Author
M. Abrahamowicz
Bio: M. Abrahamowicz is an academic researcher from McGill University. The author has contributed to research in topics: Medical prescription & Cohort. The author has an hindex of 5, co-authored 10 publications receiving 1426 citations.
Papers
More filters
••
TL;DR: Increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions.
Abstract: ContextRising costs of medications and inequities in access have sparked calls
for drug policy reform in the United States and Canada. Control of drug expenditures
by prescription cost-sharing for elderly persons and poor persons is a contentious
issue because little is known about the health impact in these subgroups.ObjectivesTo determine (1) the impact of introducing prescription drug cost-sharing
on use of essential and less essential drugs among elderly persons and welfare
recipients and (2) rates of emergency department (ED) visits and serious adverse
events associated with reductions in drug use before and after policy implementation.Design and SettingInterrupted time-series analysis of data from 32 months before and 17
months after introduction of a prescription coinsurance and deductible cost-sharing
policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy
cohort studies were conducted to estimate the impact of the drug reform on
adverse events.ParticipantsA random sample of 93 950 elderly persons and 55 333 adult
welfare medication recipients.Main Outcome MeasuresMean daily number of essential and less essential drugs used per month,
ED visits, and serious adverse events (hospitalization, nursing home admission,
and mortality) before and after policy introduction.ResultsAfter cost-sharing was introduced, use of essential drugs decreased
by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and
by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential
drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%),
respectively. The rate (per 10 000 person-months) of serious adverse
events associated with reductions in use of essential drugs increased from
5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly
persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in
welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency
department visit rates related to reductions in the use of essential drugs
also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in
elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1)
and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control
cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due
to an increase in the proportion of recipients who reduced their use of essential
drugs. Reductions in the use of less essential drugs were not associated with
an increase in risk of adverse events or ED visits.ConclusionsIn our study, increased cost-sharing for prescription drugs in elderly
persons and welfare recipients was followed by reductions in use of essential
drugs and a higher rate of serious adverse events and ED visits associated
with these reductions.
893 citations
••
TL;DR: The overall therapeutic efficiency of the myoblast transfer was poor as judged by the results in maximal voluntary force generation, dystrophin content of the muscle, magnetic resonance imaging of the Muscle, and the lack of donor‐derived DNA and dyStrophin messenger RNA in the injected muscle.
Abstract: One biceps muscle of 8 patients with Duchenne muscular dystrophy was injected at 55 sites with a total of 55 million viable, purified, and contamination-free normal myoblasts (myoblast transfer). The other biceps of each patient was injected with a placebo to serve as a control. The procedure was blinded to the patients, parents, and investigators. Myoblasts derived from a biopsy specimen of the fathers were cultured and purified under strict conditions and carefully screened for microbial contamination. All patients received cyclophosphamide for immunosuppression for 6 or 12 months. No serious complications were observed after myoblast transfer, indicating that the procedure is safe. The overall therapeutic efficiency of myoblast transfer was poor as judged by the results in maximal voluntary force generation, dystrophin content of the muscle, magnetic resonance imaging of the muscle, and the lack of donor-derived DNA and dystrophin messenger RNA in the injected muscle. An improved efficiency of the take of myoblasts might be achieved by using younger cells and injecting the myoblasts with a myonecrotic agent (to increase the prevalence of regeneration) and a basal laminal fenestrating agent.
305 citations
••
TL;DR: Licensing examination scores are significant predictors of consultation, prescribing, and mammography screening rates in initial primary care practice in Quebec.
Abstract: Context.—Clinical competence is a determinant of the quality of care delivered,
and may be associated with use of health care resources by primary care physicians.
Clinical competence is assumed to be assessed by licensing examinations, yet
there is a paucity of information on whether scores achieved predict subsequent
practice.Objective.—To determine if licensing examination scores were associated with selected
aspects of quality of care and resource use in initial primary care practice.Design.—Prospective cohort study of recently licensed family physicians, followed
up for the first 18 months of practice.Setting.—The Quebec health care system.Participants.—A total of 614 family physicians who passed the licensing examination
between 1991 and 1993 and entered fee-for-service practice in Quebec.Main Outcome Measures.—All patients seen by physicians were identified by the universal health
insurance board and all health services provided to these patients were retrieved
for the 18 months prior to (baseline) and after (follow-up) the physicians'
entry into practice. Medical service and prescription claims files were used
to measure rates of resource use (specialty consultation, symptom-relief prescribing
compared with disease-specific prescribing) and quality of care (inappropriate
prescribing, mammography screening). Baseline data were used to adjust for
differences in practice population.Results.—Study physicians saw a total of 1116389 patients, of whom 113535 (10.2%)
were elderly and 83391 (7.5%) were women aged 50 to 69 years. Physicians with
higher licensing examination scores referred more of their patients for consultation
(3.8/1000 patients per SD increase in score; 95% confidence interval [CI],
1.2-7.0; P=.005), prescribed to elderly patients
fewer inappropriate medications (−2.7/1000 patients per SD increase
in score; 95% CI, −4.8 to −0.7; P =.009)
and more disease-specific medications relative to symptom-relief medications
(3.9/1000 patients per SD increase in score; 95% CI, 0.3 to 7.4; P=.03), and referred more women aged 50 to 69 years (6.6/1000 patients
per SD increase in score; 95% CI, 1.2-11.9; P=.02)
for mammography screening. If patients of physicians with the lowest scores
had experienced the same rates of consultation, prescribing, and screening
as patients of physicians with the highest scores, an additional 3027 patients
would have been referred, 179 fewer elderly patients would have been prescribed
symptom-relief medication, 912 more elderly patients would have been prescribed
disease-specific medication, 189 fewer patients would have received inappropriate
medication, and 121 more women would have received mammography screening.Conclusions.—Licensing examination scores are significant predictors of consultation,
prescribing, and mammography screening rates in initial primary care practice.
162 citations
••
TL;DR: In this paper, the feasibility and value of using patient satisfaction ratings to evaluate the physician-patient relationship skills of medical residents was evaluated using a study conducted in the UK. But the evaluation was limited to a single patient.
Abstract: Objective: To determine the feasibility and value of using patient satisfaction ratings to evaluate the physician-patient relationship skills of medical residents.
71 citations
••
TL;DR: The data suggest that many patients with suspected new-onset CHF do not receive prompt cardiology care, as stipulated by current recommendations, and Equity of access for women and those with lower socioeconomic status appears to be problematic.
32 citations
Cited by
More filters
••
TL;DR: An inclusive definition of competence is generated: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served.
Abstract: ContextCurrent assessment formats for physicians and trainees reliably test
core knowledge and basic skills. However, they may underemphasize some important
domains of professional medical practice, including interpersonal skills,
lifelong learning, professionalism, and integration of core knowledge into
clinical practice.ObjectivesTo propose a definition of professional competence, to review current
means for assessing it, and to suggest new approaches to assessment.Data SourcesWe searched the MEDLINE database from 1966 to 2001 and reference lists
of relevant articles for English-language studies of reliability or validity
of measures of competence of physicians, medical students, and residents.Study SelectionWe excluded articles of a purely descriptive nature, duplicate reports,
reviews, and opinions and position statements, which yielded 195 relevant
citations.Data ExtractionData were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion
were broad, given the heterogeneity of interventions, complexity of outcome
measures, and paucity of randomized or longitudinal study designs.Data SynthesisWe generated an inclusive definition of competence: the habitual and
judicious use of communication, knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily practice for the benefit of the
individual and the community being served. Aside from protecting the public
and limiting access to advanced training, assessments should foster habits
of learning and self-reflection and drive institutional change. Subjective,
multiple-choice, and standardized patient assessments, although reliable,
underemphasize important domains of professional competence: integration of
knowledge and skills, context of care, information management, teamwork, health
systems, and patient-physician relationships. Few assessments observe trainees
in real-life situations, incorporate the perspectives of peers and patients,
or use measures that predict clinical outcomes.ConclusionsIn addition to assessments of basic skills, new formats that assess
clinical reasoning, expert judgment, management of ambiguity, professionalism,
time management, learning strategies, and teamwork promise a multidimensional
assessment while maintaining adequate reliability and validity. Institutional
support, reflection, and mentoring must accompany the development of assessment
programs.
2,681 citations
••
TL;DR: For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy, producing a net reduction in overall healthcare costs.
Abstract: Objective: The objective of this study was to evaluate the impact of medication adherence on healthcare utilization and cost for 4 chronic conditions that are major drivers of drug spending: diabetes, hypertension, hypercholesterolemia, and congestive heart failure. Research Design: The authors conducted a retrospective cohort observation of patients who were continuously enrolled in medical and prescription benefit plans from June 1997 through May 1999. Patients were identified for disease-specific analysis based on claims for outpatient, emergency room, or inpatient services during the first 12 months of the study. Using an integrated analysis of administrative claims data, medical and drug utilization were measured during the 12-month period after patient identification. Medication adherence was defined by days’ supply of maintenance medications for each condition. Patients: The study consisted of a population-based sample of 137,277 patients under age 65. Measures: Disease-related and all-cause medical costs, drug costs, and hospitalization risk were measured. Using regression analysis, these measures were modeled at varying levels of medication adherence. Results: For diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs. For these conditions, higher medication costs were more than offset by medical cost reductions, producing a net reduction in overall healthcare costs. For diabetes, hypercholesterolemia, and hypertension, cost offsets were observed for all-cause medical costs at high levels of medication adherence. For all 4 conditions, hospitalization rates were significantly lower for patients with high medication adherence. Conclusions: For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy.
1,689 citations
••
TL;DR: Vignettes appear to be a valid and comprehensive method that directly focuses on the process of care provided in actual clinical practice and show promise as an inexpensive case-mix adjusted method for measuring the quality of care given by a group of physicians.
Abstract: ContextBetter health care quality is a universal goal, yet measuring quality
has proven to be difficult and problematic. A central problem has been isolating
physician practices from other effects of the health care system.ObjectiveTo validate clinical vignettes as a method for measuring the competence
of physicians and the quality of their actual practice.DesignProspective trial conducted in 1997 comparing 3 methods for measuring
the quality of care for 4 common outpatient conditions: (1) structured reports
by standardized patients (SPs), trained actors who presented unannounced to
physicians' clinics (the gold standard); (2) abstraction of medical records
for those same visits; and (3) physicians' responses to clinical vignettes
that exactly corresponded to the SPs' presentations.SettingOutpatient primary care clinics at 2 Veterans Affairs medical centers.ParticipantsNinety-eight (97%) of 101 general internal medicine staff physicians,
faculty, and second- and third-year residents consented to be randomized for
the study. From this group, 10 physicians at each site were randomly selected
for inclusion.Main Outcome MeasuresA total of 160 quality scores (8 cases × 20 physicians) were generated
for each method using identical explicit criteria based on national guidelines
and local expert panels. Scores were defined as the percentage of process
criteria correctly met and were compared among the 3 methods.ResultsThe quality of care, as measured by all 3 methods, ranged from 76.2%
(SPs) to 71.0% (vignettes) to 65.6% (chart abstraction). Measuring quality
using vignettes consistently produced scores closer to the gold standard of
SP scores than using chart abstraction. This pattern was robust when the scores
were disaggregated by the 4 conditions (P<.001
to <.05), by case complexity (P<.001), by site
(P<.001), and by level of physician training (P values from <.001 to <.05). The pattern persisted,
although less dominantly, when we assessed the component domains of the clinical
encounter—history, physical examination, diagnosis, and treatment. Vignettes
were responsive to expected directions of variation in quality between sites
and levels of training. The vignette responses did not appear to be sensitive
to physicians' having seen an SP presenting with the same case.ConclusionsOur data indicate that quality of health care can be measured in an
outpatient setting by using clinical vignettes. Vignettes appear to be a valid
and comprehensive method that directly focuses on the process of care provided
in actual clinical practice. Vignettes show promise as an inexpensive case-mix
adjusted method for measuring the quality of care provided by a group of physicians.
1,161 citations
••
TL;DR: The strengths, limitations, and appropriate applications of health care utilization databases in epidemiology and health services research are considered, with particular reference to the study of medications.
1,151 citations
••
TL;DR: The properties of these cells after transplantation--the stability of resulting hybrid myofibers without immune suppression, the persistence of transgene expression, and the lack of tumorigenicity-- suggest that studies of cell-mediated gene therapy using primary myoblasts can now be broadly applied to mouse models of human muscle and non-muscle diseases.
Abstract: The transplantation of cultured myoblasts into mature skeletal muscle is the basis for a new therapeutic approach to muscle and non-muscle diseases: myoblast-mediated gene therapy. The success of myoblast transplantation for correction of intrinsic muscle defects depends on the fusion of implanted cells with host myofibers. Previous studies in mice have been problematic because they have involved transplantation of established myogenic cell lines or primary muscle cultures. Both of these cell populations have disadvantages: myogenic cell lines are tumorigenic, and primary cultures contain a substantial percentage of non-myogenic cells which will not fuse to host fibers. Furthermore, for both cell populations, immune suppression of the host has been necessary for long-term retention of transplanted cells. To overcome these difficulties, we developed novel culture conditions that permit the purification of mouse myoblasts from primary cultures. Both enriched and clonal populations of primary myoblasts were characterized in assays of cell proliferation and differentiation. Primary myoblasts were dependent on added bFGF for growth and retained the ability to differentiate even after 30 population doublings. The fate of the pure myoblast populations after transplantation was monitored by labeling the cells with the marker enzyme beta-galactosidase (beta-gal) using retroviral mediated gene transfer. Within five days of transplantation into muscle of mature mice, primary myoblasts had fused with host muscle cells to form hybrid myofibers. To examine the immunobiology of primary myoblasts, we compared transplanted cells in syngeneic and allogeneic hosts. Even without immune suppression, the hybrid fibers persisted with continued beta-gal expression up to six months after myoblast transplantation in syngeneic hosts. In allogeneic hosts, the implanted cells were completely eliminated within three weeks. To assess tumorigenicity, primary myoblasts and myoblasts from the C2 myogenic cell line were transplanted into immunodeficient mice. Only C2 myoblasts formed tumors. The ease of isolation, growth, and transfection of primary mouse myoblasts under the conditions described here expand the opportunities to study muscle cell growth and differentiation using myoblasts from normal as well as mutant strains of mice. The properties of these cells after transplantation--the stability of resulting hybrid myofibers without immune suppression, the persistence of transgene expression, and the lack of tumorigenicity--suggest that studies of cell-mediated gene therapy using primary myoblasts can now be broadly applied to mouse models of human muscle and non-muscle diseases.
975 citations