PubMed Health⌕ Search

Biomedical subjects

Dean M Reker

Publications and source records attributed to Dean M Reker.

13 recordsLinked to original sources
PubMed2006

Multiple system utilization and mortality for veterans with stroke.

BACKGROUND AND PURPOSE: Many Veteran Health Administration (VHA) enrollees receive health services outside the VHA system. However, limited information is available about poststroke utilization and mortality by veterans who used multiple sources of health care. This study assessed the likelihood of 12-month poststroke rehospitalization and mortality of veterans who used VHA only versus those who used multiple sources of care. METHODS: Our retrospective observational study examined veterans living in Florida and diagnosed with acute stroke. We categorized users into 4 groups: VHA-only, VHA-Medicare, VHA-Medicaid, and VHA-Medicare-Medicaid based on their use of each health care program. Logistic regression models were fitted for 12-month poststroke general rehospitalization, recurrent stroke readmission, and mortality, adjusting for sociodemographic and clinical factors. RESULTS: The sample consisted of 29% VHA-only users, 61% VHA-Medicare users, 3% VHA-Medicaid users, and 7% VHA-Medicare-Medicaid triple users. Compared with the VHA-only users, multiple system users were significantly more likely to be rehospitalized for any cause and for recurrent stroke 12-months postindex. Mortality outcomes depended on when the outcome was measured; at the index admission date, we found no significant difference in mortality across the user groups; at the index discharge date, the VHA-only users was less likely to die within the first 12 months than the users of the 2 dual groups (VHA-Medicare and VHA-Medicaid). CONCLUSIONS: Multiple health care source use was common among VHA enrollees with acute stroke in Florida. Multiple system users were more likely to be rehospitalized and the mortality outcomes were dependent on when the outcome was measured.

Aged↗
PubMed2004

Why ethnic designation matters for stroke rehabilitation: comparing VA administrative data and clinical records.

Using existing administrative data to look at issues of ethnic disparities in rehabilitation-related outcomes may lead to misleading results. Problems can emerge from apparently small issues of reliability that are magnified by reclassification of ethnic designation and missing data in complete-subject analyses. We compared the reliability of ethnic assignment in Department of Veterans Affairs (VA) medical rehabilitation records for stroke patients with administrative records; reclassified the racial identifier from the administrative data in two ways; and examined the different sources of ethnic information in relation to severity, length-of-stay, disability assessment, and discharge disposition. Our results show how small changes increase the potential for Type II error when describing ethnic differences in outcomes or using ethnicity as a predictor with dichotomous response variables. We discuss our results with reference to the literature on ethnic classification and underline the importance of initiatives for improved data collection on ethnicity in VA data sources and in rehabilitation research.

Databases, Factual↗
PubMed2002

Racial differences in use of colonoscopy, sigmoidoscopy, and barium enema in Medicare beneficiaries.

Colorectal cancer is often diagnosed at a later stage in blacks. We wanted to know if racial differences existed in the use of tests for detection of colorectal cancer. A 5% random sample was obtained of all Medicare beneficiaries with Part B coverage, aged 65 years and older and classified as white or black race. The numbers of colonoscopies, flexible sigmoidoscopies, and barium enemas were determined from the Physician/Supplier file. Blacks were 18% less likely to receive colonoscopy and 39% less likely to receive flexible sigmoidoscopy after controlling for age, sex, income, and access to care in a multivariable logistic regression model. Barium enema was not significantly different between the races. Black men had 25% lower use of colonoscopy and 50% decreased use of flexible sigmoidoscopy. Blacks receive less colonoscopy and flexible sigmoidoscopy than whites. Black men are particularly vulnerable to the under-use of these tests.

Black or African American↗
PubMed2002

Postacute stroke guideline compliance is associated with greater patient satisfaction.

OBJECTIVE: To determine if the structure of care or the process of stroke care, as measured by compliance with stroke guidelines published by the Agency for Healthcare Research and Quality (AHRQ), is associated with patient satisfaction. DESIGN: Prospective inception cohort study of new stroke admissions including postacute care with follow-up interviews at 6 months poststroke. SETTING: Eleven Veterans Affairs medical centers (VAMCs). PARTICIPANTS: A total of 288 new stroke patients admitted to VAMCs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Compliance with AHRQ stroke guidelines and patient satisfaction with care using a stroke-specific instrument. RESULTS: Process of care was positively and significantly associated with greater patient satisfaction even after controlling for patient functional outcome. The most visible (to the patient) process of care dimensions correlated most highly with patient satisfaction. Sixty-four percent (73/115) of patients expressed some dissatisfaction with 1 or more survey items. CONCLUSIONS: "What we do" and "how we do it" while providing postacute care to stroke patients was associated with patient satisfaction. This linkage of process to outcome is an important validation of satisfaction as a significant patient outcome. This linkage is further evidence that compliance with AHRQ stroke guidelines may be a valid quality of care indicator.

Aged↗
PubMed2002

The hazards of stroke case selection using administrative data.

BACKGROUND: Administrative data and ICD-9-CM diagnostic codes are frequently used in research efforts to evaluate risk adjusted patient outcomes, particularly mortality. Varying ICD-9-CM sampling algorithms have been used to identify stroke patients. OBJECTIVES: This study evaluates the effects of different sampling strategies (one high sensitivity and one high specificity) on modeling stroke mortality as a performance indicator. RESEARCH DESIGN: Risk adjustment models were developed for two stroke cohorts identified using differing ICD-9-CM algorithms. Standard mortality ratios were calculated in a validation sample as network performance measures and compared across the two stroke samples. SUBJECTS: VHA inpatients with stroke during years 1997 (model development) and 1998 (model validation) were selected from the Patient Treatment File based on cerebrovascular diagnostic codes. MEASURES: Patient mortality within 30 days of admission. RESULTS: The model development and validation for each stroke sampling method produced consistent results: c-statistics 0.74 to 0.75, R2 0.07 to 0.09, concordance 73% to 74%. However, ranking differences in network performance varied by 5 or more positions for 7 of the 22 patient networks. CONCLUSIONS: These findings highlight a potential problem when using administrative data to assess stroke mortality. In the absence of an agreed upon definition of stroke patients, results of provider profiling will vary depending on the ICD-9 algorithm used.

Algorithms↗
PubMed2002

Structure, process, and outcomes in stroke rehabilitation.

BACKGROUND: The health services research framework of structure, process, and outcome is used commonly to examine quality of care, and it indicates that structure influences process, which in turn influences outcomes. However, little empirical work has been done to test this hypothesis, particularly for medical rehabilitation. OBJECTIVES: To determine if, among stroke patients, (1) structure of care was associated with process of care, and (2) structure of care was associated with outcomes after adjusting for process. RESEARCH DESIGN: Two-year, prospective study of 288 acute stroke patients in 11 VA medical centers, of whom 128 were included in the current analysis. MEASURES: Structure of care: systemic organization, staffing expertise, and technological sophistication. Process of care: compliance with the AHCPR poststroke rehabilitation guidelines. PATIENT CHARACTERISTICS: baseline prior walking ability and Functional Independence Measure (FIM) motor subscale. OUTCOMES: the FIM motor subscale 6-months poststroke. RESULTS: The combination of systemic organization and staffing expertise, along with technological sophistication, were independent predictors of process of care (beta coefficients 0.21, P<0.05 and 0.37, P<0.001, respectively). When controlling simultaneously for patient characteristics, structure and process of care, structure of care did not have and process of care did have a statistically significant association (beta coefficient 0.18, P<0.01) with functional outcomes. CONCLUSIONS: Better process of care was associated with better 6-month functional outcomes, therefore improving process of care probably would improve stroke outcomes. However, our results indicate that improving key structure of care elements might facilitate improving process of care for stroke patients.

Activities of Daily Living↗
PubMed2002

Evaluation of proxy responses to the Stroke Impact Scale.

BACKGROUND AND PURPOSE: The purposes of this study were to compare proxy-patient responses on each domain of the Stroke Impact Scale (SIS) and the SIS-16, estimate the bias, and evaluate the validity of proxy scores. METHODS: Two hundred eighty-seven patient and proxy pairs from the Kansas City Stroke Registry participated in the study. All patients were assessed in their home or nursing facility between 90 and 120 days after stroke with the use of the modified Rankin Scale Motricity Index (strength), Barthel Index (activities of daily living), Lawton assessment (instrumental activities of daily living), Folstein Mini-Mental State Examination (cognition), and the SIS. Eligible proxies were individuals who were aged > or =18 years, had known the patient for at least 1 year, and saw the patient at least once each week. All proxy interviews were conducted within 7 days of (before or after) the patient's interview. RESULTS: Three hundred seventy-seven patients from the Kansas City Stroke Registry were eligible for the study. Seventy-seven patients or proxies refused participation. Thirteen patients of the consenting patient-proxy pairs were too aphasic or cognitively impaired to complete the interviews and were dropped from the study. Proxies scored patients as more severely affected than patients scored themselves on the SIS-16 and in 7 of 8 domains of the full SIS (5 were statistically significant at alpha=0.05). The proxy bias toward overrating the severity of the patient's condition tended to increase as the severity of the stroke increased. However, the magnitude of the biases between patient and proxy means, as measured by effect size, was small (range, -0.1 to 0.4). The strength of the agreement, as measured by intraclass correlation coefficients, between proxy and patient ranged from 0.50 to 0.83. Agreement was best for the observable physical domains. Both patient and proxy scores in all domains were significantly different across Rankin categories. Concurrent validity for both patient and proxy correlations with the Folstein Mini-Mental State Examination, Barthel Index, Lawton instrumental activities of daily living, and Motricity Index was good to excellent (range, 0.37 to 0.78). CONCLUSIONS: Proxies provide valid information for assessment of stroke outcomes. There are significant differences between patient and proxy reporting on SIS domains and the SIS-16. However, the observed biases are small and not clinically meaningful.

Activities of Daily Living↗
PubMed2002

Adherence to postacute rehabilitation guidelines is associated with functional recovery in stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to determine if compliance with poststroke rehabilitation guidelines was associated with better functional outcomes. METHODS: An inception cohort of 288 stroke patients in 11 Department of Veteran Affairs Medical Centers hospitalized between January 1998 and March 1999 were followed prospectively for 6 months. Data were abstracted from medical records and telephone interviews. The primary study outcome was the Functional Independence Motor Score (FIM). Secondary outcomes included Instrumental Activities of Daily Living (IADL), SF-36 physical functioning, and the Stroke Impact Scale (SIS). Acute and postacute rehabilitation guideline compliance scores (range 0 to 100) were derived from an algorithm. All outcomes were adjusted for case-mix. RESULTS: Average compliance scores in acute and postacute care settings were 68.2% (SD 14) and 69.5% (SD 14.4), respectively. After case-mix adjustment, level of compliance with postacute rehabilitation guidelines was significantly associated with FIM motor, IADL, and the SIS physical domain scores. SF-36 physical function was not associated with guideline compliance. Level of compliance with rehabilitation guidelines in acute settings was unrelated to any of the outcome measures. CONCLUSION: Greater levels of adherence to postacute stroke rehabilitation guidelines were associated with improved patient outcomes. Compliance with guidelines may be viewed as a quality-of-care indicator with which to evaluate new organizational and funding changes involving postacute stroke rehabilitation.

Activities of Daily Living↗
PubMed2002

Performance of a mail-administered version of a stroke-specific outcome measure, the Stroke Impact Scale.

OBJECTIVE: To evaluate the feasibility and concurrent validity of a new, mail-administered, stroke-specific outcome measure, the Stroke Impact Scale (SIS). DESIGN: Observational cohort study. SETTING AND PATIENTS: Stroke patients who had lived independently in the community prior to their stroke and who were candidates for post-stroke rehabilitation were recruited from nine, high-volume, Department of Veteran Affairs Medical Centers. METHODS: Two hundred and six patients were mailed the SIS after a six-month post-stroke telephone interview. Telephone assessments included the Functional Independence Measure, the Lawton IADL and the SF-36. RESULTS: The response rate for the mailed SIS was 63%, with 45% of the responses from proxies. The average rate of missing item level scores per patient was 1.3 (range 0-20) resulting in an average rate of 0.13 missing domain scores per patient (range 0-3). Nonresponders to the mailed SIS had more severe strokes with lower functional status at the time of the survey than responders. Proxies were more likely to complete the survey if the subjects were older, married, cognitively impaired and more functionally limited. The SIS did not exhibit a high rate of floor and ceiling effects, particularly in physical function domains, as did the FIM and the SF-36. CONCLUSIONS: The mailed SIS is a feasible means of assessing post-stroke function. Missing items and missing domain scores were extremely low, however, there is a trade-off between the low-cost mail SIS survey on the one hand and the resulting nonresponse bias on the other.

Activities of Daily Living↗
PubMed2002

Co-morbidity adjustment for functional outcomes in community-dwelling older adults.

OBJECTIVE: To characterize relationships between self-reported co-morbidity and functional outcomes in community-dwelling older adults, and to assess whether the impact of co-morbidity persists even after adjustment for baseline functional status. DESIGN: Prospective observational study. We examined associations between self-reported co-morbidity at baseline and functional outcomes at one year, with and without adjustment for baseline functional status. SETTING: Outpatient clinics at a managed care and a Veterans Affairs site. SUBJECTS: Four hundred and fifty-seven community-dwelling older adults representing a broad spectrum of overall health status. MAIN OUTCOME MEASURES: (a) New basic ADL (activities of daily living) problem during follow-up; (b) 10-point decline in the physical function index of the MOS-36 (MOS-PFI). RESULTS: Co-morbidity was associated with adverse functional outcomes in bivariable analyses. After adjustment for age and baseline functional status, an accumulated co-morbidity score provided additional explanatory power for predicting new ADL problems; odds ratios were 2.30 (1.09, 5.09) and 2.96 (1.48, 6.25) for 2 and > or = 3 affected co-morbidity domains, respectively. The impact of baseline status was also important; odds ratios for new ADL problems were 4.77 (2.68, 8.81) when at least one instrumental activity of daily living (IADL) problem was present at baseline, and 15.6 (8.05, 31.3) when at least one basic ADL problem was present at baseline. CONCLUSIONS: Accumulated self-reported co-morbidity has significant negative effects on function at one year; these effects are attenuated but not eliminated by adjustment for baseline status. Co-morbidity adjustment is probably an important design element in clinical research focused on functional outcomes in older adults.

Activities of Daily Living↗
PubMedDate not supplied

Development of an integrated stroke outcomes database within Veterans Health Administration.

A fundamental goal of the Rehabilitation Outcomes Research Center of Excellence is to improve care and outcomes for veterans with rehabilitation needs. To achieve this goal, the Center's primary objective is increasing research capacity. The Integrated Stroke Outcomes Database is a collection of Veterans Health Administration (VHA) clinical and administrative data containing patient information on a cohort of stroke patients found in the Functional Status Outcomes Database (FSOD), National Patient Care Database (NPCD), and other VHA sources. Clinical and administrative data were abstracted from several VHA data sources and linked to form an integrated outcomes database. A primary cohort of stroke patients treated during fiscal year (FY) 2001 was identified from the FSOD. Matching data from the NPCD, Decision Support System, Health Economics Resource Center, and the National Veterans Survey were obtained, merged, and reported in brief. This integrated database structure will provide valuable support to enhance the VHA capacity to perform stroke rehabilitation research.

Ambulatory Care↗
PubMedDate not supplied

Race/ethnicity: who is counting what?

Misclassification of race and ethnicity in administrative data may produce misleading results if it is overlooked or ignored. In this study, we examined the racial/ethnic classifications of 1,084 veterans with stroke in Florida who received inpatient and outpatient services within the Department of Veterans Affairs (VA) healthcare system and who were also eligible for Medicare between 2000 and 2001. We compared the reliability of racial/ethnic classifications between VA inpatient data, VA outpatient data, and Medicare data. Our results showed that (1) the rate of unknown racial/ethnic classification in VA outpatient and inpatient data was high, (2) minimizing the unknowns by substituting known values from other data when available would greatly enhance the overall and individual classification reliability, (3) black and white classifications in the VA data had stronger agreement with Medicare data, and (4) Medicare data may under-represent Hispanic patients.

Databases, Factual↗