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Biomedical subjects

Donald Miller

Publications and source records attributed to Donald Miller.

10 recordsLinked to original sources
PubMed2006

Determinants of sustained uncontrolled blood pressure in a national cohort of persons with diabetes.

BACKGROUND: Randomized clinical trials have demonstrated that strict blood pressure (BP) control in diabetes reduces cardiovascular morbidity and mortality. Previous observational studies have confirmed that hypertension is inadequately controlled in the general population of the United States. In this study we evaluated the prevalence and determinants of severe, sustained, uncontrolled hypertension in a national cohort of persons with diabetes. METHODS: We identified 64,105 veterans from the national Veterans Administration diabetes registry for whom BP, survey, laboratory, and medication data were available. Using mean BP from three visits in fiscal year 2000, we determined the prevalence of sustained BP readings > or = 160/100, > or = 140/90, or > or = 130/80 mm Hg. We determined predictors of the three thresholds using demographic variables, self-reported medical comorbidities, estimated glomerular filtration rate, and number of BP-lowering medications. RESULTS: Over a mean interval of 131.0 days (+/-81.4), we found that 6,347 (9.9%) of the 64,105 veterans with diabetes had mean BP > or = 160/100 mm Hg. Similarly 25,924 (40.4%) had a mean BP > or = 140/90 mm Hg, and 38,296 (59.7%) had a mean BP > or = 130/80 mm Hg. Independent predictors of mean BP > or = 160/100 mm Hg included age, ethnicity, education level, cardiovascular comorbidities, alcohol use, and number of BP-lowering medications. CONCLUSIONS: Administrative databases can be used to identify patients with sustained uncontrolled hypertension within health care systems. Our findings suggest important patient-level factors that can be targeted for quality improvement programs in diabetes.

Age Factors↗
PubMed2006

Risk-adjusted mortality as an indicator of outcomes: comparison of the Medicare Advantage Program with the Veterans' Health Administration.

BACKGROUND: The Medicare Advantage Program (MAP) and the Veterans' Health Administration (VHA) currently provide many services that benefit the elderly, and a comparative study of their risk-adjusted mortality rates has the potential to provide important information regarding these 2 systems of care. OBJECTIVE: The objective of this retrospective study was to compare mortality rates between the MAP and the VHA after controlling for case-mix differences. SUBJECTS: This study consisted of 584,294 MAP patients and 420,514 VHA patients. MEASURES: We used the Death Master File to ascertain the vital status of each study subject over approximately 4 years. We used Cox regression models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for the MAP compared with VHA patients. RESULTS: The average age for male MAP patients was 73.8 years (+/- 5.6) and for male VHA patients was 74.05 years (+/- 6.3). Unadjusted mortality rates of males for VHA and MAP were 25.7% and 22.8%, respectively, over approximately 4 years (P < 0.0001), respectively. The case-mix of VHA patients, however, was sicker than those from MAP. After adjusting for case-mix, the HR for mortality in the MAP was significantly higher than that in the VHA (HR, 1.404; 95% CI = 1.383-1.426). We obtained similar results when we compared the mortality rates of females for VHA and MAP. CONCLUSIONS: After adjusting for their higher prevalence of chronic disease and worse self-reported health, mortality rates were lower for patients cared for in the VHA compared with those in the MAP. Further studies should examine what differences in care structures and processes contribute to lower mortality in the VHA.

Aged↗
PubMed2005

Health-related quality-of-life assessment in patients with cutaneous T-cell lymphoma.

OBJECTIVE: To measure and evaluate the health-related quality of life (HRQOL) in patients with cutaneous T-cell lymphoma (CTCL), a visible cutaneous malignancy that may have a profound effect on patients' lives. DESIGN: Monocenter, cross-sectional study. SETTING: The Skin Oncology Program, Department of Dermatology, and the Photopheresis Unit of Boston Medical Center. PATIENTS: A total of 22 adult patients with confirmed CTCL. MAIN OUTCOME MEASURES: (1) Evaluation of general oncologic and skin disease-specific HRQOL using, respectively, the Functional Assessment of Cancer Therapy-General (FACT-G) and Skindex-29 profiles; (2) assessment of HRQOL association with disease stage (early stage, IA-IIA; late stage, IIB-IVB). RESULTS: Patients with more advanced CTCL stages reported more effects on general health (FACT-G), particularly in the physical, emotional, and functional domains (P < .05). Patients with early-stage CTCL reported better skin-specific HRQOL overall (Skindex-29; P = .002) and for each specific domain than did patients with late-stage disease. The Skindex-29 scales had high internal consistency, and the confirmatory factor structure was similar to that of previous studies. CONCLUSIONS: The HRQOL of patients with CTCL can be evaluated using the Skindex-29 and FACT-G instruments. Patients with more advanced stages of CTCL had lower HRQOL scores.

Adaptation, Physiological↗
PubMed2005

Cognitive dysfunction after total knee arthroplasty: effects of intraoperative cerebral embolization and postoperative complications.

Cerebral emboli identified as high-intensity transient signals (HITS) occur during total knee arthroplasty (TKA). Their effects on cognitive outcome remain speculative. Intraoperative HITS and postoperative complications were correlated with the cognitive function of TKA patients. Cognitive function was assessed both before and after surgery (1 week and 3 months). High-intensity transient signals occurred in 22 of 37 patients. Counts of HITSs were higher in patients with sonographically detected intracardiac shunts. Cognitive dysfunction was found in 41% of patients at 1 week, but in only 18% at 3 months. High-intensity transient signal counts were not associated with the prevalence of cognitive deficits. At 1 week, 58% of patients with cognitive deficits had at least 1 postoperative complication (6% in nondeficit patients). All cognitively impaired patients at 3 months had complications (17% in the nondeficit group). This raises the possibility that postoperative complications might be associated with cognitive dysfunction in TKA patients.

Aged↗
PubMed2004

Differences in health-related quality of life in rural and urban veterans.

OBJECTIVES: We sought to determine whether disparities in health-related quality of life exist between veterans who live in rural settings and their suburban or urban counterparts. METHODS: We determined health-related quality-of-life scores (physical and mental health component summaries) for 767109 veterans who had used Veterans Health Administration services within the past 3 years. We used rural/urban commuting area codes to categorize veterans into rural, suburban, or urban residence. RESULTS: Health-related quality-of-life scores were significantly lower for veterans who lived in rural settings than for those who lived in suburban or urban settings. Rural veterans had significantly more physical health comorbidities, but fewer mental health comorbidities, than their suburban and urban counterparts. Rural-urban disparities persisted in all survey subscales, across regional delivery networks, and after we controlled for sociodemographic factors. CONCLUSIONS: When compared with their urban and suburban counterparts, veterans who live in a rural setting have worse health-related quality-of-life scores. Policymakers, within and outside the Veterans Health Administration, should anticipate greater health care demands from rural populations.

Chi-Square Distribution↗
PubMed2004

Dual-system utilization affects regional variation in prevention quality indicators: the case of amputations among veterans with diabetes.

OBJECTIVE: To determine the impact of dual-system utilization by veterans on regional variation in lower-extremity amputation rates. STUDY DESIGN: Retrospective longitudinal cohort analysis. PATIENTS AND METHODS: Subjects were veterans with diabetes who used Veterans Health Administration (VHA) care and were dually enrolled in Medicare fee for service in fiscal years (FY) 1997--1999. We evaluated the impact of Centers for Medicare and Medicaid Services (CMS) data on prevalence of baseline foot risk factors, medical comorbidities, and amputations in FY 1997--1998, and ranking of 22 regions using risk-adjusted major and minor amputation rates in FY 1999. RESULTS: The addition of CMS data significantly increased the prevalence of amputations and risk factors for the 218,528 dually eligible veterans (all Pvalues <.001). In FY 1999, we identified 3.1 minor and 4.5 major amputations per 1000 patients (VHA data) versus 5.5 minor and 8.6 major amputations per 1000 patients (VHA/CMS data); the prevalence of any peripheral vascular condition in FY 1997--1998 was 5.7% (VHA) versus 13.0% (VHA/CMS). The impact of including CMS data varied across regions for amputation outcomes, ranging from an additional 34.3% to 150.7%. Using observed-to-expected amputation ratios and 99% confidence intervals, the addition of CMS data changed the outlier status for 8 of 22 regions for both major and minor amputations. CONCLUSION: Risk covariates and amputation outcomes were substantially underestimated using VHA data only. Our findings demonstrate the importance of evaluating dual-system utilization when conducting program evaluations for healthcare systems with a substantial number of dual enrollees.

Aged↗
PubMed2003

Xerostomic medications and oral health: the Veterans Dental Study (part I).

OBJECTIVES: To quantify the adverse effects of the number of xerostomic medications on dental caries, oral mucosa, and periodontal disease. DESIGN: Secondary analysis of a cross-sectional study of the Veterans Dental Study. SETTING: Four New England area VA outpatient clinics. SUBJECTS: The sample consists of 345 male veterans participating in The Veteran's Dental Study who also had pharmacy records. MAIN OUTCOME MEASURES: Oral health data included total surfaces of coronal caries, a modification of the root caries index, mean oral mucosa scores, and Community Periodontal Index of Treatment Need (CPITN). Oral health parameters were measured and recorded in clinical dental examinations. EXPOSURES: Intake of xerostomic medications 14-385 days prior to the dental examination. STATISTICAL ANALYSES: The relationships between exposure and outcome were analyzed via linear and logistic regression methods adjusting for possible confounding factors such as disease burden index, alcohol consumption, dental care, and smoking status. RESULTS: Veterans who were taking at least one xerostomic medication were almost three times more likely to have mean mucosa scores in the worst 25 percentile than veterans taking no xerostomic medications, OR = 2.63 (confidence interval [CI] 1.34, 5.16, p = 0.03) after adjusting for age, number of teeth, disease burden index, income, smoking and alcohol use. Participants who were taking at least one xerostomic medication experienced higher but non-significant increases in coronal (OR = 1.21; CI. 0.66, 2.25) and root caries (OR = 1.10 CI. 0.54, 2.24) measured by numbers of total decayed surfaces. CONCLUSION: There were significant deleterious effects of xerostomic medications on oral mucosa. However, xerostomic medications do not appear to increase coronal caries, or periodontal index measured by CPITN among ambulatory, community dwelling participants who were able to perform routine preventive oral care.

Adult↗