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Biomedical subjects

Charles Maynard

Publications and source records attributed to Charles Maynard.

At least 55 records · Page 3Linked to original sources
PubMed2004

Data resources in the Department of Veterans Affairs.

OBJECTIVE: To provide an overview of databases that are maintained by the Department of Veterans Affairs (VA) and are of relevance to investigators involved in epidemiologic, clinical, and health services research. RESEARCH DESIGN AND METHODS: We reviewed both national and local VA databases and identified their strengths and limitations. We also referenced specific studies that have assessed the validity and reliability of VA databases. RESULTS: There are numerous national databases housed at the Austin Automation Center in Austin, Texas. These include the Patient Treatment File (hospital abstracts), the Outpatient Care File, the Beneficiary Identification Record Locator System death file for assessing vital status, and the Decision Support System, which provides integrated clinical and financial information for managerial decision making. The major limitation of these databases is that clinical detail below the level of ICD-9-CM diagnosis and procedure codes is not uniformly available nationally. These databases offer an excellent opportunity to monitor the health of veterans over time because they track all inpatient and outpatient utilization in the VA. However, at the local or medical center level, the Veterans Health Information and Systems and Technology Architecture contains extensive clinical information, but has fewer patients, varies in format across medical centers, and poses difficulties with data extraction for statistical analysis. CONCLUSIONS: Both local and national VA databases are valuable resources for investigators who have interests in a wide array of research topics, including diabetes. The potential for investigating important scientific questions with VA databases becomes greater as communications and database management technologies improve.

Confidentiality↗
PubMed2004

The burden of diabetes-associated cardiovascular hospitalizations in Veterans Administration (VA) and non-VA medical facilities.

OBJECTIVE: This study examines the relative burden of cardiovascular disease in diabetic and nondiabetic admissions to Veterans Administration (VA) and non-VA hospitals. RESEARCH DESIGN AND METHODS: Calendar year 1997 hospitalization data were collected from the VA Patient Treatment File and the National Hospital Discharge Survey, National Center for Health Statistics. Discharge diagnoses based on ICD-9 codes were used to classify cardiovascular events and procedures and diabetes. Proportionate hospitalization ratios (PHRs) were calculated based on the number of cardiovascular hospitalizations from among all hospitalizations. RESULTS: We identified 119,653 VA hospitalizations (19.1%) and 3,765,696 non-VA hospitalizations (16.8%) that coded diabetes among the discharge diagnoses. Cardiovascular hospitalizations, primarily coronary in origin, accounted for nearly 50% of all hospitalizations of persons with diabetes within VA and non-VA medical care systems. Coronary events and procedures (PHR = 1.85 and 1.68) and, to a lesser extent, cerebrovascular events and procedures (PHR = 1.55 and 1.33) were more common in VA hospitalizations where diabetes was listed as a comorbidity than in VA hospitalizations where diabetes was not listed. The burden of coronary hospitalizations was larger in VA than non-VA facilities for men (PHR = 1.82 vs. 1.66) and smaller in VA than non-VA facilities for women (PHR = 3.11 vs. 3.44) in age and race-standardized analyses. The burden of coronary hospitalization was higher for whites and blacks in VA facilities (PHR = 1.83 and 2.01) when compared with non-VA facilities (PHR = 1.68 and 1.84). CONCLUSIONS: The burden of cardiovascular hospitalizations is not equally borne across hospitalizations with and without diabetes and across VA and non-VA facilities.

Cardiovascular Diseases↗
PubMed2004

Diabetes in nonveterans, veterans, and veterans receiving Department of Veterans Affairs health care.

OBJECTIVE: To compare behavioral risk factors and health and disease characteristics among three groups of adults with diabetes: nonveterans, veterans not receiving Department of Veterans Affairs (VA) health care, and veterans using VA services. RESEARCH DESIGN AND METHODS: Two data sources were used to describe the veteran population. First, the 2000 Behavioral Risk Factor Surveillance System (BRFSS) characterized the U.S. adult population by preventive health practices and risk behaviors linked to chronic and preventable diseases. New to the 2000 survey were questions on veteran status, which were administered in all states. Second, VA administrative and veterans benefits data were analyzed to describe comorbidity, education services, and veterans benefits. RESULTS: The estimated prevalence of diabetes in male veterans receiving VA care was 16%. Male veterans with diabetes using VA care were more likely to be nonwhite, not employed, have lower income, lower health status, and more activity limitations than male veterans not using these services. Computerized records indicate VA users with diabetes also had high concurrent comorbidity. Frequency of VA diabetes and preventive care services, as measured by selected quality indicators, was equivalent to or higher than the levels reported by veterans not receiving VA care and nonveterans. In addition to health care, nearly one-fourth of veterans with diabetes also received monthly awards for compensation and pension. CONCLUSIONS: Males receiving VA care with self-reported diabetes indicated receiving preventive care services at equivalent or higher levels than their counterparts receiving care outside the VA and nonveterans.

Diabetes Mellitus↗
PubMed2004

The epidemiology of lower-extremity disease in veterans with diabetes.

OBJECTIVE: To describe the epidemiology of lower-extremity complications of diabetes in veterans who are users of the Department of Veterans Affairs (VA). RESEARCH DESIGN AND METHODS: Hospital discharge records for care provided in all VA hospitals in 1998 were obtained. All hospitalizations for lower-extremity ulceration, peripheral vascular procedures, and amputation were analyzed using frequency tables. A diabetes denominator was defined as a veteran with at least three ambulatory care visits with at least one diabetes diagnosis code. Age-specific and total age-adjusted rates of discharge with ulceration, vascular procedures, and amputation were calculated. RESULTS: Veterans with diabetes comprised over half of all hospitalizations for lower-extremity ulceration, one-third of all hospitalizations for peripheral vascular procedures, and two-thirds of all hospitalizations for amputation. The age-specific discharge rate per 1,000 diabetic persons for age 0-64 years, 65-74 years, and 75 years and older for ulceration were 28.4, 31.0, and 37.9; for vascular procedures, the rates were 3.5, 4.4, and 4.4; and for amputation, the rates were 7.3, 9.0, and 10.0, respectively. CONCLUSIONS: Veterans with diabetes comprise a significant proportion of hospitalizations for lower-extremity ulceration, peripheral vascular bypass, and amputation. Age-specific rates of diabetic amputation in veterans are lower than U.S. rates.

Adult↗
PubMed2004

Diabetes and renal disease in veterans.

OBJECTIVE: To describe the frequency and sequelae of diabetic renal disease in veterans who receive health care from the Veterans Administration (VA). RESEARCH DESIGN AND METHODS: Veterans with a diagnosis of diabetes, diabetic nephropathy, other kidney diseases, and end-stage renal disease (ESRD) were identified by diagnosis codes from national VA databases for FY1998. Data were obtained and analyzed for prevalence of renal disease, comorbid conditions, and 1-year mortality. RESULTS: A total of 44,671 (10.7%) of the 415,910 veterans with diabetes had a concomitant diagnosis of any renal disease. The average age was 67 years; 98% were male and 60% were white. The prevalence of diabetic nephropathy was 6.0% (n = 25,263). ESRD secondary to diabetes was present in 4.2% (17,636) of subjects. The age-standardized prevalence of diabetes and any renal disease was 72.6/1,000 persons and differed by race (white 76.1/1,000, black 103.4/1,000 persons). Diabetes-associated ESRD prevalence was higher among black versus white veterans and male versus female veterans. One-year age-standardized mortality was 10.7%. CONCLUSIONS: Nephropathy is prevalent in veterans with diabetes. Greater mortality is observed among those with renal disease compared with those without renal disease. Additional surveillance is needed to identify persons likely to progress to diabetic nephropathy and to plan for appropriate and timely health care for these individuals.

Aged↗
PubMed2004

Eye disease in veterans with diabetes.

OBJECTIVE: To describe the screening, prevalence, and management of eye disease in veterans cared for by the Veterans Affairs (VA) System. RESEARCH DESIGN AND METHODS: Eye examinations, treatments, and diseases were identified in veterans with diabetes who received care in inpatient and outpatient VA settings during FY1998. Analysis was conducted to characterize the patient population and screened population and to compare them to the total VA patient population with diabetes. Logistic regression was performed to predict eye screening. RESULTS: Overall 48% of veterans with diabetes had an eye examination in FY1998. One-third of all veterans had an eye condition and 8.6% of veterans had ophthalmic manifestations of diabetes. In addition 11% reported glaucoma and 17.8% reported cataract surgery. Approximately 11,500 (2.7%) veterans were blind. CONCLUSIONS: Visual impairment is a common complication of diabetes. Half of this population of veterans had a visual examination recorded in VA. The VA is testing a more targeted screening and treatment approach for diabetic eye disease in order to prevent the serious eye complications.

Aged↗
PubMed2004

Diabetes-related utilization and costs for inpatient and outpatient services in the Veterans Administration.

OBJECTIVE: -The purpose of this study was to calculate the total number of inpatient hospitalizations, outpatient clinic visits, and total direct health care costs associated with veterans with diabetes receiving care in Veterans Administration (VA) facilities. RESEARCH DESIGN AND METHODS-The number of inpatient hospitalizations is tracked for years 1994-1998, and outpatient clinic visits are tracked for years 1997 and 1998. Trends in utilization across different age and racial groups, as well as total direct inpatient and outpatient costs for 1998, are presented. RESULTS: -Between 1994 and 1998, hospitalization rates decreased from 1.68 to 1.61. The average number of outpatient visits was 4.5 in 1997 and 4.6 in 1998. VA incurred $214.8 million in outpatient expenditures and $1.45 billion in inpatient expenditures for veterans with diabetes receiving VA care. CONCLUSIONS: -Health care delivery systems and payors track the cost and utilization of services by specific patient groups to support disease management, quality improvement, external reporting, and cost containment. Tracking the utilization and cost of diabetes care is necessary to understand the financial impact of diabetes on health care systems and the overall burden of diabetes on individuals.

Aged↗
PubMed2003

Changes in the use of coronary artery revascularization procedures in the Department of Veterans Affairs, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample, 1991-1999.

BACKGROUND: There have been dramatic increases in the number of coronary artery bypass surgeries (CABS) and percutaneous coronary interventions (PCI) performed during the last decade. Whether this finding is true for revascularization procedures performed in Department of Veterans Affairs (VA) medical centers is the subject of this paper. METHODS: This study compared the number of revascularization procedures and rates of use in the VA, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample. Included were men who underwent isolated CABS and/or PCI, including stenting, between 1991 and 1999, although data for the Nationwide Inpatient Sample were available only between 1993 and 1997. Age adjusted use rates were calculated with the direct method of standardization. RESULTS: The percent of users of VA healthcare 75 years and older increased from 10% in 1991 to 20% in 1999. In the VA, the number of isolated CABS declined from 6227 in 1991 to 6147 in 1999, whereas age adjusted rates declined from 167.6 per 100,000 in 1991 to 107.9 per 100,000 in 1999. In the 2 national surveys, both the estimated numbers of procedures and use rates increased over time. In all 3 settings, there were increases in both numbers and rate of PCI from 1993, although in the VA, use rates decreased from 191.2 per 100,000 in 1996 to 139.7 per 100,000 in 1999. VA use rates for both CABS and PCI were lower than those in the 2 national surveys. CONCLUSION: Age adjusted rates of CABS and PCI were lower in the VA than in 2 national surveys. Since 1996, there has been a decrease in the rate of use of revascularization procedures in the VA.

Adult↗
PubMed2003

Winter respiratory viruses and health care use: a population-based study in the northwest United States.

To quantify health care use among adults during influenza and respiratory syncytial virus (RSV) seasons, we identified a cohort of veterans aged >or=18 years who used Department of Veterans Affairs (VA) facilities in Oregon and Washington states as their source of health care. During 1998-2000, veterans accrued 237,159 person-years of follow-up. Using VA data sources, we measured acute cardiopulmonary hospitalizations and primary care and urgent care visits. Differences between rates of study events when influenza and/or RSV were circulating and event rates when neither virus was circulating were used to calculate winter virus-attributable morbidity. Inpatient and outpatient event rates were consistently higher during winter virus season, compared with non-winter virus season. Annual rates of cardiopulmonary hospitalizations attributable to influenza or RSV infection ranged from 0.8 (95% confidence interval [CI], 0.1-1.5) per 1000 low-risk individuals aged 18-49 years, to 10.6 (95% CI, 7.5-13.6) per 1000 high-risk individuals aged >or=65 years. Each year, circulation of influenza and RSV coincide with predictable increases in medical care use.

Adolescent↗
PubMed2003

Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population.

BACKGROUND: Primary care physicians need a brief alcohol questionnaire that identifies hazardous drinking and alcohol use disorders. The Alcohol Use Disorders Identification Test (AUDIT) questions 1 through 3 (AUDIT-C), and AUDIT question 3 alone are effective alcohol-screening tests in male Veterans Affairs (VA) patients, but have not been validated in women. METHODS: Female VA patients (n = 393) completed self-administered questionnaires, including the 10-item AUDIT and a previously proposed modification to AUDIT question 3 with a sex-specific threshold for binge drinking (>/=4 drinks/occasion), and in-person interviews with the Alcohol Use Disorder and Associated Disabilities Interview Schedule. The AUDIT-C, AUDIT question 3 alone, and the 10-item AUDIT were each evaluated with and without the sex-specific binge question and compared with past-year hazardous drinking (>7 drinks/week or >/=4 drinks/occasion) and/or active Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition alcohol abuse or dependence, based on interviews. RESULTS: Eighty-nine women (22.6%) met interview criteria for past-year hazardous drinking and/or active alcohol abuse or dependence. Standard and sex-specific AUDIT-Cs were sensitive (0.81 and 0.84, respectively) and specific (0.86 and 0.85, respectively). Their areas under the receiver operating characteristic curves were equivalent (0.91, and 0.92, respectively) and slightly higher than for the standard 10-item AUDIT (0.87). A single, sex-specific question about binge drinking (modified AUDIT question 3) had a sensitivity of 0.69 and specificity of 0.94, whereas the standard AUDIT question 3 was specific (0.96) but relatively insensitive (0.45). CONCLUSIONS: The standard and sex-specific AUDIT-Cs are effective screening tests for past-year hazardous drinking and/or active alcohol abuse or dependence in female patients in a VA study.

Adult↗
PubMed2003

Time-dependent predictors of primary cardiac arrest in patients with acute myocardial infarction.

To understand predictors of cardiac arrest early in acute myocardial infarction (AMI), for the Thrombolytic Predictive Instrument, we developed a multivariable regression model predicting primary cardiac arrest using time-dependent variables based on a case-control study of emergency department (ED) patients with AMI: 65 cases with sudden cardiac arrest and 258 without cardiac arrest. Within the first hour of AMI symptom onset, adjusting for age, systolic blood pressure, serum potassium, and infarct size, increased risk of cardiac arrest was associated with electrocardiographic prolonged QTc interval and a greater sum of ST-segment elevation. After 1 hour, the effect of ST-segment elevation was much reduced and the effect of the QTc interval was reversed, so prolonged QTc appeared protective. Accordingly, for patients presenting 30 minutes after chest pain onset, compared with a QTc of 0.44, the risk for cardiac arrest for patients with QTc of 0.50 was more than doubled (odds ratio [OR] 2.20, 95% confidence intervals [CI] 1.17 to 4.13), whereas for those presenting after an hour, it was much lower (e.g., at 1.5 hours, OR 0.21, 95% CI 0.06 to 0.73). Patients presenting 30 minutes after chest pain onset with a sum of ST elevation of 20 mm had a threefold higher risk than patients with a sum of ST elevation of 5 mm (OR 3.37, 95% CI 1.83 to 6.20). However, if presenting 1.5 hours after chest pain onset, the risk was barely elevated (OR 1.18; 95% CI 1.09 to 1.29). Thrombolytic therapy was protective, halving the odds of cardiac arrest (OR 0.51, 95% CI 0.27 to 0.93). Thus, the relation of prolonged QTc interval and substantial ST segment elevation to cardiac arrest in AMI may be obscured because patients with these risks are more likely to die soon after AMI onset, before ED presentation, and are thereby unavailable for study. Those with prolonged QTc or substantial ST elevation who survive the initial 1.5-hour period are those less susceptible to these risks.

Aged↗
PubMed2003

Quantitative clinical assessment of chronic anterior myocardial infarction with delayed enhancement magnetic resonance imaging and QRS scoring.

BACKGROUND: Both the regional and global myocardial extent of chronic myocardial infarction (MI) are important prognostic factors for length and quality of life and also crucial for the choice of therapy in patients with ischemic heart disease. Our aim was to develop and validate techniques for comparison between regional and global size of remote anterior MI in the left ventricle quantified with both magnetic resonance imaging (MRI) and electrocardiogram (ECG). METHODS: Delayed-enhancement (DE) MRI was used as a clinical "gold standard" for MI size to evaluate the extent of MI estimated with the commonly available standard 12-lead ECG. A method for comparing global and regional quantifications of MI with DE-MRI and ECG was developed. The Selvester QRS-scoring system was used for estimating MI size electrocardiographically. RESULTS: Twenty-five patients with chronic single anterior MI, documented with DE-MRI, were studied. The best agreement for mean % MI per regional segment of the left ventricle was found in the middle third (26% vs 27%), whereas the most significant discrepancy was found in the apex (56% vs 30%). The global MI size of the left ventricle averaged 21 +/- 9% with DE-MRI and 22% +/- 12% with ECG, with a correlation of r = 0.40 (P <.05). CONCLUSIONS: The current Selvester QRS scoring system performs well for quantifying anterior MI in the mid-regions of the left ventricle. The diagnostic performance of the Selvester QRS-scoring system for quantifying MI in the other regions, particularly the left ventricular apex, can potentially be improved, with DE-MRI as the gold standard.

Adult↗
PubMed2003

A modified Anderson-Wilkins electrocardiographic acuteness score for anterior or inferior myocardial infarction.

BACKGROUND: Optimal treatment of acute myocardial infarction (AMI) depends on the duration of the ischemia. The Anderson Wilkins (AW) electrocardiographic acuteness score has been shown to complement the historical timing in estimating the time interval from acute thrombotic coronary occlusion in patients presenting with chest pain and evolving myocardial infarction. The purposes of this study were to (1) compare the distributions of the previously developed AW acuteness score in a training population with either anterior or inferior AMI and (2) propose modifications to the formula to achieve distributions similar to the observed distributions of historical times from onset of pain. METHODS: Two hundred three and 177 patients were included as training and testing population, respectively. All patients had an anterior or an inferior AMI and were without confounding factors on the electrocardiogram. RESULTS: The training population had similar distributions of historical times from onset of pain, but differences in distributions of AW acuteness scores, between patients with anterior and inferior AMI (P <.0001). Eighty percent of the inferior AMI group had the highest possible AW acuteness score. Modification of a Q-wave criterion from > or =30 to > or =20 ms resulted in similar distributions in patients with anterior and inferior AMI both in the training and an independent testing population. CONCLUSIONS: These results suggest that a modified AW acuteness score using a lower Q-wave duration criterion provides similar AMI timing information in patients with anterior and inferior locations. Clinical use of the AW acuteness score will only be practical if the calculation is automated.

Electrocardiography↗
PubMed2003

The effect of left internal mammary artery utilization on short-term outcomes after coronary revascularization.

BACKGROUND: The purpose of this study was to determine whether use of the left internal mammary artery (LIMA) during coronary revascularization influences short-term morbidity in all patients undergoing revascularization, as well as in patients over the age of 75 years, female patients, and patients with diabetes. The study also explored variability in the utilization of LIMA grafts across an entire state. METHODS: Using the Clinical Outcomes Assessment Program (COAP) of the state of Washington, procedural outcomes were compared for patients receiving and patients not receiving LIMA grafts as part of revascularization procedures from January 1, 1999 to December 31, 2000. Mortality and major complications were examined, both as unadjusted rates and after adjusting for baseline patient risk factors. RESULTS: A total of 16 centers performed 8,797 nonemergent coronary artery revascularizations, including 81.7% with LIMA grafts. The use of a LIMA graft was associated with a significantly lower mortality (3.7% No LIMA vs 1.6% LIMA), as well as decreases in ventricular arrhythmias, need for postoperative dialysis, need for transfusions, ventilator dependence, and length of hospital stay. These trends were true for the population as a whole as well as for all subgroups analyzed, and they persisted after correcting for differences in comorbid conditions. In addition, there was wide variability in the use of LIMA grafts from center to center in the state. CONCLUSIONS: The use of LIMA grafts for coronary revascularization is associated with decreased mortality and morbidity. Despite these advantages, there is great variability in its application across the state of Washington.

Adult↗
PubMed2003

A case-control study of endoscopy and mortality from adenocarcinoma of the esophagus or gastric cardia in persons with GERD.

BACKGROUND: This study assessed whether EGD reduces mortality from adenocarcinoma of the esophagus or gastric cardia for patients with gastroesophageal reflux. METHODS: A case-control study was performed. A total of 245 incident cases of death caused by adenocarcinoma of the esophagus or gastric cardia (1995-1999) in which reflux was present were identified using Veterans Health Administration databases. A total of 980 controls with reflux but no death from adenocarcinoma were frequency matched for age, gender, and race. The occurrences of EGD from 1990 onward were compared for cases and controls. Logistic regression analysis with adjustment for potential confounding factors was performed. RESULTS: All the subjects were men. Cases were significantly less likely to have had an EGD in the time period of interest as compared with controls (adjusted odds ratio 0.66: 95% CI [0.45, 0.96], p = 0.03). This negative association was as strong for any EGD performed within 1 to 8 years before diagnosis as for a more recent EGD. However, there were no controls that included esophagectomy and no controls with a nonfatal diagnosis of adenocarcinoma, raising the question of whether EGD and reduced mortality are causally linked. The risk of dying from adenocarcinoma was significantly lower for men with a diagnosis of GERD as an inpatient relative to men in whom the diagnosis was made as an outpatient (adjusted odds ratio 0.21: 95% CI [0.15, 0.31], p < 0.01). CONCLUSIONS: For patients with GERD, performing an EGD is associated with reduced mortality from adenocarcinoma of the esophagus or gastric cardia, but whether this is a causative association remains unclear.

Adenocarcinoma↗
PubMed2003

The relative accuracies of ECG precordial lead waveforms derived from EASI leads and those acquired from paramedic applied standard leads.

Accurate precordial electrode placement can be difficult in emergency situations leading either to loss of time or diminished accuracy. A possible solution is the quasi-orthogonal EASI lead system, with only five electrodes and easily defined landmarks to provide a derived 12-lead electrocardiogram (ECG). The purpose of this study was to test the hypothesis that precordial waveforms in EASI-derived ECGs have no greater deviation from those in gold standard ECGs, than do the precordial waveforms in paramedic acquired standard ECGs. Twenty paramedics applied the standard precordial electrodes employing the routine procedure. A certified ECG technician applied the 6 standard precordial electrodes in their correct gold standard positions, and the EASI electrodes. 12-lead ECGs were obtained from the paramedics' standard leads, and derived from the EASI leads, for comparison with the gold standard ECG. In each precordial lead recording, 6 computer-measured QRS-T waveform parameters were considered. Differences between deltaEASI-gold standard versus deltaparamedic-gold standard were calculated for every waveform in every lead resulting in 720 comparisons. EASI and paramedic results were "equally accurate" in 47%, the paramedic was more accurate in 31%, and EASI was more accurate in the remaining 22%. The differences from gold standard recording of precordial waveforms in ECGs derived from the EASI leads and those acquired via paramedic-applied standard electrodes are similar. The results suggest that the EASI lead system may provide an alternative to the standard ECG precordial leads to facilitate data acquisition and possibly save valuable time in emergency situations.

Electrocardiography↗