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Differences between patients with heart failure treated by cardiologists, internists, family physicians, and other physicians: Analysis of a large, statewide database

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AMERICAN HEART JOURNAL 2000年第3期139卷 491-496页

作者： Philbin, EF Jenkins, PL Henry Ford Hosp Sect Heart Failure & Cardiac Transplantat Div Cardiovasc Med Detroit MI 48202 USA Bassett Healthcare Mary Imogene Bassett Res Inst Cooperstown NY USA

Background The management of heart failure (HF) by cardiologists may be better than that of other physicians in that cardiologists' treatment choices more frequently conform with published guidelines and the results of clinical trials. Whether cardiologists' management of HF is more or less cost-effective is up for debate. Methods Information on all 1995 New York state hospital discharges assigned ICD-9-CM codes indicative of HF in the principal diagnosis position was obtained. Demographic and clinical characteristics, process of care, resource utilization, and short-term HF-related outcomes were compared between patients of cardiologists and patients of other physicians. Results A total of 44,926 patients were identified, with 10,506 (23%) receiving care from cardiologists, 28,300 (63%) from internists 4812 (11%) from family practitioners, and 1308 (3%) from other physicians. Patients of cardiologists were younger, more frequently male, and less frequently residents of nursing homes. They were more likely to have associated cardiovascular diagnoses but less likely to have comorbid general medical conditions. Patients of cardiologists were more likely to undergo cardiac catheterization (9%) than those of internists (3%) and family practice (2%) physicians but had similar adjusted hospital length of stay and charges. Mortality and hospital readmission rates for HF were similar among the groups. Patients in the "other" group (managed mostly by surgeons) were the youngest, underwent more invasive and cardiac surgical procedures, and had the longest length of stay and highest hospital charges. Conclusions Cardiologists' management of HF is not economically disadvantageous. The relations among physician specialty, process of care, resource utilization, and clinical outcomes require further study before rational and evidence-based health care staffing recommendations can be formulated.

关键词：心脏病学/经济学心脏病学/统计学和数值数据队列研究共病现象冠心病/流行病学数据库事实型家庭医学/经济学家庭医学/统计学和数值数据心脏导管插入术/利用心脏瓣膜疾病/流行病学医院收费/统计学和数值数据内科学/经济学内科学/统计学和数值数据肾疾病/流行病学住院时间/经济学住院时间/统计学和数值数据肺疾病/流行病学纽约比值比结果评价(卫生保健)/统计学和数值数据医师诊疗模式/统计学和数值数据患病率老年人女(雌)性人类男(雄)性

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Safety and efficacy of endoscopic repair of CSF leaks and encephaloceles: A survey of the members of the American Rhinologic Society

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AMERICAN JOURNAL OF RHINOLOGY 2001年第1期15卷 21-25页

作者： Senior, BA Jafri, K Benninger, M Henry Ford Hosp Dept Otolaryngol Head & Neck Surg Detroit MI 48202 USA

The purpose of this article is to review the endoscopic management of cerebrospinal fluid (CSF) leaks and encephaloceles, with particular emphasis on safety and efficacy, by retrospective assessment utilizing the results of a mailed questionnaire. Surveys were mailed to members of the American Rhinologic Society with practices in both academic centers and/or private settings. Survey results were then assessed and tabulated. There were 635 mailings, with 197 responses (31%). Seventy-two (36% of respondents) indicated that they performed endoscopic management of CSF leaks and encephaloceles, while 125 (64% of respondents) did not. Respondents reported similar to 522 cases of CSF leaks and similar to 128 cases of encephaloceles managed by endoscopy. Success rates after a single procedure were estimated at 90% for CSF leaks and 93% for encephaloceles. Success rates after a secondary procedure were estimated at 86% and 97%, respectively;29% of respondents have, at some point, made a referral to neurosurgery. A total of 13 complications related to endoscopic repairs were reported (2.5%). For CSF leak repair complications included seizures, 0.2%;meningitis, 1.1%;and one reported case each of cavernous sinus thrombosis, temporary visual problems, sinusitis, and intracranial hypertension/bleed. There was only one reported death in the similar to 522 cases. Eleven complications following encephalocele repairs (8.5%) included seizures, 3.1%;meningitis, 2.3%;and one reported case each of brain abscess, sinusitis, false aneurysm of middle cerebral artery, and mild dizziness. No deaths following encephalocele repair were reported The endoscopic management of CSF leaks and encephaloceles has become increasingly popular and has proven to have low morbidity and mortality with high success. Overall, our results confirm that in the hands of the skilled endoscopist, endoscopic management of CSF leaks and encephaloceles is highly efficacious and has a very low incidence of significant c

关键词：绷带脑脊液鼻漏/诊断脑脊液鼻漏/外科学引流术脑疝/诊断脑疝/外科学内窥镜检查/方法内窥镜检查/死亡率内窥镜检查/利用年患病率耳鼻咽喉科学/仪器和设备耳鼻咽喉科学/方法耳鼻咽喉科学/统计学和数值数据医师诊疗模式/统计学和数值数据问卷调查回顾性研究安全治疗结果美国/流行病学人类

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Evaluation of physician preferences for guideline implementation

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AMERICAN JOURNAL OF MEDICAL QUALITY 1999年第4期14卷 170-177页

作者： Stone, TT Kivlahan, CH Cox, KR Univ Missouri Sch Med Program Hlth Serv Management Dept Hlth Management & Informat Columbia MO 65211 USA Univ Missouri Off Clin Outcomes & Med Management Ctr Hlth Sci Columbia MO 65211 USA

Although current literature supports the use of evidence-based clinical practice guidelines (CPGs) by physicians, there is limited research concerning operational issues that may be inhibiting effective CPG implementation. The objective of our research was to increase under standing of clinical practice patterns by identifying physician preferences for CPG accessibility, format, content and learning strategies. Semistructured interviews were conducted with resident and faculty physicians in an academic medical center after they were presented with a CPG during treatment of a patient with acute pancreatitis. The results of our study revealed that physicians prefer CPGs in the form of evidence-based algorithms with treatment-specific information that is placed on the front of the patient chart during treatment. In addition, they felt that discussion of the guideline with colleagues, reminder notes/stickers on front of the patient chart, and verbal reminders from a nurse were the most effective means of encouraging utilization.

关键词：医学科学研究中心急性病算法医务工作者的态度评价研究循证医学全体教工医学院校坚持准则实习医师和住院医师职务胰腺炎/治疗医师诊疗模式/统计学和数值数据问卷调查专业医学美国人类

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Stress testing: National patterns and predictors of test ordering

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AMERICAN HEART JOURNAL 1999年第6期138卷 1019-1024页

作者： Cohen, MC Stafford, RS Misra, B Maine Med Ctr Div Cardiol Portland ME 04102 USA Univ Vermont Coll Med Burlington VT USA Harvard Univ Sch Med Massachusetts Gen Hosp Div Gen Med Boston MA USA

Objective To determine predictors of ordering of exercise stress tests. Background Because exercise stress testing is routinely used and widely available and may have an effect on subsequent evaluation of and therapy for heart disease, understanding current patterns of ordering exercise stress rests may have important implications for national health care costs. We hypothesized that factors other than clinical condition exert an influence on ordering of exercise stress tests. Methods Data from the 1991 and 1992 National Ambulatory Medical Core Surveys conducted by the National Center for Health Statistics were analyzed by means of multivariate logistic regression. Results In an estimated 1.12 billion adult visits to office-based physicians in the United Stares (95% confidence interval [CI], 1.07-1.16 billion), 6.2 million (95% CI, 4.8-7.6 million) exercise stress tests were ordered. After adjustment for clinical and nonclinical variables associated with the office visit, cardiologists were 3.7 (95% CI, 2.7-5.1) times more likely to order exercise stress tests than were internists, who were more likely to order an exercise stress test than were family and general practitioners (0.5, 95% CI, 0.3-0.7). Nonclinical factors associated with increased ordering of exercise stress tests included male sex (odds ratio 2.5;95% CI, 2.0-3.2), white race (odds ratio 1.6;95% CI, 1.1-2.3), new referral status (odds ratio 3.8;95% CI, 2.5-5.8), and private insurance (odds ratio 1.4;95% CI, 1.1-1.8). Medicare recipients were about half (95% CI, 0.4-0.9) as likely as other patients to have an exercise stress test ordered. Conclusions Factors other than clinical condition exert an influence on ordering of exercise stress tests and may represent modifiable elements associated with appropriate practice.

关键词：运动试验/统计学和数值数据运动试验/利用医师诊疗模式/统计学和数值数据美国成年人老年人女(雌)性人类男(雄)性中年人

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Cardiologists' discussions about sexuality with patients with chronic coronary artery disease

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AMERICAN HEART JOURNAL 2002年第2期144卷 239-242页

作者： Bedell, SE Duperval, M Goldberg, R Lown Cardiovasc Ctr Brookline MA 02446 USA Harvard Univ Sch Med Brookline MA USA Univ Massachusetts Sch Med Worcester MA USA

Background Sexuality is an important factor influencing quality of life that may be altered for patients with coronary disease. Little is known about the extent to which patients want their cardiologists to counsel them about sexuality. Purpose Our study evaluated the extent to which patients with known coronary disease expect cardiologists to discuss matters related to sexuality. A secondary goal was to determine the extent to which patients' preferences correspond to the realities of clinical practice. Results On the basis of the results of a questionnaire survey completed by 48 women and 188 men with known coronary disease in an outpatient cardiology practice, we found that most patients believed that their cardiologist should talk with them about sexual functioning. However, only a minority (3% men, 18% women) believed that they were adequately informed about their sexual functioning. Chart review demonstrated that most discussions occurred with male patients and that sexual dysfunction was also more likely to be discussed with men (43%) than with women (13%). Conclusions Our study suggests that patients welcome the chance to talk with their cardiologist about sexual function. More attention should be given to this aspect of quality of life, especially for women with coronary disease.

关键词：健康态度病史记录/统计学和数值数据医师诊疗模式/统计学和数值数据医生病人关系人群监测生活质量/心理学问卷调查性欲/心理学美国/流行病学老年人女(雌)性人类男(雄)性

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Self-reported differences between cardiologists and heart failure specialists in the management of chronic heart failure

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AMERICAN HEART JOURNAL 1999年第1期138卷 100-107页

作者： Bello, D Shah, NB Edep, ME Tateo, IM Massie, BM Vet Affairs Med Ctr Cardiol Sect 111C San Francisco CA 94121 USA Univ Calif San Francisco Dept Med San Francisco CA 94143 USA Univ Calif San Francisco Inst Cardiovasc Res San Francisco CA 94143 USA

Background Heart failure (HF) is responsible for considerable mortality morbidity rates and resource utilization. Recently, several studies have reported improved outcomes when patients are managed by special HF clinics, but it is uncertain whether this improvement reflects differences in physician practices or other aspects of the operation of these clinics. Objectives This study was designed to identify differences in HF management practices between general cardiologists and cardiologists specializing in the treatment of patients with HF. Methods A survey examining diagnostic and treatment practices in patients with HF was sent to a sample of cardiologists derived from the American Medical Association Masterfile and to HF specialists who were members of the Society of Transplant Cardiologists or principal investigators in HF trials. Responses were examined in relation to guidelines issued by the Agency for Health care Policy and Research released 9 months previously, Results In general both groups practice in conformity with published guidelines. However, there were important differences between the practice patterns of general cardiologists and HF specialists. For instance, in patients being evaluated for the first time, cardiologists reported using a chest radiograph to assist in the diagnosis more than did HF specialists (47% vs 12%), whereas HF specialists were more likely to use an echocardiogram (73% vs 48%). Both groups were likely to evaluate their patients for ischemia and possible revascularization, even in patients not having angina. However, HF specialists tended to use coronary angiography as the initial diagnostic test, whereas cardiologists were more likely to use stress testing. HF specialists more often used angiotensin-converting enzyme inhibitors as pari of their initial therapy in patients with mild to moderate HF (94% vs 86%) and during maintenance therapy(91% vs 80%). Also, HF specialists were more likely than cardiologists to titrate angiote

关键词：心脏病学/统计学和数值数据病例管理混杂因素(流行病学) 医师诊疗模式/统计学和数值数据问卷调查疾病严重程度指数专门化/统计学和数值数据美国成年人女(雌)性人类男(雄)性中年人

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Outcomes of care and resource utilization among patients with knee or shoulder disorders treated by general internists, rheumatologists, or orthopedic surgeons

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AMERICAN JOURNAL OF MEDICINE 2000年第1期108卷 28-35页

作者： Katz, JN Solomon, DH Schaffer, JL Horsky, J Burdick, E Bates, DW Brigham & Womens Hosp Div Rheumatol Allergy & Immunol Robert Brigham Multipurpose Arthrit & Musculoskel Boston MA 02115 USA Harvard Univ Brigham & Womens Hosp Sch Med Dept Orthoped Surg Boston MA 02115 USA Harvard Univ Brigham & Womens Hosp Sch Med Div Gen Internal Med Boston MA 02115 USA Harvard Univ Brigham & Womens Hosp Sch Med Dept Med Boston MA 02115 USA

PURPOSE: Previous studies have suggested that specialists may achieve better clinical outcomes for patients, albeit often at greater cost. We sought to compare outcomes of care and resource utilization among patients with shoulder or knee problems who were heated by general internists, rheumatologists, and orthopedic surgeons. SUBJECTS AND METHODS: Outpatients with knee or shoulder complaints who were seen by general internists, rheumatologists, or orthopedic surgeons at an academic medical center were administered questionnaires at enrollment in the study and again 3 months later. The questionnaires included validated measures of satisfaction, functional status, and pain severity, as well as resource utilization. We compared baseline clinical characteristics, satisfaction with care, resource utilization, and changes in function and symptoms during 3 months of follow-up among patients who were cared for by the three different types of providers. RESULTS: A total of 534 patients responded to the baseline survey and 436 (82%) to the 3-month follow-up survey. About 60% (n = 323) had knee pain. Orthopedists cared for 40% (n = 211) of the patients, with the remainder treated in approximately equal numbers by general internists or rheumatologists. At baseline, patients of internists had less severe pain (differences of 0.3 to 0.6 points on a 1 to 5 scale, P <0.05) and functional limitations (differences of 0.4 to 0.6 points on a 1 to 5 scale, P <0.0006) than patients of rheumatologists and orthopedic surgeons. Adjusting for baseline differences, there were no significant differences among provider groups in pain relief or functional improvement during follow-up. However, in adjusted analyses, patients with shoulder pain who were cared for by orthopedic surgeons were least satisfied with the office environment [adjusted mean (+/- SD) satisfaction score of 1.6 +/- 0.8 on a 1 to 4 scale for orthopedic surgeons vs 1.3 +/- 0.8 for rheumatologists and 1.4 +/- 0.8 for internists

关键词：医学科学研究中心波士顿卫生资源/利用内科学/统计学和数值数据关节疾病/外科学关节疾病/治疗膝关节矫形外科学/统计学和数值数据结果与过程评价(卫生保健) 疼痛测定病人满意度医师诊疗模式/统计学和数值数据问卷调查风湿病学/统计学和数值数据疾病严重程度指数肩关节治疗结果成年人老年人女(雌)性人类男(雄)性中年人

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Influence of postal distribution of The Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial

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FAMILY PRACTICE 2000年第1期17卷 46-52页

作者： Kerry, S Oakeshott, P Dundas, D Williams, J Univ London St Georges Hosp Sch Med Dept Gen Practice & Primary Care London SW17 0RE England

Background. The Royal College of Radiologists (RCR) have produced regularly updated guidelines on radiological referrals since 1990. A small study in 1992 showed postal distribution of guidelines reduced general practitioners' referrals over the subsequent 9 weeks. However there have been no randomized trials of the longer term effects of radiological guidelines and feedback on referral rates on X-ray requests from primary care. Objectives. To see if the introduction of radiological guidelines into general practices together with feedback on referral rates reduces the number of GP radiological requests over one year;and to explore GPs' attitudes to the guidelines. Methods. Sixty-nine practices referring patients to St George's Healthcare Trust were randomly allocated to intervention or control groups. In February 1995 a GP version of the RCR guidelines was sent to each GP in the 33 practices in the intervention group. After 9 months intervention, practices were sent revised guidelines with individual feedback on the number of examinations requested in the past 6 months. The total number of requests per practice was compared for the year before and the year after the introduction of the guidelines. Control practices were sent the guidelines at the end of the study. All doctors were sent a questionnaire about the guidelines. Results. A total of 43 778 radiological requests were made during the two years 1994-1996. In practices receiving the guidelines there was a 20% reduction in requests for spinal examinations compared with control practices (P < 0.05). This corresponded to the effect reported by GPs. There was also a 10% difference between the groups in the total number of requests made, but due to wide interpractice variation in referral rates this failed to reach statistical significance. Conclusions. Introduction of radiological guidelines together with feedback on referral rates was effective in reducing the number of requests for spinal examinations over one y

关键词：医务工作者的态度置信区间家庭医学/统计学和数值数据反馈随访研究伦敦医师诊疗模式/统计学和数值数据邮政问卷调查放射摄影术/统计学和数值数据放射摄影术胸部/统计学和数值数据放射学转诊和会诊/统计学和数值数据脊柱/放射摄影术人类

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Variations in the use of cardiac procedures in the Veterans Health Administration

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AMERICAN HEART JOURNAL 1999年第4期137卷 706-713页

作者： Mirvis, DM Graney, MJ Univ Tennessee Dept Prevent Med Memphis TN 38105 USA Univ Tennessee Dept Med Memphis TN 38105 USA Dept Vet Affairs Med Ctr Memphis TN USA

Background Considerable variability exists in the use of cardiac procedures for patients with heart disease. One cause for this variability is the availability of local facilities to perform these procedures. This study was initiated to identify health system features that are related to rates of catheterization, percutaneous coronary angioplasty, and coronary artery bypass graft surgery in the Veterans Affairs health care system in which structured referral systems are intended to compensate for variation in local resource availability Methods Medical records of 30,901 patients admitted to a Veterans Affairs medical center with coronary artery disease were analyzed. Odds ratios (OR) and 95% confidence intervals (CI) for undergoing each procedure, based on clinical variables (age, sex, race, coronary artery disease type, and a computed comorbidity score), and local Veterans Affairs facility features (geographic region, primary service area size, and hospital complexity) were estimated by logistic regression. Results Regression models demonstrated significant associations between the odds of undergoing each procedure and medical center geographic and complexity features, after adjustment for clinical variables. Associations included the presence of a cardiac catheterization laboratory For undergoing catheterization (OR 1.86, CI 1.76 to 1.95) and the presence of a cardiac surgical program for angioplasty (OR 1.46, CI 1.36 to 1.57) and bypass grafting (OR 1.43, CI 1.34 to 1.53). Including health system variables in addition to clinical variables in the regression models improved the discriminating ability of the models by 44.2% to 51.4%. Conclusions Geographic location and the complexity of the local Veterans Affairs hospital are important determinants of the use of cardiac procedures in the Veterans Affairs health care system, even though referral networks are intended to correct for local differences in hospital complexity.

关键词：血管成形术经腔经皮冠状动脉/利用置信区间冠状动脉分流术/利用卫生服务易得程度/统计学和数值数据心脏导管插入术/利用医院退伍军人/统计学和数值数据医院退伍军人/利用 Logistic模型病案心肌缺血/外科学比值比医师诊疗模式/统计学和数值数据美国美国退伍军人事务部利用情况审核/统计学和数值数据老年人女(雌)性人类男(雄)性中年人

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Prescribing practice for antibiotic prophylaxis for cesarean section in a teaching hospital in Brazil

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AMERICAN JOURNAL OF INFECTION CONTROL 2002年第6期30卷 341-345页

作者： Heineck, I Ferreira, MBC Schenkel, EP Univ Fed Rio Grande do Sul Fac Farm BR-90610000 Porto Alegre RS Brazil Univ Fed Rio Grande do Sul Dept Farmacol ICBS BR-90610000 Porto Alegre RS Brazil

Background: The contribution of antibiotic prophylaxis to reduce surgical wound infection and endometritis after cesarean section is well-known. Despite the knowledge about the effectiveness of antibiotic prophylaxis with this procedure, the administrative regimens are often inappropriate. Methods: The use of antibiotic prophylaxis in cesarean section was evaluated in a reference school hospital. Data were collected from medical records, and they correspond to the 9-month observation during 1995 and 1996. Results: The cesarean section rate was 26.4% in this period. The total procedures observed was 587. Antibiotic prophylaxis was prescribed in 358 procedures (61%). Cephalothin was the most prescribed drug (98.6%), with a regimen of 2 g intravenously after clamping of the umbilical cord and 2 more doses of 1g every 6 hours. Antibiotic prophylaxis was indicated more frequently in patients younger than 30 years and in those with rupture of membranes for more than 6 hours;such differences were significant (P < .05 and P < .00001, respectively). Conclusion: The prescribers met the hospital guidelines for antibiotic prophylaxis in only 37.1% of the cesarean sections performed.

关键词：抗菌药/投药和剂量抗生素预防/利用细菌感染/预防和控制巴西剖宫产术/统计学和数值数据用药计划表药物利用/统计学和数值数据医院教学医师诊疗模式/统计学和数值数据诊疗准则(主题) 外科伤口感染/预防和控制成年人女(雌)性人类妊娠

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