Hypertension management: relationship between visit interval and control.

OBJECTIVE: Hypertension is one of the most common diagnoses resulting in an office visit to the physician. We examined the relationship between the variation in the interval between follow-up visits for hypertensive patients and the control of blood pressure. METHODS: The sample consisted of 113 patients who made 399 visits. Data included current medical problems, medications, type of health insurance, and socioeconomic status for each patient. RESULTS: The mean number of days between visits was 70.6 with a standard deviation of 76.3. No significant relationship was found between visit interval and severity of hypertension (p = 0.14). Sample size made it possible to detect a 20% difference with a likelihood of 0.80 at a significance level of 0.05. CONCLUSIONS: Our findings are limited by our focus on patient behavior rather than physician recommendation concerning the interval between visits, and by the distinct possibility that many of the visits were made for reasons other than follow-up of hypertension.

Transurethral prostatectomy versus transurethral dilatation of the prostatic urethra for benign prostatic hyperplasia: a cost-utility analysis.

Transurethral prostatectomy is the treatment currently preferred for benign prostatic hyperplasia. A new procedure, transurethral dilatation of the prostatic urethra, has lower costs and mortality and complication rates but may be less effective. These two strategies were evaluated by using cost-utility analysis, a form of cost-effectiveness analysis in which the benefit is defined in terms of individual preferences. Under the model assumptions, the cost of transurethral dilatation is less than the cost of transurethral prostatectomy for patients with benign prostatic hyperplasia ($7084 versus $8647) and slightly more effective: 11.787 quality adjusted life years versus 11.766. Thus, transurethral prostatectomy is said to be dominated. Results indicate that if patients are rigorously selected, and if balloon catheters of 30-35mm in size are utilized, transurethral dilatation could be the initial treatment of choice for eligible patients with benign prostatic hyperplasia.

The evaluation and treatment of men with asymptomatic prostate nodules in primary care: a decision analysis.

BACKGROUND: Whether to perform periodic rectal examinations in asymptomatic men as a screening test for prostatic cancer remains controversial. A randomized clinical trial that tests the efficacy of further evaluation and treatment of men who have been found to have asymptomatic prostate nodules may never be carried out. Decision analysis was therefore used to further investigate this clinical issue. METHODS: A decision tree was developed to model the decision of whether to biopsy an asymptomatic prostate nodule found by digital rectal examination in a 65-year-old man by his primary care physician. Test operating characteristics, probabilities of disease at different stages, probabilities of side effects from various treatments, and average life expectancies were obtained from the medical literature. Utilities for the various possible health outcome states were obtained from ratings by two experienced primary care physicians using the Kaplan-Anderson Quality of Well-Being Scale. These were used to adjust the quality-of-life expectancies for each outcome state. Multiple sensitivity analyses were performed to assess the robustness of the conclusions. RESULTS: Disregarding patient utilities, the average survival benefit of evaluation and treatment is 1.1 months. When quality-of-life adjustments are included in the analysis, evaluation and treatment results in an average loss of 3.5 quality-adjusted months of life. Factors that shift the decision toward evaluation and treatment include a positive predictive value of a prostate nodule for cancer of 49% or greater, specificity of prostate biopsy of 98.3% or greater, and the availability of much more effective treatment for stage D cancers. Factors that do not substantially affect the decision are cancer-free life expectancy, the percentage of cancers that are stage B at time of discovery, the sensitivity of prostate biopsy, and more effective treatment for stage C cancer, assuming the same rate of adverse consequences from treatment. CONCLUSIONS: The evaluation and treatment of prostatic nodules found by digital rectal examination in asymptomatic men in the primary care setting does not lead to significant improvement in life expectancy and adversely affects quality of life. Digital rectal examination should not be performed by primary care physicians as a screening test for prostate cancer.

Recurrent otitis media: a cost-utility analysis of simulated treatment using tympanostomy tubes vs antibiotic prophylaxis.

Using a cost-utility analysis, the effectiveness of tympanostomy tubes was compared to that of antibiotic chemoprophylaxis in young patients with recurrent otitis media. The tympanostomy approach (T-tubes) consisted of placement of a polyethylene grommet in the tympanic membrane, with systemic and local antibiotics administered for one week. The chemoprophylaxis approach consisted of antibiotics in full doses for seven to ten days, followed by continuous antibiotic chemoprophylaxis for six months. Because the T-tube strategy under the model assumptions was more expensive ($396.44 vs $281.30) and yielded slightly less benefit (net utility of .9325 vs. .9476 for initial antibiotic therapy), the chemoprophylaxis option was preferred. We conclude that the initial treatment for recurrent otitis media should consist of acute antibiotics followed by chemoprophylaxis, with T-tubes reserved for treatment failure. Extreme changes in the baseline probabilities of cure or recurrence with antibiotic therapy or in the cost of antibiotic therapy or tympanostomy surgery were required to alter this conclusion. Varying therapy preference (utility) values did not materially alter the conclusions.

Circumcision: a decision analysis of its medical value.

Routine neonatal circumcision has long been controversial. Presented here is a cost-effectiveness analysis of the consequences of the treatment choices (circumcision versus no circumcision) using a decision tree model. For a simulated 85-year life expectancy, routine neonatal circumcision had an expected lifetime cost of $164.61 per patient circumcised and a quality-adjusted survival of 84.999 years. Conversely, for the noncircumcision approach, the expected average lifetime cost was $139.26 per patient, and the quality-adjusted survival was 84.971 years. The net cost-effectiveness ($919.87 per quality-adjusted life year) is within the range usually considered worthwhile for public health policy. However, because of the minor differences in lifetime cost ($25) and benefit (10 days of life) for an individual and the tenuous values available for disease incidence and surgical risk, we conclude that there is no medical indication for or against circumcision. Additional analyses suggested that reported benefits in preventing penile cancer and infant urinary tract infections are insignificant compared to the surgical risks of post neonatal circumcision. The decision regarding circumcision may most reasonably be made on nonmedical factors such as parent preference or religious convictions.

Colloids versus crystalloids in fluid resuscitation: an analysis of randomized controlled trials.

BACKGROUND: Controversy about fluid therapy in resuscitation has existed since the 1960s. The difficulty could be that fluid behavior at the lung capillary membrane level may vary depending on the patient's particular pathology. METHODS: Mortality rates taken from randomized controlled trials were analyzed to compare colloidal and crystalloidal fluid for resuscitation efforts. We controlled for the underlying pathological process by categorizing subjects into three groups: (1) surgical stress, (2) hypovolemia, and (3) severe pulmonary failure. A cost-effectiveness analysis also was performed. RESULTS: No statistically significant differences in mortality rates were found. The cost of each life saved using crystalloids is $45.13, and the cost of each life saved using colloidal solutions is $1493.60. CONCLUSIONS: Because there is no significant mortality-rate advantage to using colloids, and because the cost-effectiveness ratio for crystalloids is much lower than for colloids, it is concluded that crystalloids should always be used in resuscitation efforts.

Documentation of referrals: recording bias due to patient insurance type.

This study explores a possible association between the propensity of primary care physicians to record referrals on special referral forms and the source/mechanism of payment for services. Using a randomly selected sample of visits to University faculty family physicians over a 12-month period, referrals were identified from three sources: progress notes, a special form that was included in the patient's chart, and a computerized list that was generated from the special referral form. A notation in one or more of these sources constituted a referral. Using all three sources, the referral rates were 13.8 referrals per 100 patient encounters for Health Maintenance Organization (HMO) patients, compared with 14.1 for Preferred Provider Organization (PPO) patients and 10.4 for patients with other insurance (p = .83). The progress note in the patient chart was the best source for determining whether a referral had been requested, with approximately 85% documentation. Special forms were not likely to be completed for referrals, especially for non-HMO patients (less than 30% documentation). Thus, reliance on a special form for documentation of referrals would have led to the erroneous conclusion of higher referral rates for HMO patients. The tendency of providers to be more complete in recording referrals of HMO patients (a recording bias) may account for the observed higher rate of referral of such patients in other studies.