The path to a clinical pathway: collaborative care for the patient with an ostomy

A colostomy and ileostomy clinical pathway was developed at a southeastern teaching hospital in 1990 in response to excessive lengths of stay and costs at our hospital compared with national data for this patient group. A multidisciplinary clinical pathway team was formed and charged with the development, implementation, and ongoing monitoring of the clinical pathway tool and its effect on the outcomes of the population of patients with colostomies and ileostomies. Through this multidisciplinary collaboration, length of stay and cost have been reduced while quality care indicators have been maintained. This article presents the sample pathway we developed and describes the pathway development process, documentation, the variance analysis process, and the outcomes achieved with implementation. A urostomy/urinary diversion pathway that was developed after variance analysis review of the colostomy and ileostomy clinical pathway is also presented.     

Nonorthogonal two-way analysis of variance.

Examined the advantage of disadvantages of 5 different exact analyses of variance for nonorthogonal 2-way designs with respect to orthogonality of the analyses, parametric hypotheses tested, and model comparisons made by the analyses. It is proposed that experimenters, when faced with the necessity of performing a 2-way ANOVA, carefully consider these analyses with regard to the a priori information they have about the data, the questions they expect the analysis to help answer, and the questions each analysis is best equipped to answer. It is also suggested that experimenters choose the analysis that best fits their needs rather than depend on one for all situations. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multivariate analysis of variance.

We provide an expository presentation of multivariate analysis of variance (MANOVA) for both consumers of research and investigators by capitalizing on its relation to univariate analysis of variance models. We address several questions: (a) Why should one use MANOVA? (b) What is the structure of MANOVA? (c) How are MANOVA test statistics obtained and interpreted? (d) How are MANOVA follow-up tests obtained and interpreted? (e) How is strength of association assessed in MANOVA? (f) How should the results of MANOVA be presented? (g) Are there any alternatives to MANOVA? We use an example data set throughout the article to illustrate these points. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Erythrocyte Na+/Li+ countertransport and Na+/K+-2Cl- co-transport measurement in essential hypertension: useful diagnostic tools or failure? A meta-analysis of 17 years of literature

1.A meta-analysis of 17 years of literature on erythrocyte Na+/Li+ countertransport (NLCT) and Na+/K+ co-transport (COT) measurements in relation to essential hypertension is presented. The analysis aimed to answer two questions: (i) Which clinical or laboratory variables influence NLCT and COT flux values? (ii) How useful are NLCT and COT measurements as a diagnostic aid in essential hypertension?2. Regression analysis was performed on the mean flux values and relevant clinical and laboratory values. Studies in both normotensive and hypertensive subjects were stratified for variables which showed a significant association with the measured flux. For hypertensive subjects the studies were also stratified for medication. Means of strata were calculated after weighing the mean of a study by the inverse of its own variance and were compared in normotensive as well as hypertensive subjects using a t-test.3.The analysis did not demonstrate systematic effects of laboratory variables for either NLCT or COT. It was found that essential hypertension, family history of hypertension, gender and antihypertensive medication are main determinants for the flux values of both transport systems. After stratification for these determinants, significant differences in weighed mean flux values between normotensive and hypertensive subjects were demonstrated. However, these differences are much smaller than the variance in the weighed mean flux values, suggesting the existence of other unknown variables that strongly affect the flux rates.4.In conclusion, NLCT and COT measurements cannot be of diagnostic use in essential hypertension.     

Strategies for analyzing ecological momentary assessment data.

Studies incorporating repeated observations of momentary phenomena are becoming more common in behavioral and medical science. Analysis of such data requires the use of statistical techniques that are unfamiliar to many investigators. Some common ways of analyzing momentary data are reviewed—aggregation strategies, repeated measures analysis of variance, pooled within-person regression, and two-stage estimation procedures for multilevel models—and are found to be usually suboptimal, possible leading to incorrect inferences. A broad class of statistical models for multilevel data that can address many research questions typically asked of momentary data are then described. Analytic issues that merit careful consideration include the scaling of momentary variables, allowance for serial autocorrelation of residuals, and the treatment of coefficients that vary across individuals as fixed versus random effects. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical pathway management of total knee arthroplasty

Using a retrospective cohort study design, the authors examined complications, readmissions, morbidity and mortality, and function scores in two groups of patients attended by the same surgeon for the year before and the year after the implementation of an outcomes management program with clinical pathways for patients undergoing total knee arthroplasty at an academic health center. The effectiveness of the pathway constantly was adjusted using variance analysis and continuous quality improvement techniques. This program reduced the length of stay by 57% from a premanagement value of 10.9 +/- 5.4 days in 1994 (Group 1) to 4.7 +/- 1.4 days in 1996 (Group 2). Hospital costs (based on an inflation adjusted cost to charge ratio) for all total knees were reduced 11% from $13,328 +/- $3905 in 1994 to $11,862 +/- $4763 in 1996. Preoperative and postoperative knee scores were 41.1 +/- 16.3 and 84.2 +/- 16.0 for Group 1 and 42.5 +/- 13.0 and 87.0 +/- 10.4 for Group 2, respectively. There was no statistically significant difference between the preoperative or the postoperative knee scores of Groups 1 and 2. The application of clinical pathways, variance analysis, and continuous quality improvement toward the treatment of patients who had total knee arthroplasty at an academic health center resulted in significant savings in length of stay without adversely affecting overall outcome.     

Evolution de la confiance excessive en fonction du nombre d'indices re?us pour répondre à une question.

Studied the development of overconfidence with regard to answering a general knowledge questionnaire when questions were given with no clues and repeated with 1 to 3 clues. Human subjects: 25 male and female Canadian adults (mean age 30 yrs 2 mo). Ss were given a notebook with 50 questions: all questions appeared 4 times—once with no clues, and 3 times with 1 to 3 clues. Ss were asked to answer the questions and to indicate on a scale of 0.5 to 1 how sure they were of their answers. The results were analyzed statistically according to sex, confidence level, and number of clues, using an analysis of variance (ANOVA). (English abstract) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multivariate analysis of variance by multiple regression methods.

Discusses multivariate analysis of variance as a general case of familiar multiple regression analysis. A consequence of this approach is a unified treatment of multivariate analysis of variance which can be used by psychologists who are generally familiar with multiple regression approaches to univariate analysis of variance. It is suggested that the generality of the approach permits solutions consistent with any of the several available strategies for dealing with problems of unequal and disproportionate cell frequencies. Inherent in the multiple regression formulation is the otherwise not so obvious fact that univariate analysis of variance results are an integral part of the multivariate solution and that both are important for understanding complex data. Methods of interpreting multivariate analysis of variance results in complex factorial experimental designs are discussed. (32 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neural networks as a prognostic tool for patients with non-small cell carcinoma of the lung

Patients with non-small cell carcinoma of the lung (NSCLC) have a poor prognosis (64 and 41% survival rates in Stages I and II). It is currently not possible to predict which patients with Stage I or II NSCLC will survive the disease. Sixty-seven patients with NSCLC, including 49 patients with Stage I NSCLC and 18 with Stage II disease (11 with squamous cell carcinomas, 35 with adenocarcinomas, and 21 with large cell carcinomas) were treated with lobectomy and followed for a minimum of 5 years. The tumors were studied with DNA flow cytometry and quantitative immunocytochemical studies for proliferation cell nuclear antigen, p53 protein, and MIB-1. The data were analyzed with backpropagation neural networks, univariate analysis of variance, the Kaplan-Meier survival method, and Cox proportional hazards model. The dependent variables were "free of disease" and "recurrence or dead from disease." Twenty neural network models were trained, using all cases but one, after 1883 to 2000 training cycles. At 5 years, 30 patients were free of disease and 37 were dead or had recurrence. Proliferating cell nuclear antigen was the only statistically significant prognostic factor by univariate analysis of variance and Cox proportional hazards analysis. The S phase was statistically significant by univariate analysis of variance (P <.05). All of the 20 models classified the test cases correctly. Study with backpropagation neural networks using multiple prognostic features from patients with NSCLC suggests that this technology might be useful for prediction of survival. This preliminary study must be validated with data from a larger group of patients with NSCLC before its clinical adequacy is established.     

Evidence-based medicine

The need to improve the quality of health care and to contain its costs has become mandatory. Simultaneously we are confronted by a growing body of clinical information, most of it irrelevant. This paper describes the origin and methods of Evidence-Based Medicine, a new alternative to the usual ways of medical information. The recent development of computerized data bases is permitting the rapid location of relevant clinical information concerning specific questions on diagnosis, therapy or prognosis. Critical analysis is then used to determine the validity of the evidence obtained, which can be employed in clinical decision making. The future role of Evidence-Based Medicine in education and clinical practice seems highly promissory.     

The trait-state-error model for multiwave data.

Although researchers in clinical psychology routinely gather data in which many individuals respond at multiple times, there is not a standard way to analyze such data. A new approach for the analysis of such data is described. It is proposed that a person's current standing on a variable is caused by 3 sources of variance: a term that does not change (trait), a term that changes (state), and a random term (error). It is shown how structural equation modeling can be used to estimate such a model. An extended example is presented in which the correlations between variables are quite different at the trait, state, and error levels. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mega-analysis of meta-analysis: an examination of meta-analysis with an emphasis on once-daily aminoglycoside comparative trials

Meta-analysis is increasingly performed to try and answer clinical questions around which controversy exists. We performed meta-analyses using three different methods as examples to illustrate problems and points to consider when doing such work. The questions of interest were comparing frequency of nephrotoxicity and clinical effectiveness with once-daily aminoglycoside regimens versus multiple-daily dose aminoglycoside regimens. Inclusion and exclusion criteria were established. Studies were obtained from literature searches, and included published studies and abstracts. The overall odds ratio (95% confidence interval) for nephrotoxicity and clinical effectiveness meta-analyses of these studies using the Mantel-Haenszel-Peto method were 0.70 (0.51-0.94, p = 0.042) and 0.79 (0.59-1.07, p = 0.09), respectively. Analyzing the data by Fisher's combined test and the Mean-P method showed agreement with the other methods' conclusions for nephrotoxicity but not for clinical effectiveness. Meta-analysis is not an exact procedure and contains various problems and inconsistencies. Combining studies of poor quality is not ideal for answering unresolved clinical questions.     

Content analysis of archival data

Content analysis can be a particularly suitable method for measuring cognitive variables from archived texts. Although content analysis has been underused by clinical psychologists, there are many benefits to this strategy. Longitudinal studies can be conducted retrospectively, the range of possible research participants can be expanded to include individuals otherwise unavailable (e.g., the famous or the dead), existing data sets can be used and reused to answer new questions, and studies across cultures and across levels of analysis (individual vs. group) can be facilitated. To illustrate the use and usefulness of content analysis to measure cognitive variables, the authors focus on the examples of causal attributions and integrative complexity, describing past research and sketching future applications to clinical research and practice.     

Insulin-like growth factor binding protein production in human follicular thyroid carcinoma cells

OBJECTIVE: The study investigated the value of using national or regional data bases to examine care in a specific hospital. DATA SOURCES: The following data sources were included: (1) the results of the 1992 HCFA analysis of the index hospital for patients hospitalized in fiscal year 1990; (2) the 1989 Medicare Provider Analysis and Review (MEDPAR) file; and (3) clinical information from bypass surgery patients in Wisconsin and from the index hospital. PRINCIPAL FINDINGS: The assessment of the mortality rates in the index hospital for all conditions combined and for CABG patients differed depending on what data base was used and how the data were analysed. The national data were most useful in establishing that the coding practices for all patients and the mortality rate for intra-aortic balloon patients differed between the index hospital and other hospitals. The regional clinical data base for bypass surgery patients was used to establish that the high mortality rates for intra-aortic balloon patients were due to patient selection. CONCLUSIONS: National claims data must be analysed carefully before applying results to an individual hospital. Even a careful analysis is more for raising questions about care at a specific hospital rather than for reaching definitive conclusions.     

Expertise psycho-juridique: Une évaluation de deux types de rapports et de leur influence sur la perception de jurés potentiels.

Studied the influence of a clinical report and a statistical report used in expert testimony on the perception of potential jurors. 188 undergraduate students (aged 18–40 yrs) participated in a simulated trial. In addition to the usual information about the trial, Ss were exposed to an expert witness favoring a clinical report, an expert witness favoring a statistical report, or no expert witness. They then answered a series of questions concerning their perception of the trial, the expert, the report, and the verdict. Analyses of variance were performed. (English abstract) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Statistical models for renal micropuncture studies

Statistical issues relating to data analysis of re-collection micropuncture experiments are presented. In the presence of significant animal-treatment interaction, namely, differential response of each animal at different levels of the treatment, the conventional paired or unpaired t testing would not be entirely appropriate. Accordingly, two analysis of variance (ANOVA) models have been derived for the appropriate paired and unpaired designs of micropuncture experiments. Interactive computer programs have been written for both these analyses, and the results are illustrated with experimental data. An example is presented in which the results are statistically significant with paired t testing and by analysis of variance for unequal number of tubules but not when the animal-treatment interaction is included in the analysis of variance model. To investigate linkage in renal transport mechanisms, we propose the use of partial correlation analysis. Experimental results from our laboratory are used to illustrate these techniques.     

Evidence for an endogenous cAMP-adenosine pathway in the rat kidney

In the rat kidney, exogenous adenosine-3'-5'-monophosphate (cAMP) is converted to adenosine via the metabolism of cAMP to adenosine-5'-monophosphate by phosphodiesterase and adenosine-5'-monophosphate to adenosine by 5'-nucleotidase. Our purpose was to investigate whether in the rat kidney adenosine is synthesized from endogenous cAMP via the same pathway. Rat kidneys were perfused with Tyrode's solution, and stabilized for 3 hr to minimize basal renal purine secretion. In control experiments (n = 6), the renal venous secretion rate of adenosine, inosine, hypoxanthine and Sigmapurines (adenosine + inosine + hypoxanthine) did not change over the two 10-min experimental periods. In contrast, the beta adrenoceptor agonist (+/-)-isoproterenol (1 and 10 microM added to the perfusate) caused a significant (1-factor analysis of variance with repeated measures; n = 31) increase in the renal venous secretion of adenosine (P <.0001), inosine (P <.0007), hypoxanthine (P <.0007) and Sigmapurines (P <.0001) as measured by high-performance liquid chromatography with ultraviolet detection. The Sigmapurines was the most discriminating index of isoproterenol-induced changes in purine release, and the renal venous secretion of Sigmapurines was significantly (2-factor analysis of variance with repeated measures) attenuated by inhibition of beta adrenoceptors with propranolol (.1 microM, n = 6; P <.05), phosphodiesterase with 3-isobutyl-1-methylxanthine (1 mM, n = 5; P <.002) and 5'-nucleotidase with alpha, beta-methyleneadenosine-5'-diphosphate (0.1 mM, n = 5; P <.03). Our data indicate that activation of beta adrenoceptors increases purine biosynthesis in the rat kidney via a mechanism that involves phosphodiesterase and 5'-nucleotidase. These results support the existence of an endogenous cAMP-adenosine pathway in the rat kidney.     

Detection of human herpesvirus 8 DNA in Kaposi''s sarcoma lesions and peripheral blood of human immunodeficiency virus-positive patients and correlation with serologic measurements

PURPOSE: We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery. METHODS: We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed. RESULTS: Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% (p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate (p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS (p < 0.01) and charges (p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure (p < 0.01) and fluid overload (p < 0.01). CONCLUSIONS: Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% (p < 0.05) and overall LOS reduction of 3.5 days (p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care.     

Coenzyme A independent acylation of phosphatidylethanolamine in isolated bovine rod cell outer segments

RATIONALE AND OBJECTIVES: The purpose of this prospective randomized study was to compare the long-term instructional effectiveness of a computer-based radiology multimedia textbook (MMTB) with that of a traditional lecture. METHODS: Volunteer faculty/fellows and residents were randomly assigned to either a computer-based MMTB group or to a lecture group. The course content for each instructional group was the same. Pretests, posttests, and 1-year long-term retention tests were administered to both groups. The same 10 questions were on all tests. The resulting data were analyzed using analysis of variance procedures available on the Statistical Analysis System. RESULTS: A comparison of the long-term instructional effectiveness of an MMTB versus a lecture showed that the MMTB computer instructional method was at least comparable in spite of the initial short-term appearance of lecture superiority. CONCLUSION: These results suggest a promising future for MMTB and other forms of computer-based education in radiologic instruction for medical students and radiologists.