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Abstract
We performed a review of the economic literature to identify what is known about the relationship between Expanded Disability Status Scale (EDSS) categories and cost of multiple sclerosis (MS). We sought cohort studies of patients with multiple sclerosis that described the costs attributed to each EDSS score and utilized specific inclusion criteria for the selection of 10 studies. We found that both direct and indirect costs rise continuously with increasing EDSS category, and this rise is qualitatively exponential. The rise in indirect costs appears at lower EDSS scores. The cost of a relapse occurring in any given EDSS category exceeds that associated with that particular EDSS category. Few studies comprehensively assessed the entire spectrum of the costs, and much of the literature is based on EDSS categories in coarse groupings. In spite of several variations between studies, one important conclusion that we can draw is that rise in cost is positively correlated to scores on the EDSS categories, and therefore agents with a capacity to prevent or arrest the rate of MS progression may affect the overall cost of MS.
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Affiliation(s)
- M B Patwardhan
- Duke Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC 27705, USA.
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Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer 2008; 98:294-9. [PMID: 18182991 PMCID: PMC2361446 DOI: 10.1038/sj.bjc.6604161] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Accepted: 11/28/2007] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to determine the efficacy of palliative oxygen for relief of dyspnoea in cancer patients. MEDLINE and EMBASE were searched for randomised controlled trials, comparing oxygen and medical air in cancer patients not qualifying for home oxygen therapy. Abstracts were reviewed and studies were selected using Cochrane methodology. The included studies provided oxygen at rest or during a 6-min walk. The primary outcome was dyspnoea. Standardised mean differences (SMDs) were used to combine scores. Five studies were identified; one was excluded from meta-analysis due to data presentation. Individual patient data were obtained from the authors of the three of the four remaining studies (one each from England, Australia, and the United States). A total of 134 patients were included in the meta-analysis. Oxygen failed to improve dyspnoea in mildly- or non-hypoxaemic cancer patients (SMD=-0.09, 95% confidence interval -0.22 to 0.04; P=0.16). Results were stable to a sensitivity analysis, excluding studies requiring the use of imputed quantities. In this small meta-analysis, oxygen did not provide symptomatic benefit for cancer patients with refractory dyspnoea, who would not normally qualify for home oxygen therapy. Further study of the use of oxygen in this population is warranted given its widespread use.
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Affiliation(s)
- H E Uronis
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Health Services Research and Development, Durham Veteran's Affairs Medical Center, Durham, NC, USA
| | - D C Currow
- Department of Palliative and Supportive Services, Division of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - D C McCrory
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC, USA
| | - G P Samsa
- Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - A P Abernethy
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Palliative and Supportive Services, Division of Medicine, Flinders University, Bedford Park, South Australia, Australia
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3
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Patwardhan MB, Samsa GP, Michael MA, Prosnitz RG, Fisher DA, Mantyh CR, McCrory DC. Quality measures for the diagnosis and management of colorectal cancer. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.16031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
16031 Background: The huge burden of illness from colorectal cancer (CRC) can be reduced by improving the quality of care for CRC patients. Identifying appropriate quality measures that can assess the processes of care is the first step in this process. Therefore we conducted a comprehensive literature search to identify process measures available in the United States to assess the quality of care for diagnosing and managing patients with CRC and the extent to which they were field-ready. Methods: We conducted a standard literature search using MEDLINE and the Cochrane Database; also explored gray literature, and identified 3771 abstracts. By sequential exclusion, 74 of them were finally included. We included quality measures from traditional QI literature, and supplemented them with those included in studies where these measures were used as part of their research agenda. All measures were abstracted into evidence tables and evaluated using a set of standard criteria regarding their importance, usability, and scientific acceptability. In order to assess the extent to which they were field-ready, we devised a summary rating scale for each quality measure using three criteria: importance and usability, scientific acceptability, and extent of testing. Results: Overall, the coverage of general process measures in CRC is extensive. Process measures are available for diagnostic imaging, staging, surgical therapy, adjuvant chemotherapy, adjuvant radiation therapy, and colonoscopic surveillance. The highest rated measures were those related to chemotherapy (abstract submitted by Morse et al) and pathology reporting. There were no process measures for assessing the quality of: polyp removal, surgical management of stage IV rectal cancer, hepatic metastasis, chemotherapy for stage II colon cancer, stage IV rectal cancer, radiation for stage IV rectal cancer, and notes for endoscopy, surgery, chemotherapy and radiology - all because of lack of guidelines. Conclusions: Our evidence report suggests that we need to actively pursue the task of developing scientifically accurate quality measures for leverage points in the diagnosis and management of CRC; so we can evaluate the quality of care delivered by providers and initiate quality improvement activities, with the aim of providing better patient care. No significant financial relationships to disclose.
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Abstract
OBJECTIVE VA Stroke Study (VASt) data were analyzed to determine whether neurologist management affected the process and outcome of care of patients with ischemic stroke. METHODS VASt prospectively identified patients with stroke admitted to nine VA hospitals (April 1995 to March 1997). Demographics, stroke severity (Canadian Neurologic Score), stroke subtype (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] classification), tests/procedures, and discharge status (independent, Rankin < or = 2, vs dead or dependent, Rankin 3 through 5) were compared between patients who were or were not cared for by a neurologist. RESULTS Of 1,073 enrolled patients, 775 (neurologist care, n = 614; non-neurologist, n = 161) with ischemic stroke were admitted from home. Stroke severity (Canadian Neurologic Score 8.7 +/- 0.1 vs 8.4 +/- 0.2; p = 0.44), TOAST subtype (p = 0.55), and patient age (71.4 +/- 0.4 vs 72.4 +/- 0.7; p = 0.23) were similar for neurologists and non-neurologists. Neurologists more frequently obtained MRI (44% vs 16%; p < 0.001), transesophageal echocardiograms (12% vs 2%; p < 0.001), carotid ultrasounds (65% vs 57%; p = 0.05), cerebral angiography (8% vs 1%; p = 0.001), speech (35% vs 18%; p < 0.001), and occupational therapy (46% vs 33%; p = 0.005) evaluations. Brain CT, transthoracic echocardiogram, 24-hour ambulatory ECG use, and hospitalization durations (18.2 +/- 0.8 vs 19.7 +/- 4.1 days; p = 0.725) were similar. Neurologists' patients were less likely to be dead (5.6% vs 13.5%; OR = 0.38; 95% CI 0.22, 0.68; p = 0.001) and less likely to be dead or dependent (46.1% vs 57.1%; OR = 0.64; 95% CI 0.45, 0.92; p = 0.019) at the time of discharge. The benefit remained after controlling for stroke severity and comorbidity (OR = 0.63; 95% CI 0.42, 0.94; p = 0.025). CONCLUSION Neurologist care was associated with more extensive testing, but similar lengths of hospitalization and improved outcomes.
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Abstract
OBJECTIVE To investigate whether there are differences in poststroke survival between African American and white patients, aged 65 and over, in the United States. METHODS A biracial cohort of patients was selected from a random 20% national sample of Medicare patients (age 65 and over) hospitalized with cerebral infarction in 1991, and was followed up to a period of 3 years. The Cox regression model was used for covariate adjustment. RESULTS A total of 47,045 patients (including 5,324 African Americans) were identified for our analysis. Compared to white patients, African American patients on average were 6% more likely to die post cerebral infarction. The subpopulation analyses further suggest that African Americans age 65 to 74 had much lower 3-year survival probabilities (15 to 20%) than their white counterparts. CONCLUSIONS The authors find evidence of racial disparities in survival post cerebral infarction among the elderly, although the differences by race are not as great as reported elsewhere for stroke incidence and mortality. Future analyses, using more clinically detailed data, should focus especially on whether survival differences by race persist in the young-old (age 65 to 74) population.
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Affiliation(s)
- J Bian
- Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Durham, 27705, USA
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Abstract
The psychometric characteristics of the Reasons For Quitting scale (RFQ) were assessed among a sample of African American smokers with low income (N=487). The intrinsic and extrinsic scales and their respective subscales were replicated. As hypothesized, higher levels of motivation were associated significantly, in patterns that supported the measure's construct validity, with advanced stage of readiness to quit smoking, greater perceived vulnerability to health effects of smoking, and greater social support for cessation. On the basis of the present study, the RFQ might best predict short-term cessation among older and female smokers. Refinement of the RFQ is needed to assess intrinsic motivators other than health concerns and to identify salient motivators for young and male smokers.
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Affiliation(s)
- C M McBride
- Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina 27710-2949, USA.
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Kraus WE, Torgan CE, Duscha BD, Norris J, Brown SA, Cobb FR, Bales CW, Annex BH, Samsa GP, Houmard JA, Slentz CA. Studies of a targeted risk reduction intervention through defined exercise (STRRIDE). Med Sci Sports Exerc 2001; 33:1774-84. [PMID: 11581566 DOI: 10.1097/00005768-200110000-00025] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE The Studies of a Targeted Risk Reduction Intervention through Defined Exercise (STRRIDE) trial is a randomized controlled clinical trial designed to study the effects of exercise training regimens differing in dose (kcal.wk-1) and/or intensity (relative to peak VO2) on established cardiovascular risk factors and to investigate the peripheral biologic mechanisms through which chronic physical activity alters carbohydrate and lipid metabolism to result in improvements in these parameters of cardiovascular risk in humans. METHODS We will recruit 384 subjects and randomly assign them to one of three exercise training regimens or to a sedentary control group. The recruiting goal is to attain a subject population that is 50% female and 30% ethnic minority. The overall strategy is to use graded exercise training regimens in moderately overweight subjects with impairments in insulin action and mild to moderate lipid abnormalities to investigate whether there are dose or intensity effects and whether adaptations in skeletal muscle (fiber type, metabolic capacity, and/or capillary surface area) account for improvements in insulin action and parameters of lipoprotein metabolism. We will study these variables before and after exercise training, and over the course of a 2-wk detraining period. The study sample size is chosen to power the study to examine differences in responses between subjects of different gender and ethnicity to exercise training with respect to the least sensitive parameter-skeletal muscle capillary density. RESULTS The driving hypothesis is that improvements in cardiovascular risk parameters derived from habitual exercise are primarily mediated through adaptations occurring in skeletal muscle. CONCLUSION Identification that amount and intensity of exercise matter for achieving general and specific health benefits and a better understanding of the peripheral mechanisms mediating the responses in carbohydrate and lipid metabolism to chronic physical activity will lead to better informed recommendations for those undertaking an exercise program to improve cardiovascular risk.
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Affiliation(s)
- W E Kraus
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Samsa GP, Kolotkin RL, Williams GR, Nguyen MH, Mendel CM. Effect of moderate weight loss on health-related quality of life: an analysis of combined data from 4 randomized trials of sibutramine vs placebo. Am J Manag Care 2001; 7:875-83. [PMID: 11570021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
OBJECTIVES To determine whether (1) patients who experience greater weight loss also experience correspondingly greater improvements in health-related quality of life (HRQOL); (2) the improvement in HRQOL is noticeable for patients achieving moderate (5%-10%) weight reduction; and (3) the relationship between weight reduction and HRQOL is similar for patients receiving sibutramine hydrochloride vs placebo. STUDY DESIGN We combined data from 4 double-blind, randomized, controlled trials of administration of sibutramine (20 mg/d) vs placebo. PATIENTS AND METHODS Patients (n = 555) were mildly to moderately obese and had type 2 diabetes mellitus, dyslipidemia, or hypertension that was well controlled with an angiotensin-converting enzyme inhibitor or calcium channel blocker. The HRQOL was operationalized using the Impact of Weight on Quality of Life (IWQOL) and the Medical Outcomes Study 36-Question Short-Form (SF-36) instruments. The main statistical technique was a patient-level analysis of variance predicting change in HRQOL from study, treatment, and weight change. RESULTS Moderate weight loss was associated with a statistically significant improvement in HRQOL for approximately half of the subscales evaluated (P < .05). The greatest sensitivity to change was shown by the SF-36 general health perception and change in health since last year subscales and the IWQOL overall health, mobility, and total subscales. Greater weight loss was associated with the most improvement in HRQOL. Weight losses of 5.01% to 10.00% were associated with 2-unit changes in the SF-36 general health perception subscale and 10-unit changes in the IWQOL total subscale. Results were similar across study and treatment. CONCLUSIONS Moderate weight loss is associated with noticeably improved HRQOL. Improvements in HRQOL are achievable by patients receiving sibutramine.
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Affiliation(s)
- G P Samsa
- Departments of Community and Family Medicine, Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC, USA.
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9
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Abstract
OBJECTIVE In a large, population-based cohort of patients with spinal cord dysfunction, we assessed the relationship between self-reported physical function and hours of care received. DESIGN Data were obtained by a cross-sectional, self-administered survey used to help establish a national registry of veterans with spinal cord dysfunction. Participants were originally identified from Department of Veterans Affairs databases as having a high probability of spinal cord dysfunction. All 13,542 respondents reporting spinal cord dysfunction and also having complete data on physical function and caregiver hours (CGHs) were included. Physical function was measured using the Self-Reported Functional Measure, and CGHs were obtained from a self-report of hours of caregiving received during the last 2 wk. RESULTS The relationship between self-reported disability and CGHs was strong (Spearman correlation = -0.70). Subjects with moderate levels of disability had the most variability in CGHs. After stratifying by total Self-Reported Functional Measure score, the strongest predictors of CGHs were instrumental activities of daily living and individual Self-Reported Functional Measure items, explaining a moderate amount of variation in CGHs. CONCLUSION These data support the construct validity of the Self-Reported Functional Measure and suggest that self-reported disability measures can be of use in describing the clinical epidemiology of patients with spinal cord dysfunction.
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Affiliation(s)
- G P Samsa
- Center for Clinical Health Policy Research, and Department of Medicine, Duke University Medical Center, Durham, North Carolina 27705, USA
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10
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Abstract
The psychometric characteristics of the Reasons For Quitting scale (RFQ) were assessed among a sample of African American smokers with low income (N=487). The intrinsic and extrinsic scales and their respective subscales were replicated. As hypothesized, higher levels of motivation were associated significantly, in patterns that supported the measure's construct validity, with advanced stage of readiness to quit smoking, greater perceived vulnerability to health effects of smoking, and greater social support for cessation. On the basis of the present study, the RFQ might best predict short-term cessation among older and female smokers. Refinement of the RFQ is needed to assess intrinsic motivators other than health concerns and to identify salient motivators for young and male smokers.
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Affiliation(s)
- C M McBride
- Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina 27710-2949, USA.
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Rimer BK, Halabi S, Sugg Skinner C, Kaplan EB, Crawford Y, Samsa GP, Strigo TS, Lipkus IM. The short-term impact of tailored mammography decision-making interventions. Patient Educ Couns 2001; 43:269-285. [PMID: 11384825 DOI: 10.1016/s0738-3991(00)00172-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND We assessed the short-term impact of decision-making interventions on knowledge about mammography, accuracy of women's breast cancer risk perceptions, attitudes toward mammography, satisfaction with decisions, and mammography use since the intervention. METHODS The study was conducted among women who were members of Blue Cross Blue Shield of North Carolina and were in their 40s or 50s at the time the study began in 1997. Women were randomly assigned to usual care (UC), tailored print booklets (TP) alone, or TP plus telephone counseling (TP+TC ). RESULTS 12-month interviews were completed by 1127 women to assess short-term intervention effects. Generally, women who received TP+TC were significantly more knowledgeable about mammography and breast cancer risk and were more accurate in their breast cancer risk perceptions than women in the TP and UC groups. They also were more likely to have had a mammogram since the baseline interview. In multivariable analyses, we found significant benefits of the combination of TP+TC compared to TP and to UC for knowledge, accuracy of risk perceptions, and mammography use. DISCUSSION For complex decision-making tasks, such as women's decisions about mammography in the face of controversy, the combination of TP and TC may be more effective than TP alone, and certainly more effective than UC. It is critical that investigators determine the topics for which TP is appropriate and the situations that require additional supportive interventions.
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Affiliation(s)
- B K Rimer
- Division of Cancer Control and Population Sciences, National Cancer Institute, Room 242, 6130 Executive Blvd, Rockville, MD 20852, USA.
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McCrory DC, Samsa GP, Hamilton BB, Govert JA, Matchar DB, Goslin RE, Kolimaga JT. Treatment of pulmonary disease following cervical spinal cord injury. Evid Rep Technol Assess (Summ) 2001:1-4. [PMID: 11471527 PMCID: PMC4781449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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Abstract
OBJECTIVE To investigate whether ischemic stroke severity differed among women who were receiving hormone replacement therapy (HRT) as compared with those who were not receiving these drugs. BACKGROUND Estrogen has a neuroprotective effect in animal models of ischemic stroke, but data reflecting the impact of HRT on ischemic stroke severity in humans are lacking. METHODS All women receiving HRT at the time of admission for acute ischemic stroke to an academic medical center over 3 years were identified by medical record review (n = 58). HRT users were matched with 116 HRT nonusers by age and number of stroke risk factors. Stroke severity was assessed retrospectively with the Canadian Neurological SCALE: Data were analyzed with nonparametric univariate tests (Spearman rank and chi(2) tests) and linear regression modeling using nonparametric matched-pair analysis. RESULTS History of congestive heart failure or coronary artery disease (p = 0.01), atrial fibrillation (p = 0.02), and African American race (p = 0.04), were significantly associated with greater stroke severity in the univariate analysis. There was a nonsignificant trend toward lesser stroke severity in HRT users (median Canadian Neurological Scale score, 10, vs 9.5 in non-HRT users, p = 0.08). Multivariate analysis showed no independent effect of HRT use on stroke severity (F = 1.24, p = 0.17). CONCLUSIONS There was no significant effect of HRT status on stroke severity. Because this was a retrospective analysis, prospective studies are also needed to further elucidate any potential neuroprotective effect of hormone replacement.
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Affiliation(s)
- C D Bushnell
- Duke Center for Cerebrovascular Disease, Department of Medicine (Neurology) Duke University Medical Center, Durham, NC 27710, USA.
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14
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Abstract
BACKGROUND AND PURPOSE The results of phase III trials of neuroprotective drugs for acute ischemic stroke have been disappointing. We examine the question of whether these trials may have been underpowered. METHODS Computer simulations were based on the binomial distribution. RESULTS We illustrate that even small overestimates of the efficacy of an intervention can lead to a serious reduction in statistical power, that the use of data from phase II studies tends to lead to such overestimation, and that a minimum clinically important difference derived with cost-effectiveness modeling techniques is considerably smaller than might be suggested by intuition. CONCLUSIONS We recommend placing more emphasis on minimum clinically important differences when planning stroke trials, with these differences being derived from an assessment of the public health impact obtained in conjunction with the use of epidemiological and cost-effectiveness models. Even small benefits, when averaged over a sufficiently large number of cases, will, in total, accrue to a large positive impact on the public health.
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Affiliation(s)
- G P Samsa
- Center for Clinical Health Policy Research, Department of Medicine, Duke University Medical Center, Durham, NC 27705, USA.
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Duscha BD, Annex BH, Keteyian SJ, Green HJ, Sullivan MJ, Samsa GP, Brawner CA, Schachat FH, Kraus WE. Differences in skeletal muscle between men and women with chronic heart failure. J Appl Physiol (1985) 2001; 90:280-6. [PMID: 11133920 DOI: 10.1152/jappl.2001.90.1.280] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Men with chronic heart failure (CHF) have alterations in their skeletal muscle that are partially responsible for a decreased exercise tolerance. The purpose of this study was to investigate whether skeletal muscle alterations in women with CHF are similar to those observed in men and if these alterations are related to exercise intolerance. Twenty-five men and thirteen women with CHF performed a maximal exercise test for evaluation of peak oxygen consumption (VO(2)) and resting left ventricular ejection fraction, after which a biopsy of the vastus lateralis was performed. Twenty-one normal subjects (11 women, 10 men) were also studied. The relationship between muscle markers and peak VO(2) was consistent for CHF men and women. When controlling for gender, analysis showed that oxidative enzymes and capillary density are the best predictors of peak VO(2.) These results indicate that aerobically matched CHF men and women have no differences in skeletal muscle biochemistry and histology. However, when CHF groups were separated by peak exercise capacity of 4.5 metabolic equivalents (METs), CHF men with peak VO(2) >4.5 METs had increased citrate synthase and 3-hydroxyacyl-CoA dehydrogenase compared with CHF men with peak VO(2) <4.5 METs. CHF men with a lower peak VO(2) had increased capillary density compared with men with higher peak VO(2). These observations were not reproduced in CHF women. This suggests that differences may exist in how skeletal muscle adapts to decreasing peak VO(2) in patients with CHF.
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Affiliation(s)
- B D Duscha
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Halabi S, Skinner CS, Samsa GP, Strigo TS, Crawford YS, Rimer BK. Factors associated with repeat mammography screening. J Fam Pract 2000; 49:1104-1112. [PMID: 11132060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Even organizations with differing mammography recommendations agree that regular repeat screening is required for mortality reduction. However, most studies have focused on one-time screening rather than repeat adherence. We compare trends in beliefs and health-related behaviors among women screened and adherent to the National Cancer Institute's screening mammography recommendations (on schedule), those screened at least once and nonadherent (off schedule), and those never screened. METHODS Our data are from a baseline telephone interview conducted among 1,287 female members of Blue Cross Blue Shield of North Carolina who were aged either 40 to 44 years or 50 to 54 years. RESULTS The 3 groups differed significantly on beliefs and health-related behaviors, with the off-schedule group almost consistently falling between the on-schedule and never screened groups. Off-schedule women were more likely than on-schedule women, but less likely than those never screened, to not have a clinical breast examination within 12 months, to be ambivalent about screening mammography, to be confused about screening guidelines, and to not be advised by a physician to get a mammogram in the past 2 years. Off-schedule women perceived their breast cancer risk as lower and were less likely to be up to date with other cancer screening tests. CONCLUSIONS Our findings suggest that women who are off schedule are in need of mammography-promoting interventions, including recommendations from and discussion with their health care providers. Because they are more positive and knowledgeable about mammography than women who have never been screened, they may benefit from brief interventions from health care providers that highlight the importance of repeat screening.
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Affiliation(s)
- S Halabi
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Goldstein LB, Bian J, Samsa GP, Bonito AJ, Lux LJ, Matchar DB. New transient ischemic attack and stroke: outpatient management by primary care physicians. Arch Intern Med 2000; 160:2941-6. [PMID: 11041901 DOI: 10.1001/archinte.160.19.2941] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Patients with transient ischemic attack (TIA) or stroke frequently first contact their primary care physician rather than seeking care at a hospital emergency department. The purpose of the present study was to identify a group of patients seen by primary care physicians in an office setting for a first-ever TIA or stroke and characterize their evaluation and management. METHODS Practice audit based on retrospective, structured medical record abstraction from 27 primary care medical practices in 2 geographically separate communities in the eastern United States. RESULTS Ninety-five patients with a first-ever TIA and 81 with stroke were identified. Seventy-nine percent of those with TIA vs 88% with stroke were evaluated on the day their symptoms occurred (P =.12). Only 6% were admitted to a hospital for evaluation and treatment on the day of the index visit (2% TIA; 10% stroke; P =.03); only an additional 3% were admitted during the subsequent 30 days. Specialists were consulted for 45% of patients. A brain imaging study (computed tomography or magnetic resonance imaging) was ordered on the day of the index visit in 30% (23% TIA, 37% stroke; P =.04), regardless of whether the patient was referred to a specialist. Carotid ultrasound studies were obtained in 28% (40% TIA, 14% stroke; P<.001), electrocardiograms in 19% (18% TIA, 21% stroke; P =.60), and echocardiograms in 16% (19% TIA, 14% stroke; P =.34). Fewer than half of patients with a prior history of atrial fibrillation (n = 24) underwent anticoagulation when evaluated at the index visit. Thirty-two percent of patients (31% TIA, 33% stroke; P =.70) were not hospitalized and had no evaluations performed during the first month after presenting to a primary care physician with a first TIA or stroke. Of these patients, 59% had a change in antiplatelet therapy on the day of the index visit. CONCLUSIONS Further primary care physician education regarding the importance of promptly and fully evaluating patients with TIA or stroke may be warranted, and barriers to implementation of established secondary stroke prevention strategies need to be carefully explored. Arch Intern Med. 2000;160:2941-2946
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Affiliation(s)
- L B Goldstein
- Department of Medicine (Neurology), Box 3651, Duke University Medical Center, Durham, NC 27710.
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Matchar DB, Samsa GP, Cohen SJ, Oddone EZ. Community impact of anticoagulation services: rationale and design of the Managing Anticoagulation Services Trial (MAST). J Thromb Thrombolysis 2000; 9 Suppl 1:S7-11. [PMID: 10859579 DOI: 10.1023/a:1018722001817] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We describe the design of the Managing Anti-coagulation Services Trial (MAST), a practice-improvement trial testing whether anticoagulation services are a preferred method of managing anticoagulation for stroke prevention among patients with atrial fibrillation. Most randomized trials within the health care environment are designed as efficacy studies to determine what works under ideal conditions or ideal clinical practice. In contrast, effectiveness trials seek to generalize the results of efficacy studies by determining what works under more typical practice conditions. Practice-improvement trials are effectiveness trials that examine the management of a clinical problem in the context in which care is usually given. Noteworthy features of the MAST include defining the intervention in functional terms and collaboration with managed care organizations.
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Affiliation(s)
- D B Matchar
- Center for Clinical Health Policy Research, Duke University Medical Center, Durham, North Carolina 27705, USA
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Samsa GP, Matchar DB, Goldstein LB, Bonito AJ, Lux LJ, Witter DM, Bian J. Quality of anticoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities. Arch Intern Med 2000; 160:967-73. [PMID: 10761962 DOI: 10.1001/archinte.160.7.967] [Citation(s) in RCA: 212] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Most treatment of patients at risk for stroke is provided in the ambulatory setting. Although many studies have addressed the proportion of eligible patients with atrial fibrillation (AF) receiving warfarin sodium, few have addressed the quality of their anticoagulation management. OBJECTIVE As a comprehensive assessment of quality, we analyzed the proportion of eligible patients receiving warfarin, the proportion of time their international normalized ratios (INRs) were within the target range, and, when an out-of-target range INR value occurred, the time until the next INR measurement was made. METHODS Retrospective review of the medical records of 660 patients with AF managed by general internists and family practitioners in Rochester, NY, and the Research Triangle area of North Carolina. RESULTS Only 34.7% of eligible patients with AF received warfarin. The INR values were out of the target range approximately half the time, and the response to these values was not always timely. For all the measures considered, both Rochester practices with access to an anticoagulation service had higher (albeit not ideal) quality of warfarin management than the remaining practices. CONCLUSIONS We found significant deficiencies in the practice of warfarin management and suggestive evidence that anticoagulation services can partially ameliorate these deficiencies. More research is needed to describe the quality of anticoagulation management in typical practice and how this management can be improved.
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Affiliation(s)
- G P Samsa
- Center for Clinical Health Policy Research, Department of Medicine, Duke University Medical Center, Durham, NC 27705, USA.
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Samsa GP, Matchar DB. Relationship between test frequency and outcomes of anticoagulation: a literature review and commentary with implications for the design of randomized trials of patient self-management. J Thromb Thrombolysis 2000; 9:283-92. [PMID: 10728029 DOI: 10.1023/a:1018778914477] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patient self-management (PSM) of anticoagulation, which is primarily based upon the premise that more frequent testing will lead to tighter anticoagulation control and thus to improved clinical outcomes, is a promising model of care. The goals of this paper are (1) to describe the strength of evidence correlating more frequent testing with improved outcomes; and (2) to discuss implications of these findings for the design of randomized controlled trials (RCTs) assessing the effectiveness and cost-effectiveness of PSM. METHODS We performed two literature reviews: one examining the strength of the relationship between time in target range (TTR) and the clinical outcomes of major bleeding and thromboembolism; and the second examining the strength of the relationship between frequency of testing and TTR. RESULTS We found that (1) the relationship between TTR and clinical outcomes is strong, thus supporting use of TTR as a primary outcome variable; and (2) more frequent testing seems to increase TTR, although the studies supporting this latter conclusion were relatively few and not definitive. Statistical analysis suggested that a study which uses clinical event rates as its primary outcome would need to be much larger than a comparable study which is based upon TTR. CONCLUSIONS When designing randomized trials of PSM, the design should (1) use as its control group high quality anticoagulation management rather than usual care; (2) include the maximum possible amount of self-management in the intervention group; (3) include different testing intervals in the intervention group; (4) use TTR as the primary outcome variable and event rates as a secondary outcome; and (5) base the sample size calculations upon a 5-10% absolute improvement in TTR. Additional RCTs are needed in order to determine how the promise of PSM can best be fulfilled.
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Affiliation(s)
- G P Samsa
- Center for Clinical Health Policy Research, Department of Medicine, Department of Community and Family Medicine, Duke University Medical Center, Durham, NC 27705, USA.
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Mitchell JB, Ballard DJ, Matchar DB, Whisnant JP, Samsa GP. Racial variation in treatment for transient ischemic attacks: impact of participation by neurologists. Health Serv Res 2000; 34:1413-28. [PMID: 10737445 PMCID: PMC1975666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
OBJECTIVE This study evaluates the role of neurologists in explaining African American-white differences in the use of diagnostic and therapeutic services for cerebrovascular disease. DATA SOURCES/STUDY SETTING Medicare inpatient hospital records were used to identify a random 20 percent sample of patients age 65 and over hospitalized with a principal diagnosis of TIA between January 1, 1991 and November 30, 1991 (n = 17,437). STUDY DESIGN Medicare administrative data were used to identify five outcome measures: noninvasive cerebrovascular tests, cerebral angiography, carotid endarterectomy, anticoagulant therapy (as proxied by outpatient prothrombin time tests), and the specialty of the attending physician (neurologist versus other specialist). DATA COLLECTION/EXTRACTION METHODS All Medicare claims were extracted for a 30-day period beginning with the date of admission. PRINCIPAL FINDINGS Even after adjusting for patient demographics, comorbidity, ability to pay, and provider characteristics, African American patients were significantly less likely to receive noninvasive cerebrovascular testing, cerebral angiography, or carotid endarterectomy, compared with white patients, and to have a neurologist as their attending physician. At the same time, patients treated by neurologists were more likely to undergo diagnostic testing and less likely to undergo carotid endarterectomy. CONCLUSIONS The findings suggest that African American patients with TIA may have less access to services for cerebrovascular disease and that at least some of this may be attributed to less access to neurologists. More research is needed on how patients at risk for stroke are referred to specialists.
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Affiliation(s)
- J B Mitchell
- Health Economics Research Inc., Waltham, MA 02452-8414, USA
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Abstract
BACKGROUND AND PURPOSE It has recently been hypothesized that the figure of approximately half a million strokes substantially underestimates the actual annual stroke burden for the United States. The majority of previously reported studies on the epidemiology of stroke used relatively small and homogeneous population-based stroke registries. This study was designed to estimate the occurrence, incidence, and characteristics of total (first-ever and recurrent) stroke by using a large administrative claims database representative of all 1995 US inpatient discharges. METHODS We used the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, release 4, which contains approximately 20% of all 1995 US inpatient discharges. Because the accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding is suboptimal, we performed a literature review of ICD-9-CM 430 to 438 validation studies. The pooled results from the literature review were used to make appropriate adjustments in the analysis to correct for some of the inaccuracies of the diagnostic codes. RESULTS There were 682 000 occurrences of stroke with hospitalization (95% CI 660 000 to 704 000) and an estimated 68 000 occurrences of stroke without hospitalization. The overall incidence rate for occurrence of total stroke (first-ever and recurrent) was 259 per 100 000 population (age- and sex-adjusted to 1995 US population). Incidence rates increased exponentially with age and were consistently higher for males than for females. CONCLUSIONS We conservatively estimate that there were 750 000 first-ever or recurrent strokes in the United States during 1995. This new figure emphasizes the importance of preventive measures for a disease that has identifiable and modifiable risk factors and for the development of new and improved treatment strategies and infrastructures that can reduce the consequences of stroke.
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Affiliation(s)
- G R Williams
- Department of Health Outcomes Management and Research, Knoll Pharmaceutical Co, Mount Olive, NJ 07046, USA.
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Abstract
Our objective was to compare a brief, relatively new global health status measure, the Health Utilities Index Mark II (HUI), to two commonly applied health status measures (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36] and the Sickness Jgipact Profile [SIP] in a general medical outpatient population. Using a cross-sectional survey, we surveyed 160 patients in the General Medical Clinic of the Durham Veterans Affairs Medical Center. Each subject answered demographic questions and then completed the three health status measures. The mean tJgie taken to complete the measures was 3, 10, and 20 minutes for the HUI, SF-36, and SIP, respectively (p <.0001). The HUI exhibited a modest "floor" effect; that is, scores were concentrated near the sicker of the scale. In contrast, responses to the SIP were heavily concentrated near the healthier end of the scale. Spearman correlation coefficients between the HUI and scales within the other two measures ranged from. 54 (SF-36 mental health) to 0.69 (SF-36 physical functioning). Subjects accepted all measures well. These three health service measures varied in their distribution of responses and ttime required to complete. Users should consider the degree of sickness of the population to be assessed when choosing a measure.
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Affiliation(s)
- D Edelman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC 27705, USA
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Matchar DB, Samsa GP. The role of evidence reports in evidence-based medicine: a mechanism for linking scientific evidence and practice improvement. Jt Comm J Qual Improv 1999; 25:522-8. [PMID: 10522233 DOI: 10.1016/s1070-3241(16)30466-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
STUDY QUESTIONS In this article two related questions are considered: (1) Why isn't evidence-based medicine (EBM) more consistently implemented? and (2) Using the EBM paradigm, by what mechanism can we link evidence reports to concrete practice improvement activities? STUDY DESIGN To motivate a systematic analysis, answers to these questions are framed within the context of a general conceptual model for practice improvement, using as an example the application of this general model to the question of improving anticoagulation. CONCLUSIONS The potential role of evidence reports is quite broad and to be most effective, they should (1) be considered as part of a comprehensive strategy for practice improvement and (2) be designed with their customers in mind. A system-based method for using the information from evidence reports involves ultimately suggesting specific practice improvement strategies in which the strategies are defined in terms of (1) a set of functional specifications and (2) a toolbox of implementation options. Such an approach brings to bear the specialized expertise and generalized fund of scientific knowledge used to produce the evidence report, but does so in a way that facilitates local tailoring. That is, while information synthesis should be global, implementation must be local.
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Affiliation(s)
- D B Matchar
- Center for Clinical Health Policy Research, Duke University, USA.
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Matchar DB, Samsa GP. Using outcomes data to identify best medical practice: the role of policy models. Hepatology 1999; 29:36S-39S. [PMID: 10386082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2022]
Abstract
Increasingly, physicians are attempting to incorporate best evidence into their clinical decision making. However, best evidence takes a variety of forms, including clinical trials, cohort studies, administrative data, and patient preference data. Incorporating multiple data sources in a way that informs complex clinical decisions is a substantial analytical challenge. One approach to this challenge is to develop a simulation/decision model that explicitly represents the natural history of disease and the impact of treatments on that natural history. The model should be requisite--that is, sufficient in form to address the decision problem--but not overly complex. Such a model can be of value because it (1) allows a variety of viewpoints to be considered, (2) incorporates the best scientific evidence, and (3) permits sensitivity analyses to evaluate the impact of alternative clinical scenarios and uncertainty in model inputs. The Stroke Prevention Policy Model (SPPM) illustrates this approach. The SPPM is a simulation model designed to predict the best among various treatment alternatives for preventing strokes. Similar models can be applied to treatment outcomes for liver disease.
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Affiliation(s)
- D B Matchar
- Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC 27705, USA.
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Samsa GP, Reutter RA, Parmigiani G, Ancukiewicz M, Abrahamse P, Lipscomb J, Matchar DB. Performing cost-effectiveness analysis by integrating randomized trial data with a comprehensive decision model: application to treatment of acute ischemic stroke. J Clin Epidemiol 1999; 52:259-71. [PMID: 10210244 DOI: 10.1016/s0895-4356(98)00151-6] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A recent national panel on cost-effectiveness in health and medicine has recommended that cost-effectiveness analysis (CEA) of randomized controlled trials (RCTs) should reflect the effect of treatments on long-term outcomes. Because the follow-up period of RCTs tends to be relatively short, long-term implications of treatments must be assessed using other sources. We used a comprehensive simulation model of the natural history of stroke to estimate long-term outcomes after a hypothetical RCT of an acute stroke treatment. The RCT generates estimates of short-term quality-adjusted survival and cost and also the pattern of disability at the conclusion of follow-up. The simulation model incorporates the effect of disability on long-term outcomes, thus supporting a comprehensive CEA. Treatments that produce relatively modest improvements in the pattern of outcomes after ischemic stroke are likely to be cost-effective. This conclusion was robust to modifying the assumptions underlying the analysis. More effective treatments in the acute phase immediately following stroke would generate significant public health benefits, even if these treatments have a high price and result in relatively small reductions in disability. Simulation-based modeling can provide the critical link between a treatment's short-term effects and its long-term implications and can thus support comprehensive CEA.
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Affiliation(s)
- G P Samsa
- Center for Clinical Health Policy Research, Duke University, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27705, USA
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Samsa GP, Bian J, Lipscomb J, Matchar DB. Epidemiology of recurrent cerebral infarction: a medicare claims-based comparison of first and recurrent strokes on 2-year survival and cost. Stroke 1999; 30:338-49. [PMID: 9933269 DOI: 10.1161/01.str.30.2.338] [Citation(s) in RCA: 133] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Because recurrent strokes will tend to leave patients with greater disability than first strokes, patients with recurrent strokes should have poorer outcomes on average than those with first strokes. The extent of this difference has, however, not yet been estimated with precision. METHODS Using a random 20% sample of Medicare patients aged 65 years and older admitted with a primary diagnosis of cerebral infarction during calendar year 1991, we used historical data from the previous 4 years to classify patients as having either first or recurrent stroke and followed survival and direct medical costs for 24 months after stroke. First and recurrent stroke groups were compared with the log-rank test (survival) and t test (cost) and also multivariate modeling. RESULTS Survival from first stroke is consistently better than that for recurrent stroke: 24-month survival was 56.7% versus 48.3%, respectively. Costs were similar for the initial hospital stay and in months 1 to 3 after stroke. During months 4 to 24 after stroke, total costs were higher among those with recurrent stroke by approximately $375/mo across all patients, with this difference being greatest for younger patients and least for patients aged 80 years or older. Most of the difference in total monthly cost was attributable to nursing home utilization (averaging approximately $150/mo) and acute hospitalization (averaging approximately $120/mo). CONCLUSIONS Patients with recurrent stroke have, on average, poorer outcomes than those with first stroke. To be as accurate as possible, clinical policy analyses should use different estimates of health and cost outcomes for first and recurrent stroke.
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Affiliation(s)
- G P Samsa
- Center for Clinical Health Policy Research, and the Departments of Community and Family Medicine and Medicine, Duke University School of Medicine Durham, NC, USA.
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Samsa GP, Matchar DB, Goldstein L, Bonito A, Duncan PW, Lipscomb J, Enarson C, Witter D, Venus P, Paul JE, Weinberger M. Utilities for major stroke: results from a survey of preferences among persons at increased risk for stroke. Am Heart J 1998; 136:703-13. [PMID: 9778075 DOI: 10.1016/s0002-8703(98)70019-5] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patient beliefs, values, and preferences are crucial to decisions involving health care. In a large sample of persons at increased risk for stroke, we examined attitudes toward hypothetical major stroke. METHODS AND RESULTS Respondents were obtained from the Academic Medical Center Consortium (n = 621), the Cardiovascular Health Study (n = 321 ), and United Health Care (n = 319). Preferences were primarily assessed by using the time trade off (TTO). Although major stroke is generally considered an undesirable event (mean TTO = 0.30), responses were varied: although 45% of respondents considered major stroke to be a worse outcome than death, 15% were willing to trade off little or no survival to avoid a major stroke. CONCLUSIONS Providers should speak directly with patients about beliefs, values, and preferences. Stroke-related interventions, even those with a high price or less than dramatic clinical benefits, are likely to be cost-effective if they prevent an outcome (major stroke) that is so undesirable.
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Affiliation(s)
- G P Samsa
- Center for Clinical Health Policy Research, Sanford Institute of Public Policy, the Department of Medicine, Duke University, Durham, NC 27705, USA
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Goldstein LB, Cohen SJ, Matchar DB, Bonito AJ, Samsa GP. Physician-reported readiness to change stroke prevention practices. J Stroke Cerebrovasc Dis 1998; 7:358-63. [PMID: 17895113 DOI: 10.1016/s1052-3057(98)80055-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/1998] [Accepted: 03/12/1998] [Indexed: 11/17/2022] Open
Abstract
There are a series of possible impediments to the incorporation of new treatment modalities into clinical practice, and any intervention intended to alter practice must consider physicians' motivation and readiness to change. As part of a national survey in the United States, physicians from a variety of specialties were asked whether they were comfortable with, considering changing or expecting to make changes in their screening and treatment practices for a series of eight hypothetical patients at elevated risk of stroke. Readiness to change varied with the type of patient under consideration and with physician specialty, but not with a series of other physician and practice characteristics. Knowledge of physicians' states of readiness to change in combination with data relating to current practices and potential barriers to implementation should aid in targeting educational efforts and in the development of specific interventions to improve stroke prevention.
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Affiliation(s)
- L B Goldstein
- Center for Clinical Health Policy Research, Duke University, Durham, NC, USA
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30
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Benesch C, Wilder AL, Witter DM, Duncan PW, Samsa GP, Matchar DB. Inaccuracy of the ICD-9-CM in identifying the diagnosis of ischemic cerebrovascular disease. Neurology 1998. [DOI: 10.1212/wnl.51.3.922-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
BACKGROUND The aim of this study was to assess the influence of race on the treatment and survival of patients with colorectal carcinoma. METHODS This retrospective cohort study included all white or black male veterans given a new diagnosis of colorectal carcinoma in 1989 at Veterans Affairs Medical Centers nationwide. After adjusting for patient demographics, comorbidity, distant metastases, and tumor location, the authors determined the likelihood of surgical resection, chemotherapy, radiation therapy, and death in each case. RESULTS Of the 3176 veterans identified, 569 (17.9%) were black. Bivariate analyses and logistic regression revealed no significant differences in the proportions of patients undergoing surgical resection (70% vs. 73%, odds ratio 0.92, 95% confidence interval 0.74-1.15), chemotherapy (23% vs. 23%, odds ratio 0.99, 95% confidence interval 0.78-1.24), or radiation therapy (17% vs. 16%, odds ratio 1.10, 95% confidence interval 0.85-1.43) for black versus white patients. Five-year relative survival rates were similar for black and white patients (42% vs. 39%, respectively; P=0.16), though the adjusted mortality risk ratio was modestly increased (risk ratio 1.13, 95% confidence interval 1.01-1.28). CONCLUSIONS Overall, race was not associated with the use of surgery, chemotherapy, or radiation therapy in the treatment of colorectal carcinoma among veterans seeking health care at Veterans Affairs Medical Centers. Although mortality from all causes was higher among black veterans with colorectal carcinoma, this finding may be attributed to underlying racial differences associated with survival. This study suggests that when there is equal access to care, there are no differences with regard to race.
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Affiliation(s)
- J A Dominitz
- Center for Health Services Research and Development, Veterans Affairs Medical Center, Durham, North Carolina, USA
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Abstract
BACKGROUND The aim of this study was to assess the influence of race on the treatment and survival of patients with colorectal carcinoma. METHODS This retrospective cohort study included all white or black male veterans given a new diagnosis of colorectal carcinoma in 1989 at Veterans Affairs Medical Centers nationwide. After adjusting for patient demographics, comorbidity, distant metastases, and tumor location, the authors determined the likelihood of surgical resection, chemotherapy, radiation therapy, and death in each case. RESULTS Of the 3176 veterans identified, 569 (17.9%) were black. Bivariate analyses and logistic regression revealed no significant differences in the proportions of patients undergoing surgical resection (70% vs. 73%, odds ratio 0.92, 95% confidence interval 0.74-1.15), chemotherapy (23% vs. 23%, odds ratio 0.99, 95% confidence interval 0.78-1.24), or radiation therapy (17% vs. 16%, odds ratio 1.10, 95% confidence interval 0.85-1.43) for black versus white patients. Five-year relative survival rates were similar for black and white patients (42% vs. 39%, respectively; P=0.16), though the adjusted mortality risk ratio was modestly increased (risk ratio 1.13, 95% confidence interval 1.01-1.28). CONCLUSIONS Overall, race was not associated with the use of surgery, chemotherapy, or radiation therapy in the treatment of colorectal carcinoma among veterans seeking health care at Veterans Affairs Medical Centers. Although mortality from all causes was higher among black veterans with colorectal carcinoma, this finding may be attributed to underlying racial differences associated with survival. This study suggests that when there is equal access to care, there are no differences with regard to race.
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Affiliation(s)
- J A Dominitz
- Center for Health Services Research and Development, Veterans Affairs Medical Center, Durham, North Carolina, USA
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Abstract
BACKGROUND AND PURPOSE The benefit of carotid endarterectomy is highly dependent on surgical risk. However, little data are available concerning factors affecting the risk of endarterectomy performed for asymptomatic carotid artery stenosis outside the setting of a randomized controlled trial. The purpose of this study was to analyze the impact of potential preoperative risk factors on the frequency of postoperative complications in patients undergoing the operation for asymptomatic disease in academic medical centers. METHODS Data regarding postoperative complications were systematically abstracted from the medical records of a random sample of patients who underwent carotid endarterectomy at 12 academic medical centers. RESULTS Of 1160 procedures reviewed, 463 (40%) were performed for asymptomatic disease. Postoperative stroke or death occurred in 13 (2.8%), and myocardial infarction occurred in 8 (1.7%). The rate of postoperative stroke or death was lower in asymptomatic patients than in those with a history of cerebrovascular symptoms in a different vascular distribution, but the difference was not significant (1.8% versus 4.2%; P=.21). There were no significant differences in these rates based on race, a history of angina, recent myocardial infarction, chronic obstructive pulmonary disease, hypertension, the degree of stenosis of the contralateral or ipsilateral carotid artery, or the presence of angiographically recognized ulceration, intraluminal thrombus, or siphon stenosis in the ipsilateral vessel (chi(2); P>.05). Postoperative stroke or death was more frequent in women (5.3% versus 1.6% in men; P=.02), in those aged 75 years or older (7.8% versus 1.8% in those younger than 75 years; P=.01), and in those with a history of congestive heart failure (8.6% versus 2.3% in those without a history of congestive heart failure; P=.03). The risk of stroke or death was higher in the 16 patients who had carotid endarterectomy performed in combination with coronary artery bypass surgery than in those who had only endarterectomy (18.7% versus 2.1%; P<.001). CONCLUSIONS The overall risk of postoperative stroke or death was nearly twice that reported by Asymptomatic Carotid Atherosclerosis Study (ACAS) investigators in the setting of a clinical trial but was within acceptable guidelines. Women were at higher postoperative risk than men, which supported ACAS findings. Additional high-risk groups were those aged 75 years or older, those with a history of congestive heart failure, and those undergoing prophylactic endarterectomy for asymptomatic stenosis in combination with coronary surgery. Knowledge of these rates may help to better assess an individual's postoperative risk and therefore the anticipated benefit of surgery.
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Affiliation(s)
- L B Goldstein
- Center for Clinical Health Policy Research, Division of Neurology, Duke University, Department of Veterans Affairs Medical Center, Durham, NC, USA.
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Cowper PA, Weinberger M, Hanlon JT, Landsman PB, Samsa GP, Uttech KM, Schmader KE, Lewis IK, Cohen HJ, Feussner JR. The cost-effectiveness of a clinical pharmacist intervention among elderly outpatients. Pharmacotherapy 1998; 18:327-32. [PMID: 9545151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We estimated the cost and cost-effectiveness of a clinical pharmacist intervention known to improve the appropriateness of drug prescribing. Elderly veteran outpatients prescribed at least five drugs were randomized to an intervention (105 patients) or control (103) group and followed for 1 year. The intervention pharmacist provided advice to patients and their physicians during all general medicine visits. Mean fixed and variable costs/intervention patient were $36 and $84, respectively Health services use and costs were comparable between groups. Intervention costs ranged from $7.50-30/patient/unit change in drug appropriateness. The cost to improve the appropriateness of drug prescribing is thus relatively low.
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Affiliation(s)
- P A Cowper
- Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina, USA
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Holloway RG, Witter DM, Mushlin AI, Lawton KB, McDermott MP, Samsa GP. Carotid endarterectomy trends in the patterns and outcomes of care at academic medical centers, 1990 through 1995. Arch Neurol 1998; 55:25-32. [PMID: 9443708 DOI: 10.1001/archneur.55.1.25] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate whether the patterns of inpatient care and patient characteristics have changed for patients undergoing a carotid endarterectomy across a group of academic medical centers from 1990 through 1995. If changes occurred, we investigated whether they had an impact on patient outcomes. DESIGN Retrospective evaluation of patients undergoing a carotid endarterectomy using a hospital discharge data set compiled by the Academic Medical Center Consortium. SETTING Ten academic medical centers. PATIENTS A total of 7019 hospital admissions for patients who had 1 carotid endarterectomy performed as a principal procedure from January 1990 to December 1995. MAIN OUTCOME MEASURES Trends in patient demographics, comorbidities, length of stay, days in the intensive care unit, and inpatient cerebral arteriogram use were determined. Patient outcomes included inpatient mortality, discharge to an institution, 30-day readmission rate, and selected diagnoses (postoperative hemorrhage, infection, or seizure; acute myocardial infarction; or cranial nerve palsy) and postprocedure diagnostic tests (computed tomography and magnetic resonance imaging of the head and electroencephalogram) indicative of complications. RESULTS Over the 6-year study period, the number of carotid endarterectomies performed more than doubled and the percentage of hospital admissions for patients 65 years or older increased from 65% to 75%. The mean and median length of stay halved and the percentage of admissions with transfers to the intensive care unit decreased from 56% to 26% of cases. In addition, the percentage of cases with a cerebral arteriogram during the same admission but prior to the day of the carotid endarterectomy decreased from 52% to 27%. There were no trends in inpatient mortality, discharge to an institution, or 30-day readmission rate. There were no significant trends indicative of poorer quality of care as measured by the frequency of secondary diagnoses or postprocedure diagnostic test use. CONCLUSIONS Despite dramatic changes that have occurred in patient characteristics and in hospital management practices for patients undergoing a carotid endarterectomy from 1990 to 1995, we were unable to detect any measurable impact on patient outcomes. These data have implications for monitoring and evaluating the impact of systemwide change on the overall quality of care for patients undergoing a carotid endarterectomy.
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Affiliation(s)
- R G Holloway
- Department of Neurology, University of Rochester School of Medicine and Dentistry, NY 14620, USA
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Graves T, Hanlon JT, Schmader KE, Landsman PB, Samsa GP, Pieper CF, Weinberger M. Adverse events after discontinuing medications in elderly outpatients. Arch Intern Med 1997; 157:2205-10. [PMID: 9342997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Discontinuation of drug therapy is an important intervention in elderly outpatients receiving multiple medications, but it may be associated with adverse drug withdrawal events (ADWEs). OBJECTIVE To determine the frequency, types, timing, severity, and factors associated with ADWEs after discontinuing medications in elderly outpatients. PATIENTS One hundred twenty-four ambulatory elderly participants in 1-year health service intervention trial at the Durham Veterans Affairs General Medicine Clinic in Durham, NC, who stopped taking medications. METHODS A geriatrician retrospectively reviewed computerized medication records and clinical charts to determine medications no longer being taken and adverse events in the subsequent 4-month period. Possible ADWEs, determined by using the Naranjo causality algorithm, were categorized by therapeutic class, organ system, and severity. RESULTS Of 238 drugs stopped, 62 (26%) resulted in 72 ADWEs among 38 patients. Cardiovascular (42%) and central nervous system (18%) drug classes were most frequently associated with ADWEs. The ADWEs most commonly involved the circulatory (51%) and central nervous (13%) systems, and 88% were attributed to exacerbations of underlying disease. Twenty-six ADWEs (36%) resulted in hospitalization or an emergency department or urgent care clinic visit. Only the number of medications stopped was associated with ADWE occurrence (adjusted odds ratio, 1.89; 95% confidence interval, 1.33-2.67). CONCLUSIONS Most medications can be stopped in elderly outpatients without an ADWE occurrence. However, when ADWEs occur they resulted in substantial health care utilization. Practitioners should strive to discontinue drug therapy in the elderly but be vigilant for disease recurrence.
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Affiliation(s)
- T Graves
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
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Matchar DB, Samsa GP, Matthews JR, Ancukiewicz M, Parmigiani G, Hasselblad V, Wolf PA, D'Agostino RB, Lipscomb J. The Stroke Prevention Policy Model: linking evidence and clinical decisions. Ann Intern Med 1997; 127:704-11. [PMID: 9382384 DOI: 10.7326/0003-4819-127-8_part_2-199710151-00054] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Simulation models that support decision and cost-effectiveness analysis can further the goals of evidence-based medicine by facilitating the synthesis of information from several sources into a single comprehensive structure. The Stroke Prevention Policy Model (SPPM) performs this function for the clinical and policy questions that surround stroke prevention. This paper first describes the basic structure and functions of the SPPM, concentrating on the role of large databases (broadly defined as any database that contains many patients, regardless of study design) in providing the SPPM inputs. Next, recognizing that the use of modeling continues to be a source of some controversy in the medical community, it discusses the philosophical underpinnings of the SPPM. Finally, it discusses conclusions in the context of both stroke prevention and other complex medical decisions. We conclude that despite the difficulties in developing comprehensive models (for example, the length and complexity of model development and validation processes, the proprietary nature of data sources, and the necessity for developing new software), the benefits of such models exceed the costs of continuing to rely on more conventional methods. Although they should not replace the clinician in decision making, comprehensive models based on the best available evidence from large databases can support decision making in medicine.
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Parmigiani G, Samsa GP, Ancukiewicz M, Lipscomb J, Hasselblad V, Matchar DB. Assessing uncertainty in cost-effectiveness analyses: application to a complex decision model. Med Decis Making 1997; 17:390-401. [PMID: 9343797 DOI: 10.1177/0272989x9701700404] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A framework for quantifying uncertainty about costs, effectiveness measures, and marginal cost-effectiveness ratios in complex decision models is presented. This type of application requires special techniques because of the multiple sources of information and the model-based combination of data. The authors discuss two alternative approaches, one based on Bayesian inference and the other on resampling. While computationally intensive, these are flexible in handling complex distributional assumptions and a variety of outcome measures of interest. These concepts are illustrated using a simplified model. Then the extension to a complex decision model using the stroke-prevention policy model is described.
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Affiliation(s)
- G Parmigiani
- Institute of Statistics and Decision Sciences, Duke University, Durham, NC 27705, USA
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Benesch C, Witter DM, Wilder AL, Duncan PW, Samsa GP, Matchar DB. Inaccuracy of the International Classification of Diseases (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease. Neurology 1997; 49:660-4. [PMID: 9305319 DOI: 10.1212/wnl.49.3.660] [Citation(s) in RCA: 252] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
In administrative databases the International Classification of Diseases, Version 9, Clinical Modification (ICD-9-CM) is often used to identify patients with specific diagnoses. However, certain conditions may not be accurately reflected by the ICD-9 codes. We assessed the accuracy of ICD-9 coding for cerebrovascular disease by comparing ICD-9 codes in an administrative database with clinical findings ascertained from medical record abstractions. We selected patients with ICD-9 diagnostic codes of 433 through 436 (in either the primary or secondary positions) from an administrative database of patients hospitalized in five academic medical centers in 1992. Medical records of the selected patients were reviewed by trained medical abstractors, and the patients' clinical conditions during the admission (stroke, TIA, asymptomatic) were recorded, as well as any history of cerebrovascular symptoms. Results of the medical record review were compared with the ICD-9 codes from the administrative database. More than 85% of those patients with the ICD-9 code 433 were asymptomatic for the index admission. More than one-third of these asymptomatic patients did not undergo either cerebral angiography or carotid endarterectomy. For ICD-9 code 434, 85% of patients were classified as having a stroke and for ICD-9 code 435, 77% had TIAs. For code 436, 77% of patients were classified as having strokes. Limiting the identifying ICD-9 code to the primary position increased the likelihood of agreement with the medical record review. The ICD-9 coding scheme may be inaccurate in the classification of patients with ischemic cerebrovascular disease. Its limitations must be recognized in the analyses of administrative databases selected by using ICD-9 codes 433 through 436.
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Affiliation(s)
- C Benesch
- Department of Neurology, University of Rochester School of Medicine, NY, USA
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Abstract
OBJECTIVE To describe the prevalence, types, and consequences of adverse drug events (ADEs) in older outpatients with polypharmacy. DESIGN A cohort study. SETTING General Medicine Clinic at the Durham Veterans Affairs Medical Center. PATIENTS A total of 167 high risk (taking > or = 5 scheduled medications) ambulatory older veterans who participated in a year long health service intervention trial. MEASUREMENTS Potential ADEs were identified by asking patients during closeout interviews whether, in the past year, they had experienced any side effects, unwanted reactions, or other problems from any medication. All reported medications and corresponding adverse experiences were assessed for plausibility by a research clinical pharmacist using two standard pharmacological textbooks and categorized by predictability, therapeutic class, and organ system. RESULTS Eighty self-reported ADEs involving 72 medications taken by 58 (35%) of 167 patients were textbook confirmed. Seventy-six of 80 (95%) ADEs were classified as Type A (predictable) reactions. Cardiovascular (33.3%) and central nervous system (27.8%) medication classes were most commonly implicated. Gastrointestinal (30%) and central nervous system (28.8%) ADE symptoms were common. Sixty-three percent of patients with ADEs required physician contacts, 10% emergency room visits, and 11% hospitalization. Twenty percent of medications implicated with ADEs required dosage adjustments, and 48% of ADE-related medications were discontinued. No significant differences (P > .05) were observed when ADE reporters (n = 58) and nonreporters (n = 109) were compared. CONCLUSION Predictable ADEs are common in high risk older outpatients, resulting in considerable medication modification and substantial healthcare utilization.
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Affiliation(s)
- J T Hanlon
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, USA
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Samsa GP, Cohen SJ, Goldstein LB, Bonito AJ, Duncan PW, Enarson C, DeFriese GH, Horner RD, Matchar DB. Knowledge of risk among patients at increased risk for stroke. Stroke 1997; 28:916-21. [PMID: 9158625 DOI: 10.1161/01.str.28.5.916] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE Patients who recognize their increased risk for stroke are more likely to engage in (and comply with) stroke prevention practices than those who do not. We describe perceived risk of stroke among a nationally diverse sample of patients at increased risk for stroke and determine whether patients' knowledge of their stroke risk varied according to patients' demographic and clinical characteristics. METHODS Respondents were recruited from the Academic Medical Center Consortium (n = 621, five academic medical centers, inpatients of varying age); the Cardiovascular Health Study (n = 321, population-based sample of persons aged 65+ years); and United HealthCare (n = 319, five health plans, inpatients and outpatients typically younger than 65 years). The primary outcome was awareness of being at risk for stroke. RESULTS Only 41% of respondents were aware of their increased risk for stroke (including less than one half of patients with previous minor stroke). Approximately 74% of patients who recalled being told of their increased stroke risk by a physician acknowledged this risk in comparison with 28% of patients who did not recall being informed by a physician. Younger patients, depressed patients, those in poor current health, and those with a history of TIA were most likely to be aware of their stroke risk. CONCLUSIONS Over one half of patients at increased risk of stroke are unaware of their risk. Healthcare providers play a crucial role in communicating information about risk, and successful communication encourages adoption of stroke prevention practices. Educational messages should be targeted toward patients least likely to be aware of their risk.
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Affiliation(s)
- G P Samsa
- Center for Health Policy Research and Education, Duke University, Durham, NC 27705, USA
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Schmader KE, Hanlon JT, Landsman PB, Samsa GP, Lewis IK, Weinberger M. Inappropriate prescribing and health outcomes in elderly veteran outpatients. Ann Pharmacother 1997; 31:529-33. [PMID: 9161643 DOI: 10.1177/106002809703100501] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To determine the relationship of inappropriate prescribing in the elderly to health outcomes. SETTING General Medical Clinic of the Durham Veterans Affairs Medical Center. PATIENTS A total of 208 veterans more than 65 years old who were each taking five or more drugs and participated in a pharmacist intervention trial. MEASUREMENTS Prescribing appropriateness was assessed by a clinical pharmacist using the medication appropriateness index (MAI). A summed MAI score was calculated, with higher scores indicating less appropriate prescribing. The health outcomes were hospitalization, unscheduled ambulatory or emergency care visits, and blood pressure control. RESULTS Bivariate analyses revealed that mean MAI scores at baseline were higher for those with hospital admissions (18.9 vs. 16.9, p = 0.07) and unscheduled ambulatory or emergency care visits (18.8 vs. 16.3, p = 0.05) over the subsequent 12 months than for those without admissions and emergency care visits. MAI scores for antihypertensive medications were higher for patients with inadequate blood pressure control (> 160/90 mm Hg) than for those whose blood pressure was controlled (4.7 vs. 3.1, p = 0.02). CONCLUSIONS Inappropriate prescribing appeared to be associated with adverse health outcomes. This findings needs to be confirmed in future studies that have larger samples and control for potential confounders.
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Affiliation(s)
- K E Schmader
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Shelton PS, Hanlon JT, Landsman PB, Scott MA, Lewis IK, Schmader KE, Samsa GP, Weinberger M. Reliability of drug utilization evaluation as an assessment of medication appropriateness. Ann Pharmacother 1997; 31:533-42. [PMID: 9161644 DOI: 10.1177/106002809703100502] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To test the reliability of drug utilization evaluation (DUE) applied to medications commonly used by the ambulatory elderly. METHODS A DUE model was developed for four domains: (1) justification for use, (2) critical process indicators, (3) complications, and (4) clinical outcomes. DUE criteria specific to use in the elderly were developed for angiotensin-converting enzyme (ACE) inhibitors and histamine2 (H2)-antagonists, and consensus was reached by an external expert panel. After pilot testing, two clinical pharmacists independently evaluated these medications, applying the DUE criteria and rating each item as appropriate or inappropriate. Interrater and intrarater reliability was assessed by using kappa statistics. RESULTS In a sample of 208 ambulatory elderly veterans, 42 (20.2%) were taking an ACE inhibitor and 56 (26.9%) an H2-antagonist. The interrater agreement for individual domains, represented by kappa statistics, were 0.10-0.58 and 0-0.83 for ACE inhibitors and H2-antagonists, respectively. The kappa statistic for overall agreement, which considered ratings from all criteria across all domains, was 0.24 for ACE inhibitors and 0.18 for H2-antagonists. Intrarater reliability was assessed 3 months later, and kappa statistics were 0.61-0.65 (0.49 overall) and 0-0.96 (0.81 overall) for ACE inhibitors and H2-antagonists, respectively. CONCLUSIONS Intrarater reliability for DUE was good to excellent. However, interrater reliability exhibited only marginal reproducibility, particularly where evaluators were required to use subjective judgement (i.e., complications, clinical outcomes). DUE may not be a suitable standard for assessing medication appropriateness in ambulatory elderly patients.
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Affiliation(s)
- P S Shelton
- School of Pharmacy, Campbell University, Dorothea Dix Hospital, Raleigh, NC 27603, USA
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Abstract
BACKGROUND AND PURPOSE Diminished quality of life and limitations in higher levels of physical functioning are often underestimated in stroke and are not fully captured by measures such as the Barthel Index and the Rankin Outcome Scale. This study used additional measures to assess the health status of 304 persons with mild stroke and to compare these individuals with 184 persons with transient ischemic attack and 654 persons without history of stroke/transient ischemic attack but at elevated risk for stroke (asymptomatic group). METHODS Subjects were recruited from the Academic Medical Center Consortium (inpatients), the Cardiovascular Health Study (population-based sample of community-dwelling persons 65 years and older), and United HealthCare (inpatients and outpatients typically younger than 65 years). Subjects were interviewed by telephone or in person to assess activities of daily living (Barthel Index), depression (Center for Epidemiological Studies Depression Scale), health status (MOS-36), and utility for current health state. RESULTS Most respondents were independent on all Barthel items. The stroke group was more impaired on the MOS-36 than the asymptomatic group but similar to the group with transient ischemic attack. Health-related quality of life was lowest for persons with stroke. While symptom status and Barthel Index score were the strongest predictors of health status, the Barthel Index showed a consistent ceiling effect when compared with the physical function subscale of the MOS-36. CONCLUSIONS The consequences of even mild stroke affect all dimensions of health except pain. Standardized assessment of persons with stroke must evaluate across the entire continuum of health-related functions.
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Affiliation(s)
- P W Duncan
- Center on Aging, University of Kansas, Kansas City, USA.
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Abstract
BACKGROUND AND PURPOSE The reliability of the National Institutes of Health Stroke Scale (NIHSS) has been established through testing its use in live and videotaped patients. This reliability testing has primarily focused on the use of the scale by neurologists. We sought to determine the reliability of the NIHSS as used by non-neurologists in the context of a clinical trial. METHODS In anticipation of the initiation of a randomized trial of a new therapy for patients with acute ischemic stroke, 30 physician investigators (30% of whom were not neurologists) and 29 non-physician study coordinators were trained in the use of the NIHSS at an informational and training conference using standardized videotaped patient examinations. A series of 4 patients were rated initially. After 3 months, the same 4 patients were rerated, providing a measure of intraobserver reliability. An additional series of 4 new patients were also rated after 3 months and, with the initial 4 ratings, provided data for assessment of interobserver reliability. RESULTS Overall, 28% of the raters had previous experience with the NIHSS, and 22% had previously used the videotapes as used in the present trial. The coefficients of determination (r2) were each greater than .95 when the means of the two ratings of the same 4 cases were compared between (1) neurologists and other types of physicians, (2) physicians and study coordinators, (3) raters who had prior experience with the NIHSS and those without prior experience, and (4) raters who had used the videotapes in the past and those who had never viewed the tapes. The calculated r2s were greater than .98 for the initial rating of the first 4 cases and for the later rating of the 4 new cases. The slopes of the regression lines were all near 1, indicating that the raters were similarly calibrated. The intraclass correlation coefficients were .93 and .95, reflecting high levels of intraobserver and interobserver reliability. CONCLUSIONS These data extend the previously demonstrated reliability of the NIHSS to non-neurologists and show that both a variety of physician investigators and nurse study coordinators can be rapidly trained to reliably apply the scale in the context of an actual clinical trial.
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Affiliation(s)
- L B Goldstein
- Division of Neurology, Duke University Medical Center, Durham, NC 27710, USA.
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Bonito AJ, Samsa GP, Akin DR, Matchar DB. Use of a non-monetary incentive to improve physician responses to a mail survey. Acad Med 1997; 72:73. [PMID: 9008579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- A J Bonito
- Research Triangle Institute, North Carolina, USA
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Matchar DB, Samsa GP, Cohen SJ. Should we just let the anticoagulation service do it? The conundrum of anticoagulation for atrial fibrillation. J Gen Intern Med 1996; 11:768-70. [PMID: 9016428 DOI: 10.1007/bf02598998] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Hanlon JT, Landsman PB, Cowan K, Schmader KE, Weinberger M, Uttech KM, Samsa GP, Cohen HJ. Physician agreement with pharmacist-suggested drug therapy changes for elderly outpatients. Am J Health Syst Pharm 1996; 53:2735-7. [PMID: 8931817 DOI: 10.1093/ajhp/53.22.2735] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- J T Hanlon
- Center for Study of Aging and Human Development (CSAHD), Duke University Medical Center (DUMC), Durham, NC 27710, USA.
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Mitchell JB, Ballard DJ, Whisnant JP, Ammering CJ, Samsa GP, Matchar DB. What role do neurologists play in determining the costs and outcomes of stroke patients? Stroke 1996; 27:1937-43. [PMID: 8898795 DOI: 10.1161/01.str.27.11.1937] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Despite growing concern over the large numbers of specialists in the United States, little information is available on how stroke treatment varies by the specialty of the attending physician. This study compares the costs and outcomes of acute stroke patients by physician specialty, especially between neurologists and other specialists. METHODS We selected a random sample of Medicare patients aged 65 years and older admitted with cerebral infarction between January 1 and September 30, 1991, identified from the principal diagnosis on Medicare Provider Analysis and Review records. All Medicare claims for these patients were extracted from the date of admission through 90 days. The attending physician was identified as that physician billing for routine hospital visits during the first 7 days of the stay. RESULTS Neurologists treating stroke patients were significantly more expensive than other physicians but obtained better outcomes. Ninety-day mortality rates for patients treated by neurologists were significantly lower than those for other specialists. These cost and outcome differences persisted even after adjustment for patient age, comorbidity, hospital teaching status, and other characteristics. Compared with other attending physicians, neurologists were significantly more likely to order diagnostic cerebrovascular tests (especially brain MRI scans), more likely to prescribe warfarin, and more likely to discharge patients to inpatient rehabilitation facilities. CONCLUSIONS Systematic triaging to neurologists based on clinical characteristics unmeasured by administrative data might explain these observed differences between neurologists and other physicians. Alternatively, these specialists may have been better able to identify the mechanism of stroke, information that then affected the course of treatment. Given current pressures to substitute generalists for specialists, however, more research is needed on these stroke treatment differences.
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Affiliation(s)
- J B Mitchell
- Health Economics Research, Inc, Waltham, Mass, USA
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Abstract
OBJECTIVE To describe the pattern of inpatient hospital utilization, up to 15 years after injury, among a cohort of veterans with service-connected traumatic spinal cord injury (SCI). PATIENTS A cohort of 1,250 male veterans, with traumatic SCI occurring between 1970 and 1986, who visited the VA within 1 year of injury, was assembled from VA administrative files; diagnosis was verified by examining hospital discharge summaries. DESIGN Computerized record linkage among Department of Veterans Affairs (VA) administrative files was used to determine patterns of inpatient hospital utilization. MAIN OUTCOME MEASURE Pattern of inpatient admissions and length of stay (LOS). RESULTS Patients were typically white males injured in their mid-twenties. The initial VA hospitalization began approximately 6 weeks after injury and lasted 4 to 7 months, depending on injury level and completeness. Subsequent hospitalizations usually lasted approximately 10 days, but 22% of stays exceeded 1 months. Most hospitalizations took place in specialized SCI Centers. Comparing the 1980s with the 1970s, patients in the 1980s entered VA facilities sooner after injury, were more likely to visit SCI Centers, and had shorter initial stays. Rates for the incidence of rehospitalization decreased rapidly in years 2-5 after injury and declined less rapidly thereafter. Occupancy rates and proportion rehospitalized followed similar patterns. The incidence rate for persons with complete quadriplegia was approximately twice that of patients with incomplete paraplegia. Between 1970 and 1991, both the rehospitalization incidence rate and LOS decreased by approximately 20%. Only 10% of patients accounted for 46% of the total LOS. LOS during the first five years was predictive of later LOS. CONCLUSIONS The pattern of rehospitalization in VA facilities was generally consistent with that of the Model Systems. Efforts toward preventing rehospitalization should target persons with previous high utilization.
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Affiliation(s)
- G P Samsa
- Center for Health Services Research in Primary Care, Durham, NC, USA
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