PubMed Health⌕ Search

Biomedical subjects

J Whittle

Publications and source records attributed to J Whittle.

At least 19 recordsLinked to original sources
PubMed2001

Is warfarin really underused in patients with atrial fibrillation?

CONTEXT: There is agreement that warfarin decreases stroke risk in patients with atrial fibrillation (AF), but prior studies suggest that warfarin is markedly underused, for unclear reasons. OBJECTIVE: To determine if warfarin is underused in the treatment of patients with atrial fibrillation. DESIGN: Cross-sectional. SETTING: Tertiary care VA hospital. PATIENTS: All patients with a hospital or outpatient diagnosis of AF between 10/1/95 and 5/31/98. DATA COLLECTION: One or more physician investigators reviewed pertinent records for each patient. When any of the 3 investigators thought warfarin might be indicated, the patient's primary care provider completed a survey regarding why warfarin was not used. RESULTS: Of 1,289 AF patients, 844 (65%) had filled at least 1 warfarin prescription. Of the 445 remaining, 19 had died, 5 had inadequate medical records, and 54 received warfarin elsewhere, leaving 367 patients. Of these, 160 had no documented AF, 53 had only a history of AF, and 49 had only transient AF. Of the remaining 105 patients, 17 refused warfarin therapy and 72 had documented contraindications to warfarin use including bleeding risk or history, fall risk, alcohol abuse, or other compliance problems. The reasons for not using warfarin among the 16 patients remaining included provider oversight (n = 4) and various reasons suggesting provider knowledge deficits. CONCLUSION: In contrast to prior studies that suggested that warfarin is markedly underused, we found that few patients with AF and no contraindication to anticoagulation were not receiving warfarin. We believe that differing study methodologies, including the use of physician review and provider survey, may explain our markedly different rate of warfarin underutilization, although local institutional factors cannot be excluded. The findings suggest that primary providers may be far more compliant with the standard of care for patients with atrial fibrillation than previously believed.

Aged↗
PubMed2000

Understanding racial variation in the use of coronary revascularization procedures: the role of clinical factors.

BACKGROUND: Black patients undergo coronary artery bypass grafting and percutaneous transluminal coronary angioplasty less often than white patients. It is unclear how racial differences in clinical factors contribute to this variation. METHODS: A retrospective cohort study was performed of 666 male patients (326 blacks and 340 whites), admitted to 1 of 6 Veterans Affairs hospitals from October 1, 1989, to September 30, 1995, with acute myocardial infarction or unstable angina who underwent cardiac catheterization. The primary comparison was whether racial differences in percutaneous transluminal coronary angioplasty and coronary artery bypass grafting rates persisted after stratifying by clinical appropriateness of the procedure, measured by the appropriateness scale developed by the RAND Corporation, Santa Monica, Calif. RESULTS: Whites more often than blacks underwent a revascularization procedure (47% vs 28%). There was substantial variation in black-white odds ratios within different appropriateness categories. Blacks were significantly less likely to undergo percutaneous transluminal coronary angioplasty (odds ratio, 0.30; 95% confidence interval, 0.14-0.63 [P<.01]) when the indication was rated "equivocal." Similarly, blacks were less likely to undergo coronary artery bypass grafting (odds ratio, 0.44; 95% confidence interval, 0.23-0.86 [P<.01]) when only coronary artery bypass grafting was indicated as "appropriate and necessary." Differences in comorbidity or use of cigarettes or alcohol did not explain these variations. Using administrative data from the Veterans Health Administration, we found no differences in 1-year (5.2% vs 7.4%) and 5-year (23.3% vs 26.2%) mortality for blacks vs whites. CONCLUSION: Among patients with acute myocardial infarction or unstable angina, variation in clinical factors using RAND appropriateness criteria for procedures explained some, but not all, racial differences in coronary revascularization use.

Adult↗
PubMed1999

The effectiveness of surgery for congenital nystagmus.

Many individuals with CN cope remarkably well. With several different surgical approaches available, there needs to be reasonable certainty that a chosen treatment is the best for an individual patient. It is hoped that continued research into the mechanisms underlying CN will deliver a deeper understanding of exactly how extraocular surgery brings about an improvement in some cases while still being less than perfectly reliable in others.

Humans↗
PubMed1999

Race, presenting signs and symptoms, use of carotid artery imaging, and appropriateness of carotid endarterectomy.

BACKGROUND AND PURPOSE: We sought to determine whether there are racial differences in use of carotid artery imaging after controlling for clinical factors and to ascertain racial differences in presenting signs and symptoms and overall appropriateness for carotid endarterectomy (CE). METHODS: We performed a retrospective cohort study of 803 patients older than 45 years, hospitalized between 1991 and 1994 at any of 4 Veterans Affairs Medical Centers, with a discharge diagnosis of transient ischemic attack or ischemic stroke. Clinical data were abstracted from the medical record, including presenting symptoms, diagnostic test results, and use of surgical procedures. Appropriateness for CE was determined according to RAND criteria. RESULTS: Black patients were more likely than white patients to present with stroke (78% versus 55%) but less likely to present with transient ischemic attack (22% versus 45%; P=0.001). There was no racial difference in medical comorbidity or preoperative risk. Black patients were less likely to have an imaging study of their carotid arteries (67% versus 79%; P=0.001). Race remained an independent predictor of imaging after adjustment for clinical factors (odds ratio=1.50; 95% CI, 1.06 to 2.13). Because of higher prevalence of significant carotid artery stenosis, whites were significantly more likely than blacks to be assessed as appropriate candidates for surgery with the use of RAND criteria (18% versus 4%; P=0.001). CONCLUSIONS: Use of carotid artery imaging, a critical step in determining eligibility for CE, is influenced by the patient's race after controlling for clinical presentation. Adjustment for appropriateness of CE reduces but does not eliminate the importance of race.

Black or African American↗
PubMed1998

Anticoagulation therapy in patients with venous thromboembolic disease.

OBJECTIVE: To determine, in a representative sample of patients drawn from a variety of hospitals, the degree of adherence to consensus recommendations for anticoagulation among patients with deep vein thrombosis or pulmonary embolism. DESIGN: Cross-sectional review of a population-based random sample. SETTING: Twenty-one randomly selected Pennsylvania hospitals. PATIENTS: Of 357 randomly selected Medicare beneficiaries discharged from study hospitals with a diagnosis of deep venous thrombosis or pulmonary embolism during 1992, 43 charts were not reviewed for administrative reasons, 31 were miscoded or not treated with intravenous administration of heparin, and 13 were excluded for other reasons, leaving 270 in the final sample. MEASUREMENTS AND MAIN RESULTS: Overall, 179 patients (66%, 95% confidence interval [CI] 59%, 72%) received therapeutic anticoagulation (two consecutive partial thromboplastin times more than 1.5 times control) within 24 hours of starting heparin. Platelet counts were checked at least once during the first week of heparin therapy in 66% (95% CI 58%, 74%). At least 5 days of heparin therapy was given to 84% (95% CI 79%, 87%). Among 266 (99%) of the patients receiving warfarin, 193 (72%; 95% CI 63%, 80%) received heparin until the prothrombin time ratio or International Normalized Ratio was therapeutic. Patients who were started on warfarin therapy within 2 days of heparin had decreased length of stay (geometric mean 8.2 vs 9.7 days, p = .003). Compliance varied among hospitals. CONCLUSIONS: In a wide variety of hospitals, we found fair, but variable, compliance with consensus recommendations for anticoagulation of patients with venous thromboembolic disease. Simple interventions to improve compliance with these recommendations might improve quality of care and reduce costs.

Aged↗
PubMed1998

Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia.

OBJECTIVES: The authors describe the relation of provider characteristics to processes, costs, and outcomes of medical care for elderly patients hospitalized for community-acquired pneumonia. METHODS: Using Medicare claims data, Medicare beneficiaries discharged from Pennsylvania hospitals during 1990 with community-acquired pneumonia were identified. Claims data were used to ascertain mortality, readmissions, use of procedures and physician consultations, and the costs of care. The relationship of these measures to provider characteristics was analyzed using regression techniques to adjust for patient characteristics, including comorbidity and microbial etiology. RESULTS: Among 22,294 pneumonia episodes studied, 30-day mortality was 17.0%. After adjusting for patient characteristics, 30-day mortality and readmission rates were unrelated to hospital teaching status or urban location or to physician specialty. Use of procedures and physician consultations was more common and costs were 11% higher among patients discharged from teaching hospitals compared with nonteaching hospitals. Similarly, costs were 15% higher at urban hospitals compared with rural hospitals. General internists and medical subspecialists used more procedures and had higher costs than family practitioners. CONCLUSIONS: Processes and costs of care for community-acquired pneumonia varied by provider characteristics, but neither mortality nor readmission rates did. These differences cannot be explained by clinical variables in the database. Further studies should determine whether less costly patterns of care for pneumonia, and perhaps other conditions, could replace more costly ones without compromising patient outcomes.

Aged↗
PubMed1998

Understanding racial variation in the use of carotid endarterectomy: the role of aversion to surgery.

Previous studies indicate that African-American patients undergo carotid endarterectomy at one fourth the rate of white patients. This study was undertaken to determine if differences in aversion to carotid endarterectomy might account for some of the racial difference in utilization of this procedure. A sample of 185 African-American and white patients was selected from a cohort of patients hospitalized for stroke or transient ischemic attack at four Veterans Affairs medical centers. Of these patients, 115 (62%) were able to be contacted by telephone and 95 (83%) agreed to be interviewed. The interview included assessments of functional status, patient preferences for their current health status, and risk aversion to a hypothetical carotid endarterectomy. Patients from both racial groups were similar in age, marital status, level of education, and comorbid medical illnesses. All respondents were male. Functional status for both groups was high and not statistically different. There were no significant racial differences in patients' perceptions of their current health state. However, African-American patients expressed more aversion to the hypothetical surgery than whites. The median excess risk of death accepted to avoid surgery was 20% for African Americans versus 2.5% for whites. These results indicate that racial differences in the utilization of carotid endarterectomy may be due in part to differences in patients' levels of aversion to this surgery.

Black or African American↗
PubMed1997

Is warfarin underused in the treatment of elderly persons with atrial fibrillation?

BACKGROUND: Several randomized clinical trials have shown that among patients with atrial fibrillation, warfarin sodium use protects against stroke. Recently, experts have voiced concern about possible underuse of warfarin by practicing physicians. Few studies, however, have quantitated the amount of warfarin underuse. METHODS: We randomly sampled 65 Medicare beneficiaries discharged alive from each of 5 small Pennsylvania hospitals between July 1, 1993, and June 30, 1994, with a discharge diagnosis code for atrial fibrillation. Trained abstractors verified that atrial fibrillation was present at some time during the hospitalization, determined the presence of contraindications to anticoagulation, and identified warfarin or aspirin use at discharge for each patient. An internist used implicit criteria to identify the reason for warfarin nonuse in patients who had none of the explicit contraindications to warfarin and did not receive it. RESULTS: Of 322 charts reviewed, 48 patients were not in atrial fibrillation during the hospitalization, 79 had contraindications to warfarin use, 21 either died or were transferred to another hospital, and 2 were admitted with a complication of warfarin. Of the 172 remaining patients, 76 (44%) underwent anticoagulation. On implicit review of the 96 patients who did not undergo anticoagulation, the internist judged that warfarin would not have been appropriate in 54. After excluding those patients, 76 (64%) of the remaining 118 patients underwent anticoagulation. Patients not receiving warfarin were slightly older (81.6 vs 78.3 years old), but this was not statistically significant after stratifying by hospital. Rates of warfarin use at the 5 hospitals varied widely (32%, 57%, 79%, 82%, 94%; P < .001, chi2 with 4 df). Patients with newly diagnosed atrial fibrillation were not more likely to undergo anticoagulation, nor were patients treated by internal medicine or cardiology specialists. CONCLUSIONS: There may be significant warfarin underuse in some hospitals. Overall, approximately one third of patients with atrial fibrillation for whom it appeared appropriate were not anticoagulated with warfarin. Although the fact that data were not available to or were missed by our review surely justifies some of the underuse, one should recall that even a small amount of underuse may affect a large number of people with this common condition.

Aged↗
PubMed1997

Do patient preferences contribute to racial differences in cardiovascular procedure use?

OBJECTIVE: To determine whether patient preferences for the use of coronary revascularization procedures differ between white and black Americans. DESIGN: Cross-sectional survey. SETTING: Tertiary care Department of Veterans Affairs hospital. PATIENTS: Outpatients with and without known coronary artery disease were interviewed while awaiting appointments (n = 272). Inpatients awaiting catheterization were approached the day before the scheduled procedure (n = 80). Overall, 118 blacks and 234 whites were included in the study. MEASUREMENTS AND MAIN RESULTS: Patient responses to questions regarding (1) willingness to undergo angioplasty or coronary artery bypass surgery if recommended by their physician and (2) whether they would elect bypass surgery if they were in either of two hypothetical scenarios, one in which bypass surgery would improve symptoms but not survival and one in which it would improve both symptoms and survival. Blacks were less likely to say they would undergo revascularization procedures than whites. However, questions dealing with familiarity with the procedure were much stronger predictors of a positive attitude toward the procedure use. Patients who were not working or over 65 years of age were also less interested in procedure use. In multivariable analysis race was not a significant predictor of attitudes toward revascularization except for angioplasty recommended by their physician. CONCLUSIONS: Racial differences in revascularization rates may be due in part to differences in patient preferences. However, preferences were more closely related to questions assessing various aspects of familiarity with the procedure. Patients of all races may benefit from improved communication regarding proposed revascularization. Further research should address this issue in patients contemplating actual revascularization.

Adult↗
PubMed1997

Community-acquired pneumonia: can it be defined with claims data?

The use of administrative data to study pneumonia is limited because International Classification of Diseases, 9th revision, Clinical Modification (ICD9-CM) diagnosis codes do not specify whether pneumonia is community-acquired (CAP), a key clinical distinction. We classified 212 patients discharged with a diagnosis code for pneumonia as to whether or not they had CAP, using three administrative data-based systems (Diagnosis Related Groups (DRGs) alone, principal diagnosis alone, and a complex algorithm). We examined agreement with classification by clinician chart review. We also compared the length of stay (LOS) and mortality among the CAP populations identified with different methods. Agreement between the clinical review and the three administrative data methods ranged from 86 to 80%. Classification by DRG performed least well. Populations defined by claims data had similar mortality but shorter mean LOS (9.70, 9.40, and 7.91 days for the algorithm, principal diagnosis and DRG methods, respectively) than the clinically defined population (10.85 days). We conclude that studies of CAP using populations identified by claims may underestimate LOS.

Adult↗
PubMed1997

Vancomycin-resistant enterococci: an emerging health problem.

Since 1995, KePRO has worked with the peer review organization for 13 other states/commonwealths and the District of Columbia, as well as the Boston Regional Office of the Health Care Financing Administration, in the implementation of the largest study ever conducted involving Vancomycin-resistant enterococci (VRE). Fifteen Pennsylvania hospitals volunteered to participate in the study, designed to identify and assess the appropriateness of vancomycin use, contributing 19 percent of the total records used in the baseline study. This article, the first of two, describes VRE and its increasing prevalence. In the second installment, we will describe patterns of vancomycin use identified in KePRO's study of participating Pennsylvania hospitals, as well as the steps these hospitals are taking to control antibiotic use. Since all data gathered by KePRO are protected by federal confidentiality guidelines, the facilities that graciously agreed to pioneer KePRO's vancomycin utilization project will not be identified or identifiable.

Anti-Bacterial Agents↗
PubMed1997

Vancomycin-resistant enterococci: improving treatments.

Recent issues of Morbidity and Mortality Weekly Report (MMWR), a publication of the Centers for Disease Control and Prevention (CDC), described clinical isolates of Staphylococcus aureus with intermediate resistance to vancomycin in patients in Michigan and New Jersey. As described last month in the first installment of this article, vancomycin has been the only approved antibiotic to which S. aureus had been uniformly sensitive. Media coverage of this latest example of increasing antibiotic resistance included the September 4, 1997, issue of The Wall Street Journal, which carried a report of a large study of the appropriateness of vancomycin use being coordinated by the Health Care Financing Administration (HCFA). The article reported study findings that "63 percent of orders for the drug vancomycin violated guidelines from the Centers for Disease Control and Prevention." In this report, we provide additional details about that study, as well as results specific to the Pennsylvania hospitals that participated in this project. The journal article failed to point out that each of the hospitals volunteered to participate in this 15-state study, beginning in late 1995, as part of their strategy to prevent and control the spread of vancomycin-resistant enterococci (VRE). These facilities agreed with experts that optimizing vancomycin use was an important part of this strategy, in addition to traditional infection control measures such as appropriate handwashing practices, prompt and accurate identification of resistant organisms, and isolation of infected and colonized patients when indicated.

Aged↗
PubMed1993

Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system.

BACKGROUND: Previous studies have found racial differences in the use of invasive cardiovascular procedures, which may be due in part to the greater financial incentives to perform such procedures in white patients. In Department of Veterans Affairs hospitals, direct financial incentives affecting use of the procedures are minimized for both patients and physicians. METHODS: We conducted a retrospective analysis of the use of cardiovascular procedures among black and white male veterans discharged from Veterans Affairs hospitals with primary diagnoses of cardiovascular disease or chest pain during fiscal years 1987 through 1991. We used coded discharge data to determine whether cardiac catheterization, percutaneous transluminal coronary angioplasty, or coronary artery bypass grafting was performed during or immediately after such admissions. We used logistic-regression analysis to adjust for the primary discharge diagnosis, the presence of coexisting conditions, age, marital status, type of eligibility to receive care at Veterans Affairs hospitals, geographic region, and whether the hospital was equipped to perform bypass surgery. We classified the primary diagnosis as myocardial infarction, unstable angina, angina, chronic ischemia, chest pain, or "other" cardiovascular diagnosis. RESULTS: After we adjusted for all the potential confounders, we found that white veterans were more likely than black veterans to undergo cardiac catheterization (odds ratio, 1.38; 95 percent confidence interval, 1.34 to 1.42), angioplasty (odds ratio, 1.50; 95 percent confidence interval, 1.38 to 1.64), and coronary artery bypass surgery (odds ratio, 2.22; 95 percent confidence interval, 2.09 to 2.36). CONCLUSIONS: Even when financial incentives are absent, whites are more likely than blacks to undergo invasive cardiac procedures. These findings suggest that social or clinical factors affect the use of these procedures in blacks and whites.

Adult↗
PubMed1993

The parallel Lack anaesthetic breathing system.

The parallel Lack system is a new modification of the Mapleson A system comprising separate inspiratory and expiratory tubes. To determine that the function of the system was that anticipated of a Mapleson A, the fresh gas flow requirements to prevent rebreathing during spontaneous ventilation were assessed in three situations: (1) a lung model (2) conscious volunteers and (3) anaesthetised patients. Two sets of criteria to define rebreathing were used; (A) those based on changes in ventilation or end-expired carbon dioxide tension and (B) minimum inspired carbon dioxide tension. Using A, rebreathing occurred at a fresh gas flow to minute ventilation ratio (VF/VE) of 0.75 for the lung model, and 0.73 for conscious volunteers. These results were comparable to those obtained for a Magill attachment. They were also close to the point at which mechanical dead space began to increase in the lung model. Criteria B gave much lower values for the onset of rebreathing. Rebreathing was present by criteria A in five of the six anaesthetised patients at a fresh gas flow of 60 ml.kg-1.min-1 (VF/VF of 0.78). The results confirm that the parallel Lack behaves as a Mapleson A system. The resistance to breathing posed by the parallel Lack was also comparable to the Magill system.

Adult↗