PubMed Health⌕ Search

Biomedical subjects

L Rabeneck

Publications and source records attributed to L Rabeneck.

At least 37 records · Page 2Linked to original sources
PubMed1999

How good are US studies of HIV costs of care?

BACKGROUND: Valid, timely estimates of the costs of HIV care are needed by health planners and policy makers. OBJECTIVE: To perform a methodologic critique of published estimates of resource utilization and costs of HIV care. DATA SOURCES: MEDLINE database for 1990-1998. DATA SELECTION: Included articles focused on adults with a spectrum of HIV disease in which the authors developed their own resource use and cost data. Thirty one articles met these criteria. DATA EXTRACTION: Studies were compared based on: (1) utilization and cost estimates, in 1995 dollars; (2) study period; (3) research design; (4) sampling frame; (5) sample size and patient characteristics; (6) data sources and scope of services; and (7) methods used in the analysis. DATA SYNTHESIS: The most recent estimates pertain to the first half of 1995, before the use of protease inhibitor therapy. We found wide variations in the estimates and identified three major sources for this: (1) patient samples that were restricted to subgroups of the national HIV-infected population; (2) utilization data that were limited in scope (e.g., inpatient care only); and (3) invalid methods for estimating annual or lifetime costs, particularly in dealing with decedents. CONCLUSIONS: To accurately estimate resource use and costs for HIV care nationwide, a nationally representative probability sample of HIV-infected patients is required. Even in research that is not intended to provide national estimates, the scope of utilization data should be broadened and greater attention to methodologic issues in the analysis of annual and lifetime costs is needed.

Acquired Immunodeficiency Syndrome↗
PubMed1998

A randomized controlled trial evaluating nutrition counseling with or without oral supplementation in malnourished HIV-infected patients.

OBJECTIVE: To evaluate the effects of nutrition counseling with or without oral supplementation in malnourished patients infected with the human immunodeficiency virus (HIV). DESIGN: Randomized controlled trial. SUBJECTS: HIV-infected men (n=118) who were less than 90% of usual weight for height or who had lost more than 10% of body weight. INTERVENTION: Nutrition counseling alone (control group) vs nutrition counseling plus enteral supplementation (supplement group) for 6 weeks. All patients were instructed to consume a diet that exceeded estimated total energy expenditure by 960 kcal/day. MAIN OUTCOME MEASURES: Weight, skinfold thickness, fat-free mass, grip strength, quality of life, and cognitive function (Buschke test). STATISTICAL ANALYSES: Differences in baseline variables and outcomes were evaluated using analysis of variance or the Wilcoxon rank sum test. RESULTS: Ninety-nine men completed at least 4 weeks of treatment, 49 in the supplement group and 50 in the control group. Half the patients in each treatment group achieved at least 80% of their energy target. No differences in weight, skinfold thickness measurements, or quality of life were observed. Compared with the control group, the supplement group had larger increases in fat-free mass and grip strength, although the differences did not reach statistical significance. APPLICATIONS: In the short term, nutrition counseling with or without oral supplementation can achieve a substantial increase in energy intake in about 50% of malnourished HIV-infected patients. Although further study is needed to evaluate long-term effects, these findings suggest that nutrition counseling has an important role in the management of malnourished HIV-infected patients.

Adult↗
PubMed1998

Dyspepsia: how should we measure it?

This study developed and validated a multidimensional measure of dyspepsia. A questionnaire was administered to 126 patients with dyspepsia who presented for care at a VA outpatient clinic and a family physician's private office. Dyspepsia-specific health was measured by self-report using: (1) an existing dyspepsia scale that produces an aggregate score by summing ratings across pain and non-pain symptoms; (2) adaptations of two scales originally designed to measure back pain; and (3) a new scale measuring satisfaction with dyspepsia-related health. Generic health was measured using the SF-36. Results from factor analysis revealed four dimensions of dyspepsia-related health: pain intensity, pain disability, non-pain symptoms, and satisfaction with dyspepsia-related health. After refinements, scales representing the four dimensions conformed to psychometric standards for reliability, and convergent and discriminant validity. The importance of measuring dyspepsia using a multidimensional approach was confirmed by demonstrating that classification of dyspepsia severity depended on the dimension that was assessed. We conclude that dyspepsia is best measured using a multidimensional approach.

Adult↗
PubMed1998

Managing dyspepsia: what do we know and what do we need to know?

OBJECTIVE: The conceptual revolution concerning the role of Helicobacter pylori in the pathogenesis of peptic ulcer disease has raised the larger question of how to integrate this new information into the management of patients with dyspepsia. The aim of this research was to critically evaluate current knowledge about dyspepsia and its management. METHODS: Relevant articles on dyspepsia were identified from MEDLINE searches and from the bibliographies of identified articles. Studies that contained information on the prevalence of dyspepsia, endoscopic findings, and evaluations of alternative management strategies were reviewed. RESULTS: By coupling H. pylori serological testing with clinical factors such as age and nonsteroidal antiinflammatory drug use, strategies have been developed that identify patients with organic disease. Although the use of these strategies can reduce the volume of endoscopies, their effects on dyspepsia symptoms are unknown. Computerized decision analysis models have been used to evaluate the cost-effectiveness of alternative strategies. The indirect evidence obtained from these models suggests that empiric therapy, guided by H. pylori testing, may be the preferred approach. However, the models have been hampered by the lack of information concerning dyspepsia symptoms, the primary health outcome of the majority of patients seen in primary practice settings. CONCLUSIONS: Currently, the knowledge needed to integrate H. pylori tests and antimicrobial therapies into the management of patients with dyspepsia in primary practice settings has not been developed. A pressing need exists for a randomized controlled trial to evaluate alternative management strategies. In conducting such a trial, valid, reliable instruments for measuring dyspepsia will be needed.

Computer Simulation↗
PubMed1997

Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement.

Guidelines for the placement of percutaneous endoscopic gastrostomy (PEG) tubes are not available. We developed a decision-making algorithm by integrating the medical and ethical dimensions of the decision. According to our algorithm, physicians should not offer PEG tubes to patients with anorexia-cachexia syndromes. For patients with permanent vegetative states, physicians should offer and recommend against the procedure. For patients who have dysphagia without other deficits in quality of life, physicians should offer and recommend the procedure. For the the remaining patients who have dysphagia with other deficits in quality of life, the physician's role is to provide non-directive counselling regarding the short and long-term consequences of a trial of PEG tube feeding.

Algorithms↗
PubMed1997

Predicting outcomes in HIV-infected veterans: I. Progression to AIDS.

This article and the following article (Parts I and II) report the development of two clinical staging systems for HIV-infected individuals. The objective of the research reported here (Part I) was to construct a clinical staging system to predict progression to AIDS. We analyzed data from VA Cooperative Study Number 298, a multicenter, double-blind, randomized trial that compared immediate versus deferred zidovudine therapy in 338 HIV-infected individuals who did not have AIDS at enrollment. Baseline variables were tested in univariate Cox regression for their relationship to progression to AIDS, and those that appeared predictive were examined in multivariable analysis. Based on these analyses, we constructed a new clinical staging system based on CD4+ cell count, age, hemoglobin, oral hairy leukoplakia or oral thrush, and fever. The stages of the system were significant predictors of progression to AIDS (p = 0.0001, log-rank test). In conclusion, simple, valid, clinical staging systems for HIV-infected patients can be constructed using information that is readily available in clinical practice settings. Such systems provide better prognostic distinction than CD4+ cell count alone by taking into account the known prognostic effects of other variables.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Predicting outcomes in HIV-infected veterans: II. Survival after AIDS.

This article (Part II) and the preceding article (Part I) report the development of two clinical staging systems for HIV-infected individuals. The objective of the research reported here (Part II) was to construct a clinical staging system to predict survival in patients with AIDS. We analyzed data from VA Cooperative Study Number 298, a multicenter, double-blind, randomized trial that compared immediate versus deferred zidovudine therapy in HIV-infected individuals. Baseline variables obtained at the onset of AIDS in 204 individuals were tested in univariate Cox regression for their relationship to survival, and those that appeared predictive were examined in multivariable analysis. Based on these analyses, we constructed a new AIDS Clinical Staging System. The system is based on age, CD4+ cell count, type of first AIDS-defining condition, and functional status. The stages of the system were significant predictors of survival (p = 0.0001, log-rank test). In conclusion, valid, simple clinical staging systems for patients with AIDS can be developed based on a few variables that are readily available in clinical settings.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Gastric ulcers at endoscopy: brush, biopsy, or both?

OBJECTIVES: All gastric ulcers discovered at endoscopy are potentially malignant. Concurrent use of both histological biopsy and cytological brushing has been advocated as a means of increasing the diagnostic yield for neoplasia at the time of initial endoscopy. The purpose of this analysis was to determine the impact of these diagnostic strategies on the cost-effectiveness of detecting malignancy in patients with a gastric ulcer. METHODS: The diagnostic performance of biopsy and brushings in detecting gastric malignancy was estimated from a meta-analysis of published reports. Nondiscounted direct costs were determined from patient resource consumer profiles from the perspective of a Canadian hospital. A decision tree was used to compare diagnostic strategies (biopsy alone, brushing alone, or biopsy and brushing) in a hypothetical cohort of patients found to have a gastric ulcer at endoscopy. Effectiveness was expressed as diagnostic days saved. RESULTS: No strategy achieved dominance. The brushing strategy was the most cost-effective, but its cost-effectiveness ratio was only slightly lower than that of biopsy. Cost differences between the biopsy and brushing strategies were small (less than $6 per case). Performing both biopsy and brushing slightly improved the true-positive rate but resulted in a doubling of the false-positive rate, which in turn led to unnecessary laparotomies. The impact of the high false-positive rate was also seen in the incremental cost of performing both brushings and biopsy ($168-$423 per case). CONCLUSIONS: For gastric ulcers discovered at endoscopy, the preferred strategy is to perform either cytological brushing or histological biopsy. The previously recommended strategy of performing both cytological brushing and histological biopsy should be reconsidered.

Biopsy↗
PubMed1996

Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) tube placement is the preferred method for long-term enteral feeding of patients who are unable to take food by mouth. Despite the widespread acceptance of the procedure, no large-scale study of the long-term outcomes of patients receiving PEG tubes has been reported. The objective of this study was to determine the survival of patients in whom PEG tubes are placed. DESIGN: Retrospective cohort study using data obtained from two computerized databases. SETTING: Department of Veterans Affairs hospitals. PATIENTS: Seven thousand three hundred sixty-nine patients who received a PEG tube in fiscal years 1990 through 1992. RESULTS: For the 7,369 patients, the mean age was 68.1 years and 98.6% were men. PEG tubes were most commonly places in patients with cerebrovascular disease (18.9%), other organic neurologic disease (28.6%), or head and neck cancer (15.7%). Although the complication rate of the procedure itself was low (4%), because of the severity of their underlying disease, 1,732 patients (23.5%) died during the hospitalization in which the PEG tube was placed. The median survival of the full cohort was 7.5 months. CONCLUSIONS: This study documents the widespread placement of PEG tubes in severely ill patients, half of whom are in the terminal phase of their illness. Further study is needed to determine whether these patients benefit from PEG tube placement in terms of their quality of life and survival.

Adolescent↗
PubMed1996

Predicting progression to AIDS. An evaluation of two approaches.

This study evaluated the predictive validity of two clinical staging systems for HIV infection (the Rabeneck and Royce systems) using data obtained from the Department of Veterans Affairs Cooperative Study Number 298, a randomized clinical trial involving 335 symptomatic patients with CD4 counts of 200 to 500/mm3. The relation between the HIV clinical stages and progression to AIDS was examined using Kaplan-Meier estimates, and Cox models were used to determine if the stages remained predictive after controlling for CD4 count. Both systems were significant independent predictors of progression to AIDS. This work demonstrates that simple, valid staging systems for HIV infection can be developed that provide greater prognostic distinction than the CD4 count alone.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Uncertain clinical significance of duodenal mucosal abnormalities in HIV-infected individuals. Results of a case-control study.

Previous research has described abnormalities of duodenal mucosal morphology in human immunodeficiency virus (HIV)-infected individuals. We wanted to determine the frequency of disturbed villus architecture and investigate its relationship to HIV-related chronic diarrhea. We conducted a case-control study of 120 HIV-infected men, 63 with and 57 without chronic diarrhea. Stools were cultured for bacteria and examined for ova and parasites; esophagogastroduodenoscopy and flexible sigmoidoscopy with mucosal biopsies were performed. Biopsy tissue was examined using light and electron microscopy to detect enteric pathogens and to evaluate mucosal morphology. The mean CD4+ cell count was 143/min3, and enteric pathogens were detected in 56 of 120 men (47%). In approximately half the study sample (57%), duodenal villus architecture was normal; complete villus flattening was not observed. We detected no association between chronic diarrhea and altered villus architecture. Although further study is needed to clarify the pathogenesis of altered duodenal mucosal morphology, our results suggest that the clinical significance of the abnormalities may be small.

Adult↗
PubMed1996

Quantitative light microscopic detection of Enterocytozoon bieneusi in stool specimens: a longitudinal study of human immunodeficiency virus-infected microsporidiosis patients.

The clinical course of microsporidiosis caused by Enterocytozoon bieneusi and the pattern of intestinal shedding of spores have not been correlated, at least in part because detection of E. bieneusi in stools is more difficult than detection of other protozoa because of its smaller size and less intense staining. We examined with a modified trichrome stain 124 stool specimens collected over a 2-year follow-up period from 23 human immunodeficiency virus-infected patients with electron microscopic-proven E. bieneusi infection and correlated the results with electron microscopic observations from duodenal biopsy specimens taken at the beginning of the study period. E. bieneusi was detected in the stool at least once in 74% (17 of 23) of all patients, in 100% (9 of 9) of patients in whose tissue moderate or abundant numbers of parasites were seen, and in 57% (8 of 14) of patients in whose tissue few parasites were seen. In two patients with abundant tissue parasites, many microsporidia were detected in every stool specimen (13 of 13) during the follow-up period, whereas among the patients with few tissue parasites, only 23% (15 of 64) of stool specimens were positive. Furthermore, if spore stages as well as plasmodial stages were detected in tissue, stool specimens were more likely to be positive. Although most of the heavily infected stools were from patients with chronic diarrhea, microsporidia were detected in 33, 28, and 42% of stool specimens from patients with nil, intermittent, and chronic diarrhea patterns, respectively. Although quantitation of E. bieneusi spores in stool specimens was closely correlated with quantitation in tissue, it was not correlated with reported patterns of diarrhea.

AIDS-Related Opportunistic Infections↗