摘要:

Advance directives have been widely endorsed as a method to match medical interventions to patients' preferences. However, applying advance directives to unspecified future decisions may be problematic. We wondered how well scenario-based treatment choices in advance directives can be used to infer other choices specified by the same patients. We asked 495 out-patients from the Massachusetts General Hospital to state 11 treatment choices in each of four illness scenarios. We calculated likelihood ratios (LRs) to see how well one choice could predict another. Predictions within a given scenario were strong and followed a pattern that reflected the invasiveness of the treatment. Thus, decline of antibiotics predicted decline of major surgery, in the same scenario (LR 36.0-108.3). Requests for major surgery strongly predicted requests for antibiotics (LR 90.4 - 244.1). Requests for major surgery and decline of antibiotics were the two most predictive preferences; more traditionally considered decisions about cardiopulmonary resuscitation and mechanical ventilation ranged from the third to ninth most predictive among the 11 interventions. Predictions between scenarios were weaker, but still potentially useful, and followed a pattern that reflected the prognoses of the scenarios. Declining treatment in the best prognosis scenario (coma-with-a-chance) predicted declining the same treatment in other scenarios with LRs of 2.5-6.1. Requests for treatment in the worst prognosis scenario (dementia-with-terminal-illness) predicted the same request in the other scenarios with LRs of 5.2-30.5. These data suggest that patients' advance scenario-based treatment choices can provide potentially useful information to apply to unspecified decisions if inferences follow considerations of prognosis and treatment invasiveness. For maximal predictive power, treatment directives should use a range of illness scenarios and include choices, among several others, on antibiotic use and major surgery.

ISSN:0025-7079    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Since most cancer is treated in the local community, the judgments of primary care physicians about treatment of breast cancer are important. This study examined physician and practice characteristics associated with physician judgments about the treatment of Stage I and Stage II breast cancer. Data are combined from samples of 3,436 physicians: physicians affiliated with hospitals participating in the Community Clinical Oncology Program (CCOP) and a national sample of non-CCOP physicians. This study focused on 1,460 physicians who had seen breast cancer patients and participated in treatment decision-making. Judgments were elicited using brief vignettes. Judgments were more variable for Stage I than for Stage II treatments. Judgments consistent with the NIH Consensus Conferences on breast cancer were more likely from surgeons, physicians who participated in information networks focused on cancer, and those with more breast cancer patients. Concurrence with the consensus conference positions was less likely in older physicians and those in solo practice. These findings point to structures that reinforce quality of care, particularly those that enhance communication, such as group practice or the activities of hospital staffs, information networks, and organized continuing education.

ISSN:0025-7079    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

This study compared the effects of theoretically driven interventions on compliance with mammography utilization. A 2 × 2 factorial design yielded groups: a control group, a belief intervention group, an informational intervention group, and a belief/informational intervention group. A probability sample of 301 women, age 35 and older, without a history of breast cancer were randomly assigned to groups. Subjects in the intervention groups received individually tailored messages to alter beliefs or provider information related mammography screening. Belief messages were developed from Health Belief Model constructs. Belief interventions significantly influenced all belief variables except perceived susceptibility in the desired direction. Women in belief/informational intervention group were almost four times more likely than those in the control group to comply with mammography recommendations in the year following intervention (odds ratio=3.75). In addition, belief variables and intervention significantly predicted mammography compliance 1 year postintervention.

ISSN:0025-7079    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Controversy exists as to whether provider organizational characteristics such as profit status and setting are associated with the content of medical care or efficiency with which care is rendered. Following FDA approval of human recombinant erythropoietin (EPO) for use in clinical practice, Medicare approved coverage for beneficiaries in its end stage renal disease program and established a fixed payment per dose. Because cost of EPO administration varied positively with dose, providers could realize larger profit with prescription of smaller doses. We used Medicare claims data to assess EPO use by renal dialysis providers one year after FDA approval (June 1990) as a function of provider ownership (for-profit, not-for-profit, government agency) and setting (hospital-based, free-standing). Mean dose of EPO was 236 units greater (P=0.0001) for not-for-profit freestanding facilities, 593 units greater (P=0.0001) for government facilities, and 555 units greater for not-for-profit hospitals (P=0.0001 than among for-profit freestanding providers. With fixed payment per dose of EPO, for-profit, freestanding providers prescribed EPO more often and administered smaller doses than not-for-profit or government providers, behavior that is consistent with profit maximization.

ISSN:0025-7079    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

This study is a retrospective evaluation of the Soviet health care system by 1,100 Jewish physicians who immigrated to Israel in 1990, but were professionally active in the former Soviet Union before and during the Gorbachev era. Medical education and the process of specialization; gender differences within the medical profession; sources of work satisfaction and dissatisfaction; self-evaluations of professional behavior; and assessments of patient behavior are included in this empirical study. Although high levels of dissatisfaction were found regarding instrumental aspects of work, the physicians reported high levels of satisfaction with their relationships with colleagues and patients. The recent emigrants assessed their own role behavior and that of their patients more critically than did physicians who left the Soviet Union in 1972, and who answered identical questions in 1975. Among the recent emigrants, men, older physicians, and those with higher status within the profession tended to be more satisfied with their work and less critical about their own and their patients' behavior than their female, younger and lower status colleagues. The subjective perceptions of former “insiders,” which complement the reports that have appeared in recent years in the medical literature, are discussed in terms of the impact of glasnost and perestroika on reporting behavior and on the real deterioration that occurred in the health care system of the former Soviet Union.

ISSN:0025-7079    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Application of techniques such as cost-effectiveness analysis (CEA) is growing rapidly in health care. There are two general approaches to analysis: deterministic models based upon assumptions and secondary analysis of retrospective data, and prospective stochastic analyses in which the design of a clinical experiment such as randomised controlled trial is adapted to collect patient-specific data on costs and effects. An important methodological difference between these two approaches is in the quantification and analysis of uncertainty. Whereas the traditional CEA model utilizes sensitivity analysis, the mean-variance data on costs and effects from a prospective trial presents the opportunity to analyze cost-effectiveness using conventional inferential statistical methods. In this study we explored some of the implications of moving economic appraisal away from deterministic models and toward the experimental paradigm. Our specific focus was on the feasibility and desirability of constructing statistical tests of economic hypotheses and estimation of cost-effectiveness ratios with associated 95% confidence intervals. We show how relevant variances can be estimated for this task and discuss the implications for the design and analysis of prospective economic studies.

ISSN:0025-7079    

出版商:OVID    

年代:1994

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1994

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1994

数据来源: OVID

ISSN:0025-7079    

出版商:OVID    

年代:1994

数据来源: OVID