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Biomedical subjects

G S Cooper

Publications and source records attributed to G S Cooper.

At least 73 records · Page 4Linked to original sources
PubMed1998

Use of Medicare claims data to measure county-level variations in the incidence of colorectal carcinoma.

BACKGROUND: Population-based cancer registries that can be used to compare cancer incidence and mortality across regions of the U.S. are currently lacking. The authors conducted this study to validate Medicare claims as a measure of county-level colorectal carcinoma incidence among older Americans. Variations found among counties are described in this article. METHODS: A total of 183,174 hospitalized patients age 65 years in 1991-1993 with newly diagnosed colorectal carcinoma who resided in one of 480 large counties were identified in Medicare files. The county-level truncated age, race, and gender adjusted incidence rates for the population age 65 years, the proportion of patients with a code indicating distant metastases, and the 2-year case-fatality rates were determined. Corresponding rates from the SEER database were compared. RESULTS: The median truncated adjusted 3-year incidence rate was 870 per 100,000 (Quartile 1-Quartile 3, 779-955), with almost twofold differences among counties even after the exclusion of outliers. The median proportion of patients with codes indicating distant metastases was 23.4% (range, 10.2-46.9%; Quartile 1-Quartile 3, 20.8-25.8), and the average 2-year case-fatality rate was 39.2% (range, 26.5-51.4%; Quartile 1-Quartile 3, 37.0-41.6). Medicare files tended to underestimate the truncated incidence rate according to SEER, but among counties the two sets of rates were closely correlated (r = 0.94, P < 0.0001). CONCLUSIONS: Medicare files are a potential alternative source of national data for the study of colorectal carcinoma incidence among the elderly at the county level. The data also suggest significant variations among counties in colorectal carcinoma incidence, stage, and mortality that could be used in public health initiatives.

Age Factors↗
PubMed1998

Use of intensive care units for patients with low severity of illness.

OBJECTIVE: To determine variations among hospitals in use of intensive care units (ICUs) for patients with low severity of illness. DESIGN: Retrospective cohort study. SETTING: Twenty-eight hospitals with 44 ICUs in a large metropolitan region. PATIENTS: Consecutive eligible patients (N=104,487) admitted to medical, surgical, neurological, or mixed medical-surgical ICUs from March 1, 1991, to March 31, 1995. OUTCOME MEASURES: The predicted risk of in-hospital death for each patient was assessed using a validated method that is based on age, ICU admission source, diagnosis, severe comorbid conditions, and abnormalities in 17 physiologic variables. Admissions were classified as low severity if the patient's predicted risk of death was less than 1%. In a subset of 12,929 consecutive patients, use of 19 specific interventions typically delivered in ICUs was examined. RESULTS: Twenty thousand four hundred fifty-one admissions (19.6%) were categorized as low severity, including 23.6% of postoperative and 16.9% of nonoperative admissions. Alcohol and other drug overdoses accounted for 40.2% of nonoperative low-severity admissions; laminectomy and carotid endarterectomy accounted for 52.3% of postoperative low-severity admissions. Mortality among patients with low-severity illness was 0.3%, and only 28.6% received an ICU-specific intervention during the first ICU day. Although mean ICU length of stay was shorter (P<.001) in low-severity admissions (2.2 vs 4.7 days in nonoperative and 2.4 vs 4.2 days in postoperative admissions), low-severity admissions accounted for 11.1% of total ICU bed days. Rates of low-severity admissions varied (P<.001) across hospitals, ranging from 5% to 27% for nonoperative and 9% to 68% for postoperative admissions. CONCLUSIONS: A large proportion of patients admitted to the ICU have a low probability of death and do not receive ICU-specific interventions. Rates of low-severity admissions varied among hospitals. The development and implementation of protocols to target ICU care to patients most likely to benefit may decrease the number of low-severity ICU admissions and improve the cost-effectiveness of ICU care.

Adult↗
PubMed1998

Factors associated with the use of flexible sigmoidoscopy as a screening test for the detection of colorectal carcinoma by primary care physicians.

BACKGROUND: Despite current recommendations of flexible sigmoidoscopy as a screening test for the detection of colorectal carcinoma, relatively few asymptomatic patients undergo this procedure. To enhance the use of sigmoidoscopy, differences in the use of screening, as well as barriers to screening among specific physician groups, should be defined. METHODS: The authors surveyed 1762 practicing primary care physicians to determine their self-reported ability to perform sigmoidoscopy and perceived obstacles to either initiating or enhancing screening. RESULTS: A total of 884 physicians (50%) responded. Ninety percent of primary care physicians reported that they offered sigmoidoscopic screening to their patients, with 46% referring patients and 44% performing the procedure themselves. Physician characteristics were not associated with the overall use of sigmoidoscopy. In contrast, compared with physicians who referred patients for the procedure, physicians who performed sigmoidoscopy themselves were more often board certified, male, and graduated from medical school after 1970 (P < 0.001). In a multivariate analysis, these characteristics were also independently associated with the ability to perform sigmoidoscopy. The barrier to sigmoidoscopy cited most often was poor patient acceptance, whether or not the physician performed or referred patients for sigmoidoscopic screening. Other barriers cited were lack of training, lack of equipment, and time required, each of which was identified most often by physicians who did not screen at all. CONCLUSIONS: Most physicians surveyed reported using sigmoidoscopic screening to some degree in their practice, although many did not perform the procedure themselves. Population-based interventions to increase screening may benefit from targeting specific physician subgroups and attempting to improve patient acceptance of the procedure.

Colorectal Neoplasms↗
PubMed1998

Endoscopic practice for upper gastrointestinal hemorrhage: differences between major teaching and community-based hospitals.

BACKGROUND: Differences in endoscopic practice in major teaching and community hospitals are not known. METHODS: A total of 1031 consecutive patients discharged from 13 hospitals (4 major teaching, 9 others) in 1994 with upper gastrointestinal hemorrhage were studied. Data obtained from chart abstraction included endoscopic findings and therapy and selected outcomes. Multivariable analyses adjusted for admission severity of illness and endoscopic findings. RESULTS: Rates of endoscopy were similar between patients admitted to major teaching and other hospitals, although procedures to control hemorrhage were used more often in major teaching hospitals (35% vs. 19%, p < 0.001). Use of endoscopic therapy was higher in major teaching hospitals for lesions in which therapy is recommended, as well as other lesions. Recurrent bleeding was also more common in major teaching hospitals (14.3% vs. 7.8%, p = 0.001), and the difference persisted in multivariable analysis (odds ratio 1.69: 95% CI [1.09 to 2.64], p = 0.02). Unadjusted and adjusted length of stay were somewhat shorter in major teaching hospitals. CONCLUSIONS: There was large variation in the use of endoscopic therapy, with higher rates observed in major teaching hospitals for lesions in which therapy is recommended, as well as other stigmata. Further studies are needed to better define the reasons for the practice variation and to assess the impact on other outcomes such as readmission and costs.

Aged↗
PubMed1998

Clinical implications of endoluminal ultrasonography using through-the-scope catheter probes.

BACKGROUND: Ultrasound catheter probe-assisted endosonography is a relatively new technique. The aim of this prospective multicenter study was to determine its potential clinical impact by assessing changes in diagnostic and therapeutic management affected by catheter probes compared with ultrasound endoscopes. METHODS: Endosonographers at three centers selected theoretic diagnostic and therapeutic plans that would be followed if neither catheter probes nor ultrasound endoscopes were available. Patients with suitable lesions underwent endosonography with catheter probes followed by an ultrasound endoscope. Diagnostic and therapeutic plans were noted after each examination. RESULTS: Sixty-six patients, of whom 15 had a stenotic esophageal cancer, 39 had a mucosal or submucosal lesion, and 12 had a stricture of the pancreaticobiliary system or the gastrointestinal tract, were enrolled. If neither form of endosonography were available, invasive or surgical diagnostic procedures would have been performed on 23 (35%) patients and surgical therapy would have been planned in 31 (47%) patients. Catheter probe-assisted ultrasonography and endoscopic ultrasonography led to a less invasive diagnostic plan in 11 (16%) and 12 (18%) patients and a less invasive therapeutic plan in 10 (15%) and 14 (21%) patients, respectively (p > 0.1 for differences). CONCLUSIONS: Catheter probe-assisted endosonography has a modest effect on diagnostic and therapeutic management, comparable with endoscopic ultrasonography in the same patients. The vast majority of effected changes are toward less invasive management.

Digestive System Neoplasms↗
PubMed1998

Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings.

BACKGROUND: Push enteroscopy is indicated in patients with suspected small bowel gastrointestinal bleeding or small bowel mucosal disease. Our aim was to determine the diagnostic yield of enteroscopy, identify clinical predictors associated with findings, and measure frequency of management changes made on the basis of results. METHODS: Endoscopy reports, office charts, and hospital charts were reviewed for 164 patients who had enteroscopy performed, primarily with a video enteroscope, during a period of 2 years. Data extraction included details of comorbid illnesses, associated risk factors, and previous endoscopies. RESULTS: Indications for enteroscopy were suspected occult bleeding in 65, overt bleeding in 64, diarrhea in 20, and suspected mucosal disease in 15 patients. Diagnostic lesions, identified in 92 patients (56%), included 57 jejunal lesions (35%). In patients with overt bleeding, upper tract lesions were present more commonly in patients receiving nonsteroidal medication (54% versus 27%, p < 0.05). Jejunal vascular ectasia occurred more frequently in patients with documented vascular ectasias elsewhere in the gastrointestinal tract (34% versus 15%, p < 0.01). Missed lesions on previous upper endoscopy included large hiatal hernias with erosions in 10, peptic ulcers in 10, and vascular ectasias in 9 patients. Therapeutic interventions, made in 67 of 92 patients (73%) with diagnostic lesions, included small bowel resection in 12 (8%), endoscopic therapy in 21 (14%), and changes in medical regimen in 34 patients (22%). CONCLUSIONS: Push enteroscopy with video enteroscopes has a moderate diagnostic yield. Positive findings frequently lead to therapy changes. Large hiatal hernias remain an under-recognized etiology of anemia. Repeat upper endoscopy should be considered before enteroscopy in patients taking nonsteroidals who develop overt bleeding.

Adult↗
PubMed1998

Enteroscopy for the initial evaluation of iron deficiency.

BACKGROUND: Occult gastrointestinal blood loss is generally investigated with colonoscopy and esophagogastroduodenoscopy in patients with iron-deficiency anemia. The aim of this study was to prospectively measure the additional diagnostic yield of examining the jejunum at the time of upper endoscopy in patients with iron-deficiency anemia. METHODS: Asymptomatic patients with newly diagnosed iron-deficiency anemia who had no identifiable source of blood loss at colonoscopy underwent standard esophagogastroduodenoscopy with the Olympus SIF100L enteroscope followed by overtube-assisted enteroscopy. Upper tract and jejunal sources of blood loss were noted. Biopsy samples from the small bowel were taken when a bleeding lesion was not identified. RESULTS: Thirty-one consecutive patients (13 men, mean age 71) with no gastrointestinal symptomatology were studied. Eleven patients (35%) had a bleeding source that required only esophagogastroduodenoscopy for identification; 8 patients (26%) had a source only in the jejunum; 2 patients (6%) (one with sprue) had a source in upper tract as well as jejunum. The enteroscopy was rated as causing minimal or mild discomfort in 25 of 31 patients (81%). Using Medicare reimbursement figures, a strategy of performing esophagogastroduodenoscopy first would have cost $656 per patient, whereas the strategy of performing esophagogastroduodenoscopy with enteroscopy as the initial test in all patients costs $467 per patient. CONCLUSIONS: Performance of push enteroscopy along with esophagogastroduodenoscopy increases the diagnostic yield from 41% to 67% when evaluating the upper gastrointestinal tract of asymptomatic patients with iron-deficiency anemia and, because of a lower cost, should be the preferred initial diagnostic test.

Aged↗
PubMed1998

Age at natural menopause and mortality.

PURPOSE: The purpose of this study was to examine the association between age at menopause and mortality in a population-based sample of women in the United States. METHODS: This study was based on data from the National Health and Examination Survey (NHANES) Epidemiologic Follow-up Study; 3191 women aged 50-86 years were included. There were 345 deaths over a mean follow-up time of 4.0 years. We used age-stratified and Poisson regression procedures to assess mortality risk by age at natural menopause, with adjustment for age, duration of follow-up, race, education, smoking, and use of hormone replacement therapy. We conducted a separate analysis for surgical menopause with bilateral oophorectomy. RESULTS: Compared with women who were menstruating to age 50 or later, the adjusted mortality rate ratios (RR) were 1.50 (95% confidence interval (CI), 0.97-2.34) for women with a natural menopause at age < 40, 1.04 (95% CI, 0.72-1.51) for those with menopause at age 40-44, and 0.96 (95% CI, 0.72-1.26) for those with menopause at age 45-49. Women with a natural menopause at age 40-44 years experienced an increased risk of cancer-related mortality (adjusted RR 2.34, 95% CI, 1.20-4.58). No age-related increased mortality risk was seen among women who had surgical menopause with bilateral oophorectomy. CONCLUSIONS: This study provides some support for the concept that age at natural menopause serves as a biological marker of health and aging, with potential implications extending beyond cardiovascular diseases.

Adult↗
PubMed1998

Determination and validation of a predictive model for Clostridium difficile diarrhea in hospitalized oncology patients.

BACKGROUND: Clostridium difficile colitis in the cancer patient receiving chemotherapy is a frequent cause of morbidity which may prolong hospitalization. Techniques for identifying infection often delay the initiation of therapy. PATIENTS AND METHODS: In this retrospective case-control analysis, we identified predictors for C. difficile-associated diarrhea in 29 patients hospitalized from 1988 to 1993 on a hematologic malignancy/bone marrow transplant unit (hospital A). We then validated our model with 58 C. difficile cases and 74 controls admitted to an oncology unit from a different institution (hospital B). RESULTS: We found that low intensity of chemotherapy (P < 0.001), lack of parenteral vancomycin use (P = 0.03) and hospitalization within the past two months (P = 0.05) were independently predictive of C. difficile colitis by multivariate analysis. These variables were weighted for predictive capability using a receiver operator characteristic score; low intensity chemotherapy was assigned two points, lack of parenteral vancomycin received one point and prior hospitalization one point (P < 0.001 by chi 2 for trend). The receiver operating characteristic (ROC) curve areas were 0.78 for patients at hospital A and 0.70 at hospital B indicating moderate drop off in discrimination. Compared to hospital A patients, hospital B patients hospitalized between 1989 and 1994 were more often women (P = 0.04), received less systemic vancomycin (P = 0.01), were less frequently neutropenic (P < 0.05), and received less intense chemotherapy regimens (P < 0.05). Despite these differences in demographics in patients between these institutions, our predictive model was validated in hospital B patients (P = 0.02 by chi 2 for trend). CONCLUSIONS: The results of this study may help clinicians predict the risk of C. difficile disease in the hospitalized immunocompromised oncology patient and may help guide empiric therapy while awaiting results of stool toxin assays.

Case-Control Studies↗
PubMed1998

The effectiveness of early endoscopy for upper gastrointestinal hemorrhage: a community-based analysis.

OBJECTIVES: The effectiveness of upper endoscopy in unselected patients with upper gastrointestinal hemorrhage has not been well studied. This study was undertaken to identify factors associated with the performance of early endoscopy (ie, within 1 day of hospitalization) and, after adjusting for these factors, to determine associations between early endoscopy and in-hospital mortality, length of stay, and performance of surgery. METHODS: Subjects in this observational cohort study were 3,801 consecutive admissions with upper gastrointestinal hemorrhage to 30 hospitals in a large metropolitan region. Demographic and clinical data were abstracted from hospital records. A multivariable model based on factors that potentially could relate to the decision to perform endoscopy was developed to determine the propensity (0 to 100%) for early endoscopy in each patient. RESULTS: Early endoscopy was performed in 2,240 patients (59%), and although it was not associated with mortality after adjusting for severity of illness among all patients, it was associated with a higher risk of death for patients in the lowest propensity group. Early endoscopy was associated with a lower likelihood of upper gastrointestinal surgery in all patients and in the two highest propensity groups and with a shorter length of stay in the entire cohort and in all subgroups. CONCLUSIONS: In the absence of specific contraindications, early endoscopy should be considered because of associated reductions in length of stay and surgical intervention. Further studies are needed to identify subgroups in whom the procedure may be associated with adverse effects on survival.

Adult↗
PubMed1998

An ecological study of the effectiveness of mammography in reducing breast cancer mortality.

OBJECTIVES: The purpose of this study was to determine the relation of screening mammography to breast cancer incidence and case fatality. METHODS: In a sample of White female Medicare beneficiaries hospitalized in 1990-1991, age-adjusted breast cancer incidence and 2-year case fatality rates were estimated and compared with the frequency of mammographic screening from a population-based survey. RESULTS: The average rates for incidence, case fatality, and mammography within 5 years in 29 states were 414/100,000, 18.8%, and 59.2%, respectively. There was a positive state-level correlation between mammography rates and incidence and an inverse correlation between mammography and case fatality. CONCLUSIONS: High screening mammography rates in some states are associated with reduced breast cancer case fatality rates, presumably as a result of diagnosis of earlier stage cancers.

Aged↗
PubMed1997

Primary care physician recommendations for colorectal cancer screening. Patient and practitioner factors.

BACKGROUND: Current guidelines for colorectal cancer screening do not specify the role of age or comorbidity in patient selection. Reported screening practices may thus be influenced by patient, as well as physician, characteristics. METHODS: A questionnaire was sent to primary care physicians in 10 states to determine recommendations for fecal occult blood testing (FOBT) and sigmoidoscopy in 4 pairs of clinical vignettes that varied by patient age (65 or 75 years) and comorbidity (none, mild, moderate, and terminal). RESULTS: Among the 884 respondents (50%), most physicians recommended FOBT in all vignettes except those with a terminal illness and fewer than half recommended sigmoidoscopy in any vignette. Physician recommendations were influenced by comorbidity, but one third still recommended FOBT for terminally ill patients and less than 50% recommended sigmoidoscopy for patients with no comorbidity. Differences in recommended screening between vignettes that differed only in patient age were small. Among all subgroups of physicians, at least 30% recommended FOBT in terminally ill patients and no more than 60% recommended sigmoidoscopy in healthy patients. CONCLUSIONS: Primary care physicians were much more likely to recommend screening with FOBT than sigmoidoscopy, regardless of patient and practitioner factors. Although physician recommendations were influenced by patient comorbidity and age, they frequently recommended FOBT in clinically inappropriate settings and failed to recommend sigmoidoscopy when appropriate. Broad-based interventions to improve appropriate screening practices may be needed.

Aged↗
PubMed1997

Severity-adjusted mortality and length of stay in teaching and nonteaching hospitals. Results of a regional study.

CONTEXT: Major teaching hospitals are perceived as being more expensive than other hospitals and, thus, unattractive to managed care. However, little empirical data exist about their relative quality and efficiency. The current study compared severity-adjusted mortality and length of stay (LOS) in teaching and nonteaching hospitals. DESIGN: Retrospective cohort study. SETTING: Thirty hospitals in northeast Ohio. PATIENTS: A total of 89851 consecutive eligible patients discharged in 1991 through 1993 with myocardial infarction, congestive heart failure, obstructive airway disease, gastrointestinal hemorrhage, pneumonia, or stroke. MAIN OUTCOME MEASURES: In-hospital mortality and LOS of patients in major teaching (n=5), minor teaching (n=6), and nonteaching (n=19) hospitals were adjusted for admission severity of illness using multivariable models based on demographic and clinical data abstracted from patients' medical records. RESULTS: The adjusted odds of death was 19% lower (95% confidence interval [CI], 2%-34%; P=.03) for patients in major teaching hospitals compared with non-teaching hospitals but was similar (95% CI, 7% lower to 28% higher; P=.28) for patients in minor teaching hospitals. The findings were generally consistent in analyses stratified according to diagnosis, age, race, predicted risk of death, and other covariates. In addition, risk-adjusted LOS was 9% lower (95% CI, 8%-10%; P<.001) among patients in major teaching hospitals relative to nonteaching hospitals but was similar (95% CI, 2% lower to 11% higher; P=.17) in minor teaching hospitals. Major teaching hospitals also cared for higher proportions of nonwhite and poorly insured patients. CONCLUSIONS: Risk-adjusted mortality and LOS were lower for patients in major teaching hospitals than for patients in minor teaching and nonteaching hospitals. If generalizable to other regions, the results provide evidence that hospital performance, as assessed by 2 commonly used indicators, may be higher in major teaching hospitals. These findings are noteworthy at a time when the viability of many major teaching hospitals is threatened by powerful health care market forces and by potential changes in federal financing of graduate medical education.

Data Collection↗
PubMed1997

Long-term effects of reproductive-age menstrual cycle patterns on peri- and postmenopausal fracture risk.

The authors examined the association between age at menarche, menstrual cycle characteristics between ages 28 and 32 years, and peri- and postmenopausal fracture risk in a cohort of 874 women who prospectively recorded menstrual cycle data for at least 5 years from their early 20s through their menopause. Fracture history was obtained with a self-administered questionnaire. The mean age of respondents at the time the questionnaire was completed was 73 years. Wrist fracture (n = 62) risk increased with increasing age at menarche (odds ratio 3.3, 95% confidence interval 1.7-6.2) for menarche age > or = 14 years compared with 12-13 years) and increasing mean cycle length at age 28-32 (odds ratio 2.2, 95% confidence interval 1.0-4.9) for > 30.5 days compared with 26.6-30.5 days). Similar results were seen in analyses of the combined wrist, hip, or vertebral fracture group (n = 92). These prospectively recorded menstrual diary data indicate that age at menarche and menstrual cycle patterns may have a long-term association with fracture risk, with effects lasting into the postmenopausal years.

Adolescent↗