PubMed Health⌕ Search

Biomedical subjects

Charles Maynard

Publications and source records attributed to Charles Maynard.

72 records · Page 4Linked to original sources
PubMed2003

Adjusting for patient differences in predicting hospital mortality for percutaneous coronary interventions in the Clinical Outcomes Assessment Program.

BACKGROUND: The Clinical Outcomes Assessment Program (COAP) is a coordinated quality improvement program for percutaneous coronary interventions (PCIs) performed in Washington State hospitals. This study describes the development and testing of models for predicting hospital mortality in patients undergoing PCI. METHODS: The COAP PCI database contains extensive demographic, medical history, and procedural information. This study included 19,358 consecutive PCIs performed in 27 Washington hospitals in 1999 and 2000. The study population was randomly assigned to development (n = 11,591) and test (n = 7614) sets. Logistic regression mortality models were run in the development set and evaluated in the test set. RESULTS: The test and development sets were similar in demographic, medical history, and procedural characteristics. The overall hospital mortality rate was 1.6% and was similar in the test and development sets. By means of stepwise logistic regression analysis, cardiogenic shock, age, nonelective priority, elevated creatinine level, ejection fraction, number of diseased vessels, myocardial infarction <24 hours from admission, history of chronic obstructive pulmonary disease, male sex, history of peripheral vascular disease, history of PCI, and history of congestive heart failure were identified as predictors of hospital mortality. When applied to the test set, this model had excellent discrimination (c statistic = 0.87, 95% CI = 0.84-0.90). The model was also evaluated in the Northern New England PCI Registry, with very good results (c statistic = 0.85). CONCLUSION: Developing risk-adjusted models of mortality and other outcomes is an essential part of the quality improvement process for cardiac revascularization procedures. Because of the rapidly changing nature of PCI, modification of these models in the years to come will be required.

Aged↗
PubMed2003

Effects of ethnicity and nephropathy on lower-extremity amputation risk among diabetic veterans.

OBJECTIVE: To describe ethnic differences in the risk of amputation in diabetic patients with diabetic nephropathy. RESEARCH DESIGN AND METHODS: A retrospective cohort study was conducted on a national cohort of diabetic patients who received primary care within the Veterans Affairs (VA) Health Care System. Hospitalizations for lower-limb amputations were established by ICD-9-CM procedure codes. Relative risk of amputation in diabetic patients with and without diabetic nephropathy was determined using Cox proportional hazard modeling for unadjusted and adjusted models. RESULTS: Of the 429,918 subjects identified with diabetes (mean age 64 +/- 11 years, 97.4% male), 3,289 individuals were determined to have had a lower-limb amputation during the study period. Compared with diabetic patients without amputations, amputees were on average older, more likely to belong to a minority group, and were more likely to have received treatment for more comorbid conditions. Asians were more likely to have toe amputations compared with whites or other ethnicities, while Native Americans were more likely to have below-the-knee amputations. Native Americans had the highest risk of amputation (RR 1.74, 95% CI 1.39-2.18), followed by African Americans (RR 1.41, 95% CI 1.34-1.48) and Hispanics (RR 1.28, 95% CI 1.20-1.38) compared with whites. The presence of diabetic nephropathy increased the risk of amputation threefold in all groups. Asian subjects with diabetes had the lowest adjusted relative risk of amputation (RR 0.31, 95% CI 0.19-0.50). CONCLUSIONS: Among diabetic patients, certain ethnic minority individuals have an increased risk of lower-extremity amputation compared with whites. Presence of diabetic nephropathy further increases this risk.

Adult↗
PubMed2003

Racial differences in diabetic nephropathy, cardiovascular disease, and mortality in a national population of veterans.

OBJECTIVE: To determine racial differences in the prevalence of diabetic nephropathy, cardiovascular disease (CVD), and risk of mortality in a national health care system. RESEARCH DESIGN AND METHODS: A longitudinal cohort study was conducted in 429,918 veterans with diabetes. Racial minority groups were analyzed for baseline differences in prevalence of early diabetic nephropathy, diabetic end-stage renal disease (ESRD) and CVD, and longitudinal risk of mortality compared with Caucasians. RESULTS: The 429,918 patients identified with diabetes were of the following racial groups: Caucasian (56.2%), African American (15.3%), Asian (0.5%), Native American (0.4%), and unknown race (21.4%). Minority individuals were, on average, younger and less likely to have CVD but were more likely to have renal disease than Caucasians. After adjustment for age, sex, and economic status, African Americans (adjusted odds ratio [OR] = 1.3, 95% CI 1.2-1.4) and Native Americans (1.5, 1.1-2.1) were more likely to have early diabetic nephropathy than Caucasians. Diabetic ESRD was more likely to be present in African Americans (1.9, 1.9-2.0), Hispanics (1.4, 1.3-1.4), Asians (1.8, 1.5-2.1), and Native Americans (1.9, 1.5-2.3) than Caucasians. Concurrently, the adjusted OR of CVD in racial minority groups was 27-49% less than in Caucasians, whereas the 18-month risk of mortality among people from most racial minority groups was 7-12% lower than in Caucasians. CONCLUSIONS: We conclude that when access to care is comparable, microvascular complications, macrovascular disease, and subsequent death occur with different frequencies among various racial groups.

Adult↗
PubMed2002

The impact of ethnicity on outcomes following coronary artery bypass graft surgery in the Veterans Health Administration.

OBJECTIVES: We evaluated the effect of African American (AA) and Hispanic American (HA) ethnicity on mortality and complications following coronary artery bypass graft (CABG) surgery in the Veterans Health Administration (VHA). BACKGROUND: Few studies have examined the impact of ethnicity on outcomes following cardiovascular procedures. METHODS: This study included all 29,333 Caucasian, 2,570 AA, and 1,525 HA patients who underwent CABG surgery at any one of the 43 VHA cardiac surgery centers from January 1995 through March 2001. We evaluated the relationship between ethnicity (AA vs. Caucasian and HA vs. Caucasian) and 30-day mortality, 6-month mortality, and 30-day complications, adjusting for a wide array of demographic, cardiac, and noncardiac variables. RESULTS: After adjustment for baseline characteristics, AA and Caucasian patients had similar 30-day (AA/Caucasian odds ratio [OR] 1.07; 95% confidence interval [CI] 0.84 to 1.35; p = 0.59) and 6-month mortality risk (AA/Caucasian OR 1.10; 95% CI 0.91 to 1.34; p = 0.31). However, among patients with low surgical risk, AA ethnicity was associated with higher mortality (OR 1.52, CI 1.10 to 2.11, p = 0.01), and AA patients were more likely to experience complications following surgery (OR 1.28; 95% CI 1.14 to 1.45; p < 0.01). In contrast, HA patients had lower 30-day (HA/Caucasian OR 0.70; 95% CI 0.49 to 0.98; p = 0.04) and 6-month mortality risk (HA/Caucasian OR 0.66; 95% CI 0.50 to 0.88; p < 0.01) than Caucasian patients. CONCLUSIONS: Ethnicity does not appear to be a strong risk factor for adverse outcomes following CABG surgery in the VHA. Future studies are needed to determine why AA patients have more complications, but ethnicity should not affect the decision to offer the operation.

Black or African American↗
PubMed2002

The association of sex and payer status on management and subsequent survival in acute myocardial infarction.

BACKGROUND: Previous reports have generally shown lower utilization of hospital resources and lower survival in women than men with acute myocardial infarction. However, to our knowledge, no reports have described the influence of payer status on the treatment and outcome of women and men with acute myocardial infarction. METHODS: Baseline and clinical presenting characteristics, utilization of hospital resources, and subsequent clinical outcome were ascertained among 327 040 women and men enrolled in a national registry of myocardial infarction from June 1, 1994, to January 31, 1997. Separate Cox regression analyses were performed for Medicare, Medicaid, health maintenance organizations, and commercial payer groups to ascertain variables that were predictive of mortality in the study population. RESULTS: After adjustment for differences in age and other baseline and presenting characteristics, women were significantly more likely than men to die in the hospital (hazard ratio, 1.13; 95% confidence interval, 1.10-1.16), and this difference was greatest among women with health maintenance organization and commercial insurance (hazard ratios, 1.30 and 1.29, respectively), and least among women with Medicare (hazard ratio, 1.07). However, after adjustment for the additional effect on short-term survival of sex differences in the utilization of both pharmacologic treatments administered within the first 24 hours and invasive cardiac procedures, the mortality difference observed for women and men further diminished (hazard ratio, 1.08; 95% confidence interval, 1.05-1.10). CONCLUSION: In this large registry, we did not observe significant variations among payer classes in management and mortality among women and men after acute myocardial infarction.

Aged↗
PubMed2002

A primer and comparative review of major US mortality databases.

PURPOSE: Mortality data are important tools for research requiring vital status information. We reviewed the major mortality databases and mortality ascertainment services available in the United States, including the National Death Index (NDI), the Social Security Administration (SSA) files, and the Department of Veterans Affairs databases. METHODS: The content, reliability, and accuracy of mortality sources are described and compared. We also describe how investigators can gain access to these resources and provide further contact information. RESULTS: We reviewed the accuracy of major mortality sources. The sensitivity (i.e., the proportion of the true number of deaths) of the NDI ranged from 87.0% to 97.9%, whereas the sensitivity for the VA Beneficiary Identification and Records Locator System (BIRLS) ranged between 80.0% and 94.5%. The sensitivity of SSA files ranged between 83.0% and 83.6%. Sensitivity for the VA Patient Treatment File (PTF) was 33%. CONCLUSIONS: While several national mortality ascertainment services are available for vital status (i.e., death) analyses, the NDI information demonstrated the highest sensitivity and, currently, it is the only source at the national level with a cause of death field useful for research purposes. Researchers must consider methods used to ascertain vital status as well as the quality of the information in mortality databases.

Cause of Death↗
PubMed2002

The impact of financial incentives on physician productivity in medical groups.

OBJECTIVE: To estimate the effect of financial incentives in medical groups--both at the level of individual physician and collectively--on individual physician productivity. DATA SOURCES/STUDY SETTING: Secondary data from 1997 on individual physician and group characteristics from two surveys: Medical Group Management Association (MGMA) Physician Compensation and Production Survey and the Cost Survey Area Resource File data on market characteristics, and various sources of state regulatory data. STUDY DESIGN: Cross-sectional estimation of individual physician production function models, using ordinary least squares and two-stage least squares regression. DATA COLLECTION: Data from respondents completing all items required for the two stages of production function estimation on both MGMA surveys (with RBRVS units as production measure: 102 groups, 2,237 physicians; and with charges as the production measure: 383 groups, 6,129 physicians). The 102 groups with complete data represent 1.8 percent of the 5,725 MGMA member groups. PRINCIPAL FINDINGS: Individual production-based physician compensation leads to increased productivity, as expected (elasticity = .07, p < .05). The productivity effects of compensation methods based on equal shares of group net income and incentive bonuses are significantly positive (p < .05) and smaller in magnitude. The group-level financial incentive does not appear to be significantly related to physician productivity. CONCLUSIONS: Individual physician incentives based on own production do increase physician productivity.

Cross-Sectional Studies↗
PubMed2002

Electrocardiographic comparison of myocardial salvage with primary revascularization versus thrombolysis in inferior myocardial infarction.

Primary revascularization (PR) and thrombolytic therapy (TT) reduce infarct size and mortality in patients with ST-segment elevation acute myocardial infarction (AMI). Electrocardiogram methods can determine the extent of myocardial salvage with different AMI therapies by comparing infarct size predicted by initial ST-segment changes and infarct size estimated by later quantitative QRS scores. In a community hospital setting, we used quantitative electrocardiogram methods to estimate infarct size and myocardial salvage associated with TT and PR amongst 50 patients presenting with inferior ST-segment elevation AMI. Baseline and electrocardiogram characteristics did not differ between TT (n = 29) and PR (n = 21) patients. There was no difference in median myocardial salvage (%) between TT vs. PR groups, (38.3% vs. 44.9% respectively, P =.66). Among patients with inferior AMI, myocardial salvage was achieved with both TT and PR therapy and did not differ significantly between reperfusion strategies.

Aged↗
PubMed2002

Race, treatment, and survival of veterans with cancer of the distal esophagus and gastric cardia.

CONTEXT: Prior studies have found racial differences in the use of invasive procedures and in cancer survival. OBJECTIVE: To assess the influence of race on the treatment and survival of patients with distal esophageal cancer. DESIGN: Retrospective cohort study. SETTING: All Veterans Affairs Medical Centers. PATIENTS: One thousand two hundred ninety white and 231 black male veterans with a new diagnosis of distal esophageal cancer during 1993 to 1997. MAIN OUTCOME MEASURES: Utilization of surgical resection, chemotherapy, radiation therapy, and survival. RESULTS: Black patients with esophageal adenocarcinoma were less likely to undergo surgery (OR, 0.54; 95% CI, 0.30-0.96) but had similar odds of undergoing chemotherapy and radiation therapy. Black patients with squamous cell carcinoma (SCC) were less likely to undergo surgical resection (OR, 0.45; 95% CI, 0.29-0.70), but were more likely to undergo radiation therapy (OR, 1.72; 95% CI, 1.21-2.47) and chemotherapy (OR, 1.74; 95% CI, 1.19-2.54). Mortality was increased for black patients with SCC (adjusted risk ratio 1.33; 95% CI, 1.10-1.61) but not adenocarcinoma. Among those veterans who underwent surgical resection (n = 502), similar results were found. CONCLUSIONS: Black veterans with distal SCC are less likely than white veterans to undergo surgical resection, whereas the use of radiation therapy and chemotherapy, as well as mortality, is increased. Black patients with distal esophageal adenocarcinoma have lower odds of undergoing surgical resection but have similar utilization of radiation therapy and chemotherapy and similar survival. Despite the presence of an equal access medical system, treatment and outcomes differ for black and white veterans with distal esophageal cancer.

Adenocarcinoma↗
PubMed2002

Short-term outcomes after percutaneous coronary intervention: effects of stenting and institutional volume shifts.

BACKGROUND: This study examines how the dissemination of stenting and procedural shifts to high-volume facilities have affected short-term outcomes after percutaneous coronary intervention (PCI). METHODS: Discharge information from the 1994 and 1997 US Nationwide Inpatient Sample was used. Data from 1994 involved 84,036 angioplasties, 27.3% of which were performed for acute myocardial infarction (AMI), at a time when stents were generally unavailable. Data from 1997 included 118,548 angioplasties, 30.2% of which were performed for AMI and 59% of which involved stenting. Outcomes included same-admission mortality and same-admission bypass grafting surgery (CABG). RESULTS: Compared with 1994, in 1997 stents were in widespread use, and there was a significant shift in PCI procedures to high-volume facilities. There was no significant difference in overall mortality rates between 1994 and 1997. However, same-admission CABG rates were lower in 1997 than in 1994 for the AMI group (2.9% vs 4.7%, P <.0001) and for the no-AMI group (1.8% vs 3.0%, P <.0001), which was attributable almost entirely to stenting. For 1997 only, patients receiving stents had a lower mortality rate than patients undergoing PCI without stenting (AMI 2.7% vs 4.7%, P <.0001, no AMI 0.7% vs 0.9%, P =.004). CONCLUSIONS: Despite the dissemination of stenting and shifts to high-volume facilities, overall mortality rates after PCI have not significantly changed. However, patients undergoing stenting in 1997 had a significantly lower mortality rate than patients who did not undergo stenting, suggesting that stents may prevent inhospital deaths. Furthermore, same-admission CABG rates have decreased dramatically, an association seen with the introduction of stenting, but not with volume shifts.

Angioplasty, Balloon, Coronary↗
PubMedDate not supplied

Screening for post-traumatic stress disorder in female Veteran's Affairs patients: validation of the PTSD checklist.

We evaluated the screening validity of a self-report measure for post traumatic stress disorder (PTSD), the PTSD Checklist (PCL), in female Veterans Affairs (VA) patients. All women seen for care at the VA Puget Sound Health Care system from October 1996-January 1999 (n=2,545) were invited to participate in a research interview. Participants (n=282) completed the 17-item PCL, followed by a gold standard diagnostic interview for PTSD, the Clinician Administered PTSD Scale (CAPS). Thirty-six percent of the participants (n=100) met CAPS diagnostic criteria for current PTSD. Receiver Operating Characteristic (ROC) analysis was used to evaluate the screening performance of the PCL. The area under the ROC curve was 0.86 (95% CI 0.82-0.90). A PCL score of 38 optimized the performance of the PCL as a screening test (sensitivity 0.79, specificity 0.79). The PCL performed well as a screening measure for the detection of PTSD in female VA patients.

Diagnostic and Statistical Manual of Mental Disord↗
PubMedDate not supplied

Use of off-pump and on-pump CABG strategies in current clinical practice: the Clinical Outcomes Assessment Program of the state of Washington.

BACKGROUND: The purpose of this study is to assess clinical outcomes and regional differences in the use of on-pump and off-pump CABG in current clinical practice. METHODS: Between January 1, 1999, and December 31, 2000, there were 10,429 CABG procedures performed in 16 Washington state hospitals, all of which participate in Clinical Outcomes Assessment Program database. This analysis excluded patients with a history of prior CABG as well as those who underwent emergent surgery. After applying these exclusion criteria, 8402 patients (7169 on-pump and 1233 off-pump CABG procedures) were evaluated and presented as both unadjusted and risk-adjusted outcomes. OUTCOMES: Off-pump CABG constituted 14.7% of all surgical revascularization procedures. These varied enormously among individual centers from an incidence of 0% to 68.9%. The use of off-pump CABG was not associated with a decreased risk of risk-adjusted hospital mortality or stroke, but was associated with a reduction in hospital stay > 7 days (OR 0.62, CI 0.51-0.76), ventilator > 24 hours (OR 0.52, CI 0.34-0.81), dialysis (OR 0.34, CI 0.14-0.86), and RBC transfusion (OR 0.5, CI 0.40-0.61). CONCLUSIONS: Despite its highly variable use, off-pump CABG seems to be judiciously used in current clinical practice in the State of Washington and is associated with a decrease in morbidity in appropriately selected patients.

Adolescent↗
PubMedDate not supplied

Effects of cardiac rehabilitation on self-reported health status after coronary artery bypass surgery.

PURPOSE: To examine the effectiveness of cardiac rehabilitation on health status following coronary artery bypass surgery. METHODS: A prospective cohort study of patients having coronary artery bypass surgery at 14 centers in the state of Washington. Baseline clinical and demographic data were collected, as was information from the Rand Short Form, 36 (SF-36), the Seattle Angina Questionnaire, and other questions regarding health status before surgery and at 6 and 12 months after surgery. In the 12-month follow-up survey, subjects were asked to complete questions pertaining to their participation in postdischarge cardiac rehabilitation programs. RESULTS: A total of 947 subjects from 13 centers received 1-year follow-up surveys, with 75% responding. Of these, 691 (95%) answered questions about participation in cardiac rehabilitation programs. SF-36 and Seattle Angina Questionnaire scores improved significantly after surgery for both cardiac rehabilitation participants and nonparticipants. Although more than 90% of subjects who participated in the cardiac rehabilitation programs stated that they were beneficial, for eight SF-36 domains and five Seattle Angina Questionnaire domains, no significant associations were found with participation in cardiac rehabilitation. When the participation status was defined as only those participants who completed at least 8 weeks of cardiac rehabilitation, only 1 of 13 health status domains favored cardiac rehabilitation. Responses to a series of questions about perceptions of change in general and cardiac-specific health did not differ among participants and nonparticipants. CONCLUSIONS: Although patients report favorable impressions of cardiac rehabilitation after coronary artery bypass surgery, it does not appear to provide a measurable benefit in self-reported health status beyond that achieved from the revascularization procedure itself.

Activities of Daily Living↗
PubMedDate not supplied

Results from a practice-based lipid clinic model in achieving low density lipoprotein cholesterol goals.

OBJECTIVE: Lipid clinic models that combine diet and drug therapy have shown significantly better hyperlipidemia management than usual care. The objective is to demonstrate that such a model can be established and utilized in a primary care practice, replicating the results obtained in specialty clinic settings. DESIGN: This study evaluated a "lipid clinic" model for cholesterol management in a primary care setting. SETTING/PARTICIPANTS: Men and women for both the study and control groups were selected from those with abnormal lipid profiles determined during the course of routine healthcare in community internal medicine group practices. INTERVENTION: Control subjects are those selected by chart review from the practices of four general internists. These physicians treated their patients according to "usual practice". Study subjects are those from another general internal medicine practice who volunteered to enroll in that practice-based "lipid clinic". MEASUREMENT & RESULTS: This program demonstrated significant reductions in total and low density lipoprotein cholesterol in patients with coronary heart disease, diabetes mellitus, and patients without coronary heart disease defined as high and low risk. It used a specialty clinic-based intervention that included diet, medication, and follow-up by nurses and physicians. Almost 90% of all patients were on appropriate drug therapy and achieved therapeutic goals. CONCLUSION: We believe that a primary care practice-based, lipid clinic model employing physician involvement, diet, maximal drug therapy and patient tracking can result in superior achievement of treatment goals.

Aged↗