Evidence-based medicine and goal-directed, patient-centered health care seem, at times, like para... more Evidence-based medicine and goal-directed, patient-centered health care seem, at times, like parallel universes, though, at a conceptual level, they are perfectly compatible. Part of the problem is that many of the kinds of information required for decision making in primary care are often unavailable or difficult to find. Several case examples are used to illustrate this problem, and reasons and solutions are suggested. The goal-directed health care model could be helpful for directing the search for evidence that is relevant to the decisions that patients and their primary care physicians must make on a regular basis.
Our goal was to evaluate whether screening patients with diabetes for microalbuminuria (MA) is ef... more Our goal was to evaluate whether screening patients with diabetes for microalbuminuria (MA) is effective according to the criteria developed by Frame and Carlson and those of the US Preventive Services Task Force. We searched the MEDLINE database (1966-present) and bibliographies of relevant articles. We evaluated the impact of MA screening using published criteria for periodic health screening tests. The effect of the correlation between repeated tests on the accuracy of a currently recommended testing strategy was analyzed. Quantitative tests have reported sensitivities from 56% to 100% and specificities from 81% to 98%. Semiquantitative tests for MA have reported sensitivities from 51% to 100% and specificities from 21% to 100%. First morning, morning, or random urine sampling appear feasible. Assuming an individual test sensitivity of 90%, a specificity of 90%, and a 10% prevalence of MA, the correlation between tests would have to be lower than 0.1 to achieve a positive predict...
The entire academic medical community is under increasing pressure to define and measure its acti... more The entire academic medical community is under increasing pressure to define and measure its activities. Previous relative value-based systems to measure research, teaching, administration, and patient care share several features that threaten their acceptability and validity. Using a bottom-up approach, our academic family medicine department attempted to develop a measurement system that avoided some of the flaws of the earlier systems. The system was developed in two phases. In the first phase, faculty members were invited to submit lists of all their professional activities. In the second phase, the faculty rated the relative value of a comprehensive list of academic activities using an unbounded ratio scale and indicated how many times a year they did each activity. Phase One resulted in a list of 96 academic activities. The activity rated in Phase Two as having the greatest relative value was principal investigator of a funded grant (relative value=30.23), followed by sole aut...
We studied the anatomic changes that occur in the ectocervix after cryotherapy and the role these... more We studied the anatomic changes that occur in the ectocervix after cryotherapy and the role these changes play in the adequacy of follow-up colposcopic examination. We retrospectively reviewed patients' charts. Between January 1, 1991, and December 1, 1995, 268 women underwent 2 colposcopic examinations in 7 state-run public health clinics. The likelihood that a follow-up colposcopic examination would be inadequate. Of the 268 women who underwent 2 colposcopic examinations during the study period, 83 had cryotherapy, 24 had loop excision of the ectocervical portion or cervical conization, and 96 had no procedure. Sixty-five were excluded because of missing data. Subjects were similar with respect to age, whether endocervical curettage was performed, cervical dysplasia, presence of human papilloma virus, and whether glandular involvement was noted. Patients who had cryotherapy had an increased likelihood of inadequate follow-up colposcopic examination compared with women who had ...
We studied the anatomic changes that occur in the ectocervix after cryotherapy and the role these... more We studied the anatomic changes that occur in the ectocervix after cryotherapy and the role these changes play in the adequacy of follow-up colposcopic examination. We retrospectively reviewed patients' charts. Between January 1, 1991, and December 1, 1995, 268 women underwent 2 colposcopic examinations in 7 state-run public health clinics. The likelihood that a follow-up colposcopic examination would be inadequate. Of the 268 women who underwent 2 colposcopic examinations during the study period, 83 had cryotherapy, 24 had loop excision of the ectocervical portion or cervical conization, and 96 had no procedure. Sixty-five were excluded because of missing data. Subjects were similar with respect to age, whether endocervical curettage was performed, cervical dysplasia, presence of human papilloma virus, and whether glandular involvement was noted. Patients who had cryotherapy had an increased likelihood of inadequate follow-up colposcopic examination compared with women who had ...
Evidence-based medicine and goal-directed, patient-centered health care seem, at times, like para... more Evidence-based medicine and goal-directed, patient-centered health care seem, at times, like parallel universes, though, at a conceptual level, they are perfectly compatible. Part of the problem is that many of the kinds of information required for decision making in primary care are often unavailable or difficult to find. Several case examples are used to illustrate this problem, and reasons and solutions are suggested. The goal-directed health care model could be helpful for directing the search for evidence that is relevant to the decisions that patients and their primary care physicians must make on a regular basis.
Our goal was to evaluate whether screening patients with diabetes for microalbuminuria (MA) is ef... more Our goal was to evaluate whether screening patients with diabetes for microalbuminuria (MA) is effective according to the criteria developed by Frame and Carlson and those of the US Preventive Services Task Force. We searched the MEDLINE database (1966-present) and bibliographies of relevant articles. We evaluated the impact of MA screening using published criteria for periodic health screening tests. The effect of the correlation between repeated tests on the accuracy of a currently recommended testing strategy was analyzed. Quantitative tests have reported sensitivities from 56% to 100% and specificities from 81% to 98%. Semiquantitative tests for MA have reported sensitivities from 51% to 100% and specificities from 21% to 100%. First morning, morning, or random urine sampling appear feasible. Assuming an individual test sensitivity of 90%, a specificity of 90%, and a 10% prevalence of MA, the correlation between tests would have to be lower than 0.1 to achieve a positive predict...
The entire academic medical community is under increasing pressure to define and measure its acti... more The entire academic medical community is under increasing pressure to define and measure its activities. Previous relative value-based systems to measure research, teaching, administration, and patient care share several features that threaten their acceptability and validity. Using a bottom-up approach, our academic family medicine department attempted to develop a measurement system that avoided some of the flaws of the earlier systems. The system was developed in two phases. In the first phase, faculty members were invited to submit lists of all their professional activities. In the second phase, the faculty rated the relative value of a comprehensive list of academic activities using an unbounded ratio scale and indicated how many times a year they did each activity. Phase One resulted in a list of 96 academic activities. The activity rated in Phase Two as having the greatest relative value was principal investigator of a funded grant (relative value=30.23), followed by sole aut...
We studied the anatomic changes that occur in the ectocervix after cryotherapy and the role these... more We studied the anatomic changes that occur in the ectocervix after cryotherapy and the role these changes play in the adequacy of follow-up colposcopic examination. We retrospectively reviewed patients' charts. Between January 1, 1991, and December 1, 1995, 268 women underwent 2 colposcopic examinations in 7 state-run public health clinics. The likelihood that a follow-up colposcopic examination would be inadequate. Of the 268 women who underwent 2 colposcopic examinations during the study period, 83 had cryotherapy, 24 had loop excision of the ectocervical portion or cervical conization, and 96 had no procedure. Sixty-five were excluded because of missing data. Subjects were similar with respect to age, whether endocervical curettage was performed, cervical dysplasia, presence of human papilloma virus, and whether glandular involvement was noted. Patients who had cryotherapy had an increased likelihood of inadequate follow-up colposcopic examination compared with women who had ...
We studied the anatomic changes that occur in the ectocervix after cryotherapy and the role these... more We studied the anatomic changes that occur in the ectocervix after cryotherapy and the role these changes play in the adequacy of follow-up colposcopic examination. We retrospectively reviewed patients' charts. Between January 1, 1991, and December 1, 1995, 268 women underwent 2 colposcopic examinations in 7 state-run public health clinics. The likelihood that a follow-up colposcopic examination would be inadequate. Of the 268 women who underwent 2 colposcopic examinations during the study period, 83 had cryotherapy, 24 had loop excision of the ectocervical portion or cervical conization, and 96 had no procedure. Sixty-five were excluded because of missing data. Subjects were similar with respect to age, whether endocervical curettage was performed, cervical dysplasia, presence of human papilloma virus, and whether glandular involvement was noted. Patients who had cryotherapy had an increased likelihood of inadequate follow-up colposcopic examination compared with women who had ...
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