728507

Abstract

Automated quality assessment of clinician actions and patient outcomes is a central problem in guideline- or standards-based medical care. In this paper we describe a model representation and algorithm for deriving structured quality indicators and auditing protocols from formalized specifications of guidelines used in decision support systems. We apply the model and algorithm to the assessment of physician concordance with a guideline knowledge model for hypertension used in a decision-support system. The properties of our solution include the ability to derive automatically context-specific and case-mix-adjusted quality indicators that can model global or local levels of detail about the guideline parameterized by defining the reliability of each indicator or element of the guideline.

View details for PubMedID 14728124

Abstract

Automated quality assessment of clinician actions and patient outcomes is a central problem in guideline- or standards-based medical care. In this paper we describe a unified model representation and algorithm for evidence-adaptive quality assessment scoring that can: (1) use both complex case-specific guidelines and single-step population-wide performance-indicators as quality measures; (2) score adherence consistently with quantitative population-based medical utilities of the quality measures where available; and (3) give worst-case and best-case scores for variations based on (a) uncertain knowledge of the best practice, (b) guideline customization to an individual patient or particular population, (c) physician practice style variation, or (d) imperfect reliability of the quality measure. Our solution uses fuzzy measure-theoretic scoring to handle the uncertain knowledge about best-practices and the ambiguity from practice variation. We show results of applying our method to retrospective data from a guideline project to improve the quality of hypertension care.

View details for Web of Science ID 000189418100001

View details for PubMedID 12463775

Abstract

Patient-centered decision making, which in the United States is typically considered to be appropriate, may not be universally endorsed, thereby harboring the potential to complicate the care of patients from other cultural backgrounds in potentially unrecognized ways. This study compares the attitudes toward ethical decision making and autonomy issues among academic and community physicians and patients of medical center outpatient clinics in Japan and the United States.A questionnaire requesting judgments about seven clinical vignettes was distributed (in English or Japanese) to sample groups of Japanese physicians (n = 400) and patients (n = 65) as well as US physicians (n = 120) and patients (n = 60) that were selected randomly from academic institutions and community settings in Japan (Tokyo and the surrounding area) and the United States (the Stanford/Palo Alto, CA, area). Responses were obtained from 273 Japanese physicians (68%), 58 Japanese patients (89%), 98 US physicians (82%), and 55 US patients (92%). Physician and patient sample groups were compared on individual items, and composite scores were derived from subsets of items relevant to patient autonomy, family authority, and physician authority.A majority of both US physicians and patients, but only a minority of Japanese physicians and patients, agreed that a patient should be informed of an incurable cancer diagnosis before their family is informed and that a terminally ill patient wishing to die immediately should not be ventilated, even if both the doctor and the patient's family want the patient ventilated (Japanese physicians and patients vs US physicians and patients, p < 0.001). A majority of respondents in both Japanese sample groups, but only a minority in both US sample groups, agreed that a patient's family should be informed of an incurable cancer diagnosis before the patient is informed and that the family of an HIV-positive patient should be informed of this disease status despite the patient's opposition to such disclosure (Japanese physicians and patients vs US physicians and patients, p < 0.001). Physicians in both Japan and the United States were less likely than patients in their respective countries to agree with physician assistance in the suicide of a terminally ill patient (Japanese physicians and patients vs US physicians and patients, p < 0.05). Across various clinical scenarios, all four respondent groups accorded greatest authority to the patient, less to the family, and still less to the physician when the views of these persons conflicted. Japanese physicians and patients, however, relied more on family and physician authority and placed less emphasis on patient autonomy than the US physicians and patients sampled. Younger respondents placed less emphasis on family and physician authority.Family and physician opinions are accorded a larger role in clinical decision making by the Japanese physicians and patients sampled than by those in the United States, although both cultures place a greater emphasis on patient preferences than on the preferences of the family or physician. Our results are consistent with the view that cultural context shapes the relationship of the patient, the physician, and the patient's family in medical decision making. The results emphasize the need for clinicians to be aware of these issues that may affect patient and family responses in different clinical situations, potentially affecting patient satisfaction and compliance with therapy.

View details for Web of Science ID 000090008300046

View details for PubMedID 11035693

View details for Web of Science ID 000084667100016

View details for PubMedID 10638545

View details for Web of Science ID 000083972700036

View details for PubMedID 10570405

Abstract

Although Parkinson's disease is relatively common in America, with an average annual incidence of 20 cases per 100,000 population, little information exists about postoperative morbidity and mortality in those Parkinson's patients who undergo elective surgery.We performed a retrospective cohort study using the Veterans Affairs (VA) Austin database system (a cumulative index of admissions and discharges from all US VA Medical Centers) to identify 41,213 patients who underwent elective bowel resection, cholecystectomy, or radical prostatectomy between January 1, 1990, and December 31, 1995. We examined the study population using univariate analysis, acute length of stay with multivariate analysis, and postoperative complications with logistic regression.The selected surgeries were performed on 234 patients with a diagnosis of Parkinson's disease and 40,979 with no such diagnosis. In univariate analysis, patients with Parkinson's disease had significantly longer acute hospital stays than non-Parkinson's patients (11.4 +/- 15.9 days vs 8.8 +/- 9.0 days, P < .001). In addition, Parkinson's patients had a higher in-hospital mortality than non-Parkinson's patients (7.3% vs 3.8%, P = .006). After we adjusted for coexisting morbidity, age, admitting location, and gender, patients with Parkinson's disease had an average acute hospital stay 2.34 days longer than that of non-Parkinson's patients (P < .001). However, the mortality difference did not reach statistical significance in multivariate analysis (P = .098). Finally, Parkinson's patients had significantly increased incidences of urinary-tract infection (odds ratio 2.045, P < .001), aspiration pneumonia (odds ratio 3.825, P < .001), and bacterial infections (odds ratio 1.682, P < .001).Patients with Parkinson's disease are at greater risk for specific complications and longer hospital stay after elective bowel resection, cholecystectomy, or radical prostatectomy. Awareness of these complications may help caregivers to reduce postoperative mortality and morbidity and to decrease the length of hospitalization.

View details for Web of Science ID 000081880800008

View details for PubMedID 10443858

Abstract

To determine whether physicians' preferences for end-of-life decision-making differ between blacks and whites in the same pattern as patient preferences, with blacks being more likely than whites to prefer life-prolonging treatments.A mailed survey.American Medical Association (AMA) and National Medical Association (NMA) databases. To enrich the sample of black physicians, we targeted physicians in the AMA database practicing in high minority area zip codes and graduates of the traditionally black medical schools.Self-reported physician attitudes toward end-of-life decision-making and preference of treatment for themselves in persistent vegetative state or organic brain disease compared by race, controlling for age and gender.The 502 physicians (28%) who returned the questionnaire included 280 white and 157 black physicians. With regard to attitudes toward patient care, 58% of white physicians agreed that tube-feeding in terminally ill patients is "heroic," but only 28 % of black physicians agreed with the statement (P < .001). White physicians were more likely than black physicians to find physician-assisted suicide an acceptable treatment alternative (36.6% vs 26.5% of black physicians) (P < .05). With regard to the physicians preferences for future treatment of themselves for the persistent vegetative state scenario, black physicians were more than six times more likely than white physicians to request aggressive treatments (cardiopulmonary resuscitation, mechanical ventilation, or artificial feeding) for themselves (15.4% vs 2.5%) (P < .001). White physicians were almost three times as likely to want physician-assisted suicide (29.3% vs 11.8%) (P < .001) in this scenario. For a state of brain damage with no terminal illness, the majority of all physicians did not want aggressive treatment, but black physicians were nearly five times more likely than white physicians (23.0% vs 5.0%) (P < .001) to request these treatments. White physicians, on the other hand, were more than twice as likely to request physician-assisted suicide (22.5% vs 9.9%), P < .001 in this scenario.Physicians preferences for end-of-life treatment follow the same pattern by race as patient preferences, making it unlikely that low socioeconomic status or lack of familiarity with treatments account for the difference. Self-denoted race may be a surrogate marker for other, as yet undefined, factors. The full spectrum of treatment preferences should be considered in development of guidelines for end-of-life treatment in our diverse society.

View details for Web of Science ID 000080201100013

View details for PubMedID 10323652

View details for Web of Science ID 000087030100005

View details for PubMedID 17144035

Abstract

Elicited preferences for health states vary among scaling methods, manners of describing health states, and other features of the elicitation process. The authors examined the effects of changing the search procedure for a subject's utility on mean utility values.A randomized controlled trial of two search procedures (titration and "ping-pong") using two otherwise identical computer programs that describe health states related to Gaucher's disease, then measuring subjects' preferences.Paid, healthy volunteers recruited from the community through advertisements.The mean time tradeoff (TTO) and standard gamble (SG) utility values for life with severe anemia and splenomegaly and life with chronic bone pain from Gaucher's disease were between 0.10 and 0.15 higher with the titration search procedure than with the ping-pong procedure. Effects of the search procedure were additive with variability due to scaling methods, resulting in mean differences in utility ratings for the same health state of as much as 0.28 among procedures and scaling methods. Effects of search procedures on utility values persisted on repeated testing at week 2 and week 3; there was no evidence of convergence to a single "true" utility value over time.The procedure used to search for subjects' utility values strongly influences the results of preference-assessment experiments. Effects of search procedures persist on repeated testing. The results suggest that utility values are heavily influenced by, if not created during, the process of elicitation. Thus, utility values elicited using different search procedures may not be directly comparable.

View details for Web of Science ID 000071405300015

View details for PubMedID 9456212

Abstract

The authors evaluate a measure of the validity of utility elicitations and study the potential effects of invalid elicitations on population utility values.The authors used a computerized survey to describe and measure preferences for three common side-effects of anti-psychotic drugs (tardive dyskinesia [TD], akathesia [AKA], pseudo-parkinsonism). The authors compared the validity of elicitations in 41 healthy volunteers to 22 schizophrenic patients. Preferences were measured using visual analog scale (VAS), pair-wise comparison (PWC), and the Standard Gamble (SG) methods. To assess the validity of each groups' responses, the authors compared the consistency of subjects' rank-order of the desirability of states across methods of preferences assessment (CAMPA).All healthy volunteers and 82% of patients completed the computer survey; of these subjects, 97% of healthy volunteers and 70% of patients indicated they thought they understood the task required of them. However, only 78% of healthy subjects and 44% of patients had a consistent rank ordering of preferences among VAS and PWC ratings; only 80% and 61%, respectively, had a consistent rank ordering preferences among SG and PWC ratings. For two of the three health states, inconsistent subjects had statistically higher SG utilities (for TD, 0.94 versus 0.87, and for AKA 0.92 versus 0.86; P < 0.05).The CAMPA test can identify potentially invalid preference ratings. Potentially invalid preference ratings may bias the "population" utilities for health states.

View details for Web of Science ID A1997XV88500004

View details for PubMedID 9298080

Abstract

Culture is not something apart from us. It is always here, and we, like fish in an ocean, may be blind to the water in which we swim. We recommend that, in addition to learning as much as possible about people from cultures other than our own, we consider carefully the cultural roots of our own thoughts and actions. A combination of respectful behavior and a conscientious effort to understand individuals from another culture will go far in enabling us to work well with dying patients from many backgrounds.

View details for Web of Science ID A1996UL98800013

View details for PubMedID 8799356

View details for PubMedID 7572302

Abstract

Quality-adjustment weights for health states are an essential component of cost-utility analysis (CUA). Quality-adjustment weights are obtained by presenting large numbers of subjects with multiattribute descriptions of health states for rating. Comprehending multiattribute health states is a difficult task for most respondents. The authors hypothesized that multimedia (MM) presentation using computers might facilitate this task better than would a paper-based text (Text). To test this hypothesis, they developed closely matched MM and Text descriptions of health states in the first-person narrative style, and developed a method of testing the presentation of a health state. Subjects were randomized to exposure to either MM or Text and subject recall of the health state and recognition of features of the health state were tested. How well defined the preferences of the subjects were after each presentation method was assessed by having the subjects mark on a double-anchored visual-analog scale the "best" and "worst" they believed the quality of life in the health state might be. MM subjects had better recall (11.85 vs 9.44 of a total of 24 meaning units, p = 0.098) and better recognition (4.71 vs 4.22, p = 0.08). The average interval between the "best" and "worst" ratings was shorter for the MM subjects (2.19 cm vs 3.26 cm, p = 0.12).(ABSTRACT TRUNCATED AT 250 WORDS)

View details for Web of Science ID A1994PL43300004

View details for PubMedID 7528868

Abstract

Decisions about initiation and withdrawal of life-sustaining artificial nutrition and hydration are complex and sometimes are agonizing to make. Artificial feeding is considered by most medical ethicists to be a medical intervention about which decisions should be made based on the benefits, risks, and burdens of the treatment. State law varies, particularly with regard to the inclusion of artificial feeding in advance directives and in laws about its discontinuance. Conditions in which it is common for patients or families to consider refusal of artificial feeding include terminal cancer, advanced dementia, and persistent vegetative state. Alternative approaches to nutrition, such as offering favorite foods or treating underlying depression, may obviate the need for tube feeding. Competent patients may refuse any medical treatment, including life-sustaining treatment. An appropriate proxy decision maker may also refuse treatment on behalf of a mentally incapacitated patient.

View details for Web of Science ID A1994ND10400013

View details for PubMedID 8197255

Abstract

Elderly people in the United States often receive treatment through an enormous array of medical technology when they become critically ill. Some, or all, such interventions may be unwanted, and patients have the right to be informed about what prospects lie ahead. CPR, with survival rates of 2% to 20%, rarely has the effect for which it was intended, as studies over the last two decades have repeatedly demonstrated. Although it is not clear that elderly people are at higher risk for poor outcomes of CPR, it is clear most of them do not possess sufficient knowledge about either CPR or its usual outcome to make an informed choice. Ideally, an individual should choose his or her own resuscitation status, but evidence exists indicating surrogates more often than not make this decision. This is unfortunate, because both surrogates and physicians are poor judges of patients' resuscitation preferences. Advance directives, especially when coupled with effective physician-patient communication, will aid elderly persons in making decisions about life support. We encourage all physicians who care for the elderly to avert many of tomorrow's ethical dilemmas by communicating with their healthy patients today.

View details for Web of Science ID A1994PK09100007

View details for PubMedID 8168029

View details for Web of Science ID A1993ML30800002

View details for PubMedID 8252934

Abstract

Functional outcomes of clinical trials are often reported as number of dependencies in activities of daily living (ADLs). Quality-weighting for the ADLs has not been reported. We designed and pilot-tested ADLIB (ADL Index Builder), a multimedia computer program, that presents ADL health states to subjects and elicits from subjects a rating for the quality of life of each health state. Subjects, who were patients over age 50 without previous computer experience, found the program easy to use. Health care professionals specializing in geriatrics confirmed that the ADL presentations used in the program are in accord with typical practice in scoring ADLs. We plan to use the program to obtain population-based preference ratings that can be used to assess efficacy of clinical trials and to provide quality-weights for cost-effectiveness analysis.

View details for PubMedID 8130598

Abstract

Fifty-nine healthy senior center participants were interviewed to determine how, when, and why the durable power of attorney for health care is being used. The 21 users of the durable power of attorney for health care executed a form for the expected reasons; however, a majority had not given a copy of the form to their physician and few had discussed details of their preferences with the proxy. Of the 38 nonusers, the most frequent reasons for not executing a durable power of attorney for health care were: lack of awareness of the form, procrastination, and difficulty choosing a proxy. The new Patient Self-Determination Act requiring hospitals to inform patients of advance directives will help to overcome some of the obstacles in use of the durable power of attorney for health care; however, community education must still be encouraged.

View details for Web of Science ID A1992HE06900010

View details for PubMedID 1739356

Abstract

Health care professionals need to be well informed about advance directives for medical care in the event a patient becomes incapacitated. The Patient Self-Determination Act requires that all patients be advised of their options at the time of hospital admission. Hospitals and health care professionals will need to work together to plan for implementing this law. We surveyed 215 physicians, nurses, and social workers at a Veterans Affairs Medical Center about the California advance directive, the Durable Power of Attorney for Health Care. Attitudes were generally positive. All of the social workers had heard of the durable power of attorney directive, but 36% of physicians and nurses had never heard of it and an additional 20% had no experience with one. For respondents who had heard of the directive, the mean knowledge score was 6.35 of a possible 10 (5 predicted by chance). Respondents brought up the issue of durable power of attorney with patients before a crisis only 19% of the time and determined whether one had been signed for only 16% of older patients in hospital. The most commonly cited reasons for failure to discuss this with patients were lack of proper forms, pamphlets, or a place to refer a patient. Of those who had ever seen such a document in use, 42% were aware of a problem with it at some time. Whereas attitudes toward advance directives are positive, many physicians and nurses had little knowledge of the Durable Power of Attorney for Health Care and were poorly equipped to discuss it with patients. We encourage educating hospital staff to prepare for the enactment of the Patient Self-Determination Act. We also recommend that the concerns raised by professionals about the use of a durable power of attorney be addressed.

View details for Web of Science ID A1991GF77400005

View details for PubMedID 1949773

Abstract

To determine the reliability of rapid screening by clinically derived geriatric criteria in predicting outcomes of elderly hospitalized patients.Prospective cohort study of 985 patients screened at the time of hospital admission and followed for 1 year with respect to the outcomes of mortality, hospital readmission, and nursing home utilization.Palo Alto Veterans Affairs Medical Center, a tertiary care teaching hospital.Male patients 65 years of age and older admitted to the Medical and Surgical services during the period from October 1, 1985 through September 30, 1986.Patients were grouped by specific screening criteria into three groups of increasing frailty: Independent, Frail, and Severely Impaired. Each criterion focused on a geriatric condition and was designed to serve as a marker for frailty. Increasing frailty was significantly correlated with increasing length of hospital stay (P less than 0.0001), nursing home utilization (P less than 0.0001), and mortality (P less than 0.0001). Multivariate analyses revealed that the clinical groups were more predictive of mortality and nursing home utilization than were age or Diagnosis-Related Groups (DRGs). Rehospitalization was unrelated to age, clinical group, or DRG, suggesting that utilization may not be driven by the clinical factors measured in this study.Rapid clinical screening using specific geriatric criteria is effective in identifying frail older subjects at risk for mortality and nursing home utilization. Our findings suggest that geriatric syndromes are more predictive of adverse outcomes than diagnosis per se. This well operationalized screening process is inexpensive as well as effective and could easily be introduced into other hospital settings.

View details for Web of Science ID A1991GA27300006

View details for PubMedID 1906492

View details for Web of Science ID A1991FU96900020

View details for PubMedID 1905736

View details for Web of Science ID A1991FU96900017

View details for PubMedID 2061542

View details for PubMedID 1794011

Abstract

Older women may experience sexual dysfunction due to many different causes. Some problems related to menopausal hormonal change may be easily treated with estrogen supplements. Other problems involve intricate interpersonal relations between the woman and her sexual partner and may require a combination of medical therapy and sexual counseling. Gynecologic cancer and cancer treatments are often accompanied by problems in sexual functioning. These problems may then impair relations and self-image, leading to a vicious circle of deteriorating social function. Some recommendations for the clinician follow. The clinician should maintain an attitude of openness to the possibility of sexual concerns in older women. Such concerns should be taken seriously and should not be dismissed as part of aging. Routine periodic health examinations can include a question such as "Do you have any concerns about your sexual life that you would like to discuss?" In follow-up visits for procedures with a high likelihood of causing sexual dysfunction, questions that would open the door to a discussion of sexuality should be asked. Sexual dysfunction should be recognized as a couple-oriented phenomenon. A woman's anxiety about her appearance, postoperative depression, or dyspareunia may be perceived by her partner as a sexual rejection and may initiate a cycle of decreasing contact or may even lead to erectile dysfunction. Sexual counseling should include both partners. When a surgical procedure that will probably have an impact on sexual function is contemplated, provide the patient and her partner with advance counseling. Descriptions of surgery should not be simply a statement of body parts to be removed but should specifically address the anticipated sexual effects. Counseling should include a description of basic anatomy and function of the genital organs. Illustrations and appropriate demonstration during the physical examination should be used to ensure the patient's understanding. Descriptions should be accurate without being either frightening or falsely reassuring. The patient should be counseled about the benefits of including her partner in discussions. Then, when possible, the sexual partner of the patient should be invited to sessions of advance counseling on contemplated procedures. Clinicians should remain open to the possibility that the sexual partner will be a nontraditional one, e.g., an unmarried male partner or another woman. The clinician should be alert to remediable causes of dysfunction. For example, decreased vaginal lubrication may be managed with use of water-soluble lubricants.(ABSTRACT TRUNCATED AT 400 WORDS)

View details for PubMedID 2004290

View details for Web of Science ID A1989AV89600012

View details for PubMedID 2794323

Abstract

Ethical problems have become intrinsic to geriatric medicine. Physician's familiarity with ethical principles of medical decision-making, such as beneficence, autonomy, and justice, can be helpful. These principles can lead, however, to conflicting conclusions, and the decisions must be personal. An informed approach can help physicians resolve these increasingly commonplace dilemmas.

View details for Web of Science ID A1989T612300007

View details for PubMedID 2917715