Clyde B. Schechter

Effect of a Bicultural Community Health Worker on Completion of Diabetes Education in a Hispanic Population

OBJECTIVE To determine the effect of a bicultural community health worker (CHW) on completion of diabetes education in an inner-city Hispanic patient population and to evaluate the impact of completion of the education program on patient knowledge, self-care behaviors, and glycemic control. RESEARCH DESIGN AND METHODS Patients were randomized into CHW intervention and non-CHW intervention groups. All patients received individualized, comprehensive diabetes education from a certified diabetes nurse educator after baseline demographic information, diabetes knowledge, diabetes self-care practices, and glycohemoglobin levels were assessed. Rates of education program completion were determined. Diabetes knowledge, self-care practices, and glycohemoglobin levels were reassessed at program completion and at a later postprogram follow-up medical appointment and compared to baseline. Logistic regression analysis and the Mantel-Haenszel χ2 statistic were used to determine the effect of the CHW assignment on program completion. Analyses of covariance were performed with end-of-treatment behavior scores, knowledge scores, and glycohemoglobin levels as outcome variables, controlling for baseline values and testing for the effect of CHW assignment. RESULTS Of 64 patients enrolled in the study, 40 (63%) completed and 24 (37%) dropped out before completing the diabetes education program. Of the patients having CHW intervention, 80% completed the education program, compared with 47% of patients without CHW intervention (P = 0.01). “Dropouts” were younger (age 47.5 ± 12.5 years [mean ± SD]) compared with patients who completed the program (55.9 ± 9.9 years) (P = 0.004). Dropout status showed no significant relationship to educational level achieved or literacy level. For the program “completers,” knowledge levels and selected self-care practices significantly improved, and glycohemoglobin levels improved from a baseline level of 11.7% to 9.9% at program completion (P = 0.004) and 9.5% at the postprogram follow-up (P < 0.001). The effect of the CHW assignment on program completion, controlling for financial status and language spoken, was extremely robust (P = 0.007). The effect of the CHW on knowledge, self-care behavior, or glycohemoglobin outcome variables was not statistically significant. CONCLUSIONS These findings suggest that intervention with a bicultural CHW improved rates of completion of a diabetes education program in an inner-city Hispanic patient population irrespective of literacy or educational levels attained. Our data further suggests that completion of individualized diabetes educational strategies leads to improved patient knowledge, self-care behaviors, and glycemic control.

Cost Effectiveness of Cervical Cancer Screening for the Elderly

OBJECTIVE To analyze the costs and benefits of alternative cervical cancer screening schedules among elderly women. SETTING Population-based screening programs. DESIGN A Markov model predicts the outcomes of periodic screening, diagnosis, and treatment for cervical cancer among women from 65 to 109 years of age. PATIENTS A hypothetical cohort of one million 65-year-old women; representative of the U.S. population. MEASUREMENTS The costs and yields of screening. RESULTS Triennial screening reduced mortality from cervical cancer among the elderly by 74% at a cost of

Outcome prediction model for very elderly critically ill patients.

2254 per year of life saved. Annual screening increased costs to

Interpretation of the tuberculin skin test.

7345 per year of life saved; less frequent schedules yielded lower costs but decreased savings in life. These results were most sensitive to the quality of the Papanicolaou smear and the characteristics of the women using the benefit. If the sensitivity of the Papanicolaou smear was reduced from a baseline estimate of 75% to 50% and the specificity was decreased to 87% from 95%, the cost effectiveness ratio increased by nearly

Study of a needleless intermittent intravenous-access system for peripheral infusions: Analysis of staff, patient, and institutional outcomes

7000 per year of life saved. If triennial screening is targeted to women who have not had regular screening, the program will save money as well as years of life; however, screening women who have been screened regularly is considerably less efficient, increasing costs to

Effects of Practice Setting on Quality of Lipid-Lowering Management in Patients With Coronary Artery Disease

33,572 per year of life saved. CONCLUSION The success of the new Medicare benefit depends substantially on physicians assuring that their elderly patients, particularly women without regular prior screening, obtain high quality Papanicolaou smears. The data also show that after a woman 65 years of age or older has a history of regular negative smears, screening is inefficient and can cease.

Cost-Effectiveness of Rescreening Conventionally Prepared Cervical Smears by PAPNET Testing

ContextVery elderly critically ill patients have three possible hospital outcomes: discharge to home, discharge to a skilled nursing or rehabilitation facility, or death. The factors associated with these outcomes are unknown. ObjectiveTo develop a three-outcome prediction model for very elderly critically ill patients. DesignRetrospective chart abstraction with ordered logistic regression analysis. SettingAcademic medical center. PatientsFour hundred and fifty-five patients 85 yrs or older admitted to intensive care units (ICU) during 1996 and 1997. Measurements and Main Results A fitted ordinal logistic regression predictive model was developed using data from 243 patients hospitalized in 1996, and validated on data from 212 patients hospitalized in 1997. Model variables include age, gender, baseline support level, type of ICU, heart rate at ICU admission, use of mechanical ventilation, vasopressors or a pulmonary artery catheter during the ICU stay, and the development of respiratory, neurologic or hematologic failure or sepsis while in the ICU. When tested on the 1997 data, the model was well calibrated and had a high discriminant index. ConclusionsThis mathematical model can be used to predict the risks of these three hospital outcomes for this population of patients. These predictions can provide a context when discussing goals and expectations with patients, families, and other healthcare providers and to aid in hospital discharge planning.

Decision Analysis in Formulary Decision Making

OBJECTIVE: To reinterpret epidemiologic information about the tuberculin test (purified protein derivative) in terms of modern approaches to test characteristics; to clarify why different outpoints of induration should be used to define a positive test in different populations; and to calculate test characteristics of the intermediate-strength tuberculin skin test, the probabilityMycobacterium tuberculosis infection at various induration sizes, the area under the receiver operating characteristic (ROC) curve, and optimal cutpoints for positivity.METHODS: Standard epidemiologic assumptions were used to distinguish M. tuberculosis-infected from -uninfected persons; also used were data from the U.S. Navy recruit and World Health Organization tuberculosis surveys; and Bayesian analysis.RESULTS: In the general U.S. population, the test’s sensitivity is 0.59 to 1.0, the specificity is 0.95 to 1.0, and the positive predictive value is 0.44 to 1.0, depending on the outpoint. Among tuberculosis patients, the sensitivity is nearly the same as in the general population; the positive predictive value is 1.0. The area under the ROC curve is 0.997. The probability ofM. tuberculosis infection at each induration size varies widely, depending on the prevalence. The optimal cutpoint varies from 2 mm to 16 mm and is dependent on prevalence and the purpose for testing.CONCLUSIONS: The operating characteristics of the tuberculin test are superior to those of nearly all commonly used screening and diagnostic tests. The tuberculin test has an excellent ability to distinguishM. tuberculosis-infected from -uninfected persons. Interpretation requires consideration of prevalence and the purpose for testing. These findings support the recommendation to use different cutpoints for various populations. Even more accurate information can be gotten by interpreting induration size as indicating a probability ofM. tuberculosis infection.

Evaluation of Costs and Benefits of Advances in Cytologic Technology

OBJECTIVE To assess the effect on staff- and patient-related complications of a needleless intermittent intravenous access system with a reflux valve for peripheral infusions. DESIGN A 6-month cross-over clinical trial (phase I, 13 weeks; phase II, 12 weeks) of a needleless intermittent intravenous access system (NL; study device) compared to a conventional heparin-lock system (CHL, control device) was performed during 1991 on 16 medical and surgical units. A random selection of patients was assessed for local intravenous-site complications; all patients were assessed for the development of nosocomial bacteremia and device-related complications. Staff were assessed for percutaneous injuries and participated in completion of product evaluations. A cost analysis of the study compared to the control device was performed. SETTING A 1,100-bed, teaching, referral medical center. PATIENTS AND STAFF PARTICIPANTS: 594 patients during 602 patient admissions, comprising a random sample of all patients with a study or control device inserted within a previous 24-hour period on study and control units, were assessed for local complications. The 16 units included adult inpatient general medicine, surgical, and subspecialty units. Pediatrics, obstetrics-gynecology, and intensive-care units were excluded. All patients on study and control units were assessed for development of nosocomial bacteremia and device-related complications. All staff who utilized, manipulated, or may have been exposed to sharps on study and control units were assessed for percutaneous injuries. Nursing staff completed product evaluations. INTERVENTION The study device, a needleless intermittent intravenous access system with a reflux valve, was compared to the control device, a conventional heparin lock, for peripheral infusions. RESULTS During the study, 35 percutaneous injuries were reported. Eight injuries were CHL-related; no NL-related injuries were reported (P=.007). An evaluation of 602 patient admissions, 1,134 intermittent access devices, and 2,268 observed indwelling device days demonstrated more pain at the insertion site for CHL than NL; however, no differences in objective signs of phlebitis were noted. Of 773 episodes of positive blood cultures on study and control units, 6 (0.8%) were device-related (assessed by blinded investigator), with no difference between NL and CHL. Complications, including difficulty with infusion (P<.001) and disconnection of intravenous tubing from device (P<.001), were reported more frequently with CHL than with NL. Of nursing staff responding to a product evaluation survey, 95.2% preferred the study over control device. The projected annual incremental cost to our institution for hospitalwide implementation of NL for intermittent access for peripheral infusions was estimated at

In vitro glycolysis of whole blood can detect primed neutrophils in septic icu patients

82,845, or