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Biomedical subjects

Neil R Powe

Publications and source records attributed to Neil R Powe.

At least 91 records · Page 5Linked to original sources
PubMed2002

Small apolipoprotein(a) size predicts mortality in end-stage renal disease: The CHOICE study.

BACKGROUND: The high mortality rate in end-stage renal disease has engendered interest in nontraditional atherosclerotic cardiovascular disease (ASCVD) risk factors that are more prevalent in end-stage renal disease, such as elevated lipoprotein(a) [Lp(a)] levels. Previous studies suggest that high Lp(a) levels and small apolipoprotein(a) [apo(a)] isoform size are associated with ASCVD, but none have investigated the relationship between Lp(a) level, apo(a) size, and mortality. METHODS AND RESULTS: An inception cohort of 864 incident dialysis patients was followed prospectively. Lp(a) was measured by an apo(a) size-independent ELISA and apo(a) size by Western blot after SDS-agarose gel electrophoresis. Comorbid conditions were determined by medical record review. Time to death was ascertained through dialysis clinic and Health Care Financing Administration follow-up. Survival analyses were performed with adjustment for baseline demographic, comorbid conditions, albumin, and lipids. Median follow-up was 33.7 months, with 346 deaths, 162 transplantations, and 10 losses to follow-up during 1999 person-years of follow-up. Cox regression analysis showed no association between Lp(a) level and mortality. However, an association between small apo(a) isoform size and mortality was found (hazard ratio, 1.36; P=0.004) after adjusting for age, race, sex, comorbidity score, cause of renal disease, and congestive heart failure. The association was somewhat lower in white patients (hazard ratio 1.34; P=0.019) than in black patients (1.69; P=0.04). No interaction by age, race, sex, diabetes, ASCVD, or Lp(a) level was present. CONCLUSIONS: Small apo(a) size, but not Lp(a) level, independently predicts total mortality risk in dialysis patients.

Aged↗
PubMed2002

The timing of specialist evaluation in chronic kidney disease and mortality.

BACKGROUND: Care for chronic renal failure involves management of complications and preparation for possible dialysis. Patients often are not evaluated by nephrologists in a timely manner. OBJECTIVE: To identify factors associated with late evaluation by a nephrologist and to assess whether late evaluation is associated with worse survival once patients develop end-stage renal disease (ESRD). DESIGN: National prospective cohort study. SETTING: 81 dialysis facilities throughout the United States. PATIENTS: 828 patients with new-onset ESRD. MEASUREMENTS: Time from first evaluation by a nephrologist to initiation of dialysis, classified as late (<4 months), intermediate (4 to 12 months), or early (>12 months); rate of death, from initiation of dialysis to an average of 2.2 years of follow-up; and demographic, clinical, and laboratory characteristics. RESULTS: After adjustment for potential confounders, late evaluation was more common among black men than white men (44.8% vs. 24.5%; P < 0.05), uninsured patients than insured patients (56.7% vs. 29.0%; P < 0.05) and patients with severe comorbid disease than those with mild comorbid disease (35.0% vs. 23.0%; P < 0.05). Compared with patients who had early evaluation, the risk for death was greater among patients evaluated late and was graded (hazard ratio, 1.3 [95% CI, 0.87 to 2.06] for patients with intermediate evaluation and 1.8 [CI, 1.21 to 2.61] for those with late evaluation) after adjustment for dialysis method, demographic characteristics, and socioeconomic status in Cox proportional hazards regression analysis. After additional adjustment for such factors as the presence and severity of comorbid conditions, the association remained graded (hazard ratio, 1.2 [CI, 0.73 to 1.82] for patients evaluated at an intermediate point and 1.6 [CI, 1.04 to 2.39] for those evaluated late). CONCLUSIONS: Late evaluation of patients with chronic renal failure by a nephrologist is associated with greater burden and severity of comorbid disease, black ethnicity, lack of health insurance, and shorter duration of survival.

Black or African American↗
PubMed2002

Determinants of willingness to donate living related and cadaveric organs: identifying opportunities for intervention.

BACKGROUND: Although low rates of cadaveric organ donation have been attributed to potential cadaveric donors' concerns regarding their religious beliefs and mistrust of the health care system, it is unclear whether similar concerns are important to potential living related donors. It is also not known which factors might be most responsible for low rates of cadaveric and living related donation among the general public. METHODS: We conducted a cross-sectional study of households in Maryland, using a standardized telephone questionnaire, to assess factors associated with willingness to donate cadaveric and living related organs. We compared factors (demographic, cultural, attitudinal, and clinical) related to willingness to donate cadaveric organs with factors related to willingness to donate living related organs. In multivariate analyses, we assessed the independent relation of factors to willingness to donate cadaveric and living related organs, and we assessed the relative importance of these factors in explaining variation in the general public's willingness to donate. RESULTS: Of 385 participants (84% of randomized homes), 254 (66%) were extremely willing to donate to a sibling but only 179 (47%) had designated themselves a cadaveric donor on their drivers' licenses. In bivariate analysis, older age, comorbid conditions, mistrust in hospitals, and concerns about discrimination in hospitals were statistically significantly associated with less willingness to donate living related organs, although African-Americans, older age, lower education, lack of insurance, unemployment, comorbid conditions, and religion/spirituality were associated with less willingness to donate cadaveric organs. After adjusting for potential confounders, only mistrust in hospitals and concerns about discrimination remained strongly and independently associated with 50 to 60% less odds of willingness to donate living related organs [[relative odds [95% confidence intervals (CI)]: 0.4 (0.2-0.7) to 0.5 (0.3-1.0) and 0.4 (0.2-0.9), respectively]] although presence of dependents was associated with 70% higher odds of willingness to donate living related organs [relative odds (95% CI): 1.7 (1.0-3.0)]. In contrast, older age, employment status, religion/spirituality, and mistrust in hospitals were associated with 50 to 90% less odds of willingness to donate living related organs cadaveric organs [relative odds (95% CI): 0.3 (0.1-0.8), 0.4(0.2-0.8), 0.1 (0.1- 0.5) to 0.5 (0.2-0.9), and 0.3 (0.2-0.6), respectively]. Mistrust in hospitals and concerns about the surgical donation procedure contributed most to the variation in willingness to be a living related donor, although race contributed most to the variation in willingness to be a cadaveric donor. CONCLUSIONS: Many factors affect the general public's willingness to donate organs, but their relative contribution is different for living related versus cadaveric donation. Efforts to improve organ donation rates should be directed toward factors that are most important in explaining the existing variation in willingness to donate.

Adult↗
PubMed2002

Vancomycin-sensitive and vancomycin-resistant enterococcal infections in the ICU: attributable costs and outcomes.

OBJECTIVES: To determine the economic and clinical outcomes associated with infection with vancomycin-resistant Enterococcus (VRE) and to compare these outcomes to those associated with infection with vancomycin-sensitive Enterococcus (VSE). METHODS: During a 3-month, prospective, cohort study of 117 high-risk, critically ill patients we collected complete clinical and demographic and ICU cost data from all patients during their ICU stays. RESULTS: After adjusting for variables in a stepwise multiple regression model VRE infections were associated with a median attributable increased ICU cost per patient of $33,251 (38,088 euros) and an increased length of hospital stay (LOS) of 22 days, while VSE infections were associated with an increased cost of $21,914 (25,102 euros) and an increased LOS of 27 days. The effect of VRE and VSE infections were not significantly different. Over the entire cohort the attributable cost per ICU patient day associated with VRE infection was $304 (348 euros). CONCLUSIONS: The attributable cost of ICU care associated with VRE infection is $33,251 (38,088 euros) and per ICU patient day was $304 (348 euros). VRE and VSE infections do not differ in associated cost of ICU care, LOS, or mortality. Any VRE control strategy is be cost-effective if the overall cost per ICU patient-day is less than $304 (348 euros).

APACHE↗
PubMed2002

Quality of clinical reports on behavioral interventions for hypertension.

PURPOSE: The purpose of this study was to provide clinicians with the confidence to employ behavioral interventions for hypertension and to guide researchers in the development and reporting of studies. METHODS: We systematically reviewed English language articles (1970-1999) describing behavioral interventions for hypertension, evaluating aspects of design, analysis, reporting of results, and factors that were associated with higher quality of these studies. RESULTS: Of 100 articles, 49 were randomized controlled trials (RCT), 33 were observational studies with control groups, and 18 were observational studies without control groups; mean (SE) quality scores were 69.2 (1.6), 57.6 (5.3), and 60.3 (2.2), respectively. RCTs were more likely than observational studies to attain high scores in descriptions of appropriateness of control group, inclusion and exclusion criteria, study population, and the intervention protocol. In multivariate analysis, date of publication, reported funding source, and intervention type were independently associated with greater quality scores: 7.4 [95% CI: 0.03, 14.7] points greater for articles published 1990-1999 vs 1970-1979, 6.5 [95% CI: 1.4, 11.6] points greater for articles reporting government funding vs those not reporting funding sources, and 8.6 [95% CI: 0.3, 17.1], 12.9 [95% CI: 3.4, 22.4], and 14.2 [4.1, 24.4] points greater for articles examining patient education/support, change in delivery system, and mass health campaigns vs articles examining patient reminders, respectively. CONCLUSIONS: While quality has improved over time, there is considerable room for improvement. Investigators should pay particular attention to description of study population and allocation of subjects, the use of standardized outcomes reporting, and appropriate statistical analysis.

Analysis of Variance↗
PubMed2002

Growth failure, risk of hospitalization and death for children with end-stage renal disease.

Growth failure remains a significant problem for children with chronic renal insufficiency and end-stage renal disease (ESRD). We examined whether growth failure is associated with more-frequent hospitalizations or higher mortality in children with kidney disease. We studied data on prevalent United States pediatric patients with ESRD in 1990 who were followed through 1995. Patients were categorized according to the standard deviation score (SDS) of their incremental growth during 1990: severe (<-3 SDS), moderate growth failure (>-3 and <-2 SDS), and normal growth (>-2 SDS). Among 1,112 prevalent pediatric dialysis and transplant patients (<17 years, Tanner I-IV), those with severe and moderate growth failure had higher hospitalization rates [relative risk (RR) 1.14 [95% confidence interval (CI) 1.1, 1.2] and 1.24 [95% CI 1.2, 1.3]] respectively than those with normal growth after adjustment for age, gender, race, cause and duration of ESRD, and treatment modality (dialysis or transplant) in 1990. Kaplan-Meier survival analysis showed 5-year survival of 85% and 90% for patients with severe and moderate growth failure, respectively, compared with 96% for patients with normal growth ( P<0.001, log-rank). Cox proportional hazards analysis revealed that those with severe (RR 2.9, 95% CI 1.6, 5.3) and moderate growth failure (RR 2.01, 95% CI 1.1, 3.6) had an increased risk of death compared with youths with normal growth, after adjustment. A higher proportion of deaths in the severe and moderate growth failure groups were attributed to infectious causes (22% and 18.7%, respectively) than in the normal growth group (15.6%). We conclude that growth failure is associated with a more-complicated clinical course and increased risk of death for children with kidney failure.

Adolescent↗
PubMed2002

Development and use of evidence-based clinical practice guidelines for thyroid disease.

Clinical practice guidelines offer recommendations for optimizing health care. Guideline panels can rely on several methods for gathering information about current practice and synthesizing evidence that addresses specific questions. Clinical practice guidelines, including many that address thyroid disease, often rely on conventional narrative literature reviews and expert opinion rather than systematic evaluation of the published literature as the basis for their recommendations. This undermines the authority of practice guidelines and potentially results in disparate, invalid, or misleading recommendations. In contrast, incorporation of rigorous systematic reviews of literature and guidance by groups with multidisciplinary expertise decreases bias in evidence selection and increases precision of treatment effect estimates. Improved reliability and accuracy of evidence assessment, in turn, strengthens ultimate guideline recommendations. Cost-effective analyses further contribute to useful clinical practice guidelines and may encourage the explicit acknowledgment of values and preferences. Valid recommendations, however, prove futile in the absence of implementation. Adherence to guidelines may be improved with integration of user-friendly computer applications into clinical practice. By overcoming barriers to implementation and addressing the limitations of current guidelines, endocrinologists can play an essential role in improving the quality, efficiency, and cost-effectiveness of clinical practice related to thyroid disorders.

Endocrinology↗
PubMed2002

The general public's concerns about clinical risk in live kidney donation.

Difficulty in attracting live kidney donors may be related to fears regarding both the surgical procedure for kidney harvesting and future failure of the remaining kidney. We conducted a cross-sectional study of households in Maryland to identify public disincentives to living related kidney donation. In multivariate analyses, we assessed the independent effects of several factors on willingness to donate a kidney to a sibling. We also assessed thresholds for factors above which persons would not donate a kidney. Of 385 participants, 66% were extremely willing to donate to a sibling. After adjustment, those who considered the length of a hospital stay, out-of-pocket expenses, size and appearance of a scar, the time it takes to get to the transplant center, and the donor risk of developing kidney failure very important had 50-60% less odds of being extremely willing to donate. Median acceptable levels for risk of complications, hospital stay, compensated and uncompensated time from work, time requiring pain medications, and out-of-pocket expenses were greater than levels from clinical evidence regarding both laparoscopic and open nephrectomy. Unrealistic concerns among the general public regarding live donation may serve as potential disincentives to donation. Efforts to educate the public regarding live donation might help assuage fears and attract those who may not otherwise donate.

Adult↗
PubMed2002

Race-specific association of lipoprotein(a) with vascular access interventions in hemodialysis patients: the CHOICE Study.

BACKGROUND: Elevated serum levels of lipoprotein(a) [Lp(a)] and low molecular weight apolipoprotein(a) [apo(a)] isoforms are associated with atherothrombotic disease in the general population and in patients with kidney failure. Lp(a) may be more atherothrombotic in whites than in blacks. Data on the relation of Lp(a) and apo(a) isoform size to hemodialysis vascular access complications are limited. METHODS: We analyzed the intervention-free survival of the first arteriovenous (AV) access among 215 white and 112 black incident hemodialysis patients participating in the CHOICE Study, a national multicenter prospective cohort study. RESULTS: Median levels of Lp(a) protein were higher among blacks than whites (81.0 versus 37.5 nmol/L; P < 0.001) and inversely correlated with apo(a) isoform size (r = -0.57; P < 0.001). The incidence rate of access interventions was much higher in synthetic grafts (N = 193) than native fistulae (N = 134; 1.0 vs. 0.5 interventions per access-year; P < 0.001) and in patients with kidney failure primarily due to diabetes mellitus (N = 161) than others (N = 166; 0.9 vs. 0.6; P < 0.01), but did not differ by race. Blacks in the highest race-specific Lp(a) quartile (>145 nmol/L) had a significantly higher incidence rate than other blacks (1.4 vs. 0.7; P = 0.04), whereas no association was found in whites. The association in blacks remained after adjustment for access type and other characteristics (relative hazard = 1.68; 95% confidence interval: 0.98 to 2.86). No association was found with apo(a) isoform size in either race. CONCLUSIONS: Elevated Lp(a) may be a risk factor for arteriovenous access complications among black hemodialysis patients. Future studies should explore this possibility and be adequately powered to allow race-specific analyses.

Adult↗
PubMed2002

Designing and evaluating interventions to eliminate racial and ethnic disparities in health care.

A large number of factors contribute to racial and ethnic disparities in health status. Health care professionals, researchers, and policymakers have believed for some time that access to care is the centerpiece in the elimination of these health disparities. The Institute of Medicine's (IOM) model of access to health services includes personal, financial, and structural barriers, health service utilization, and mediators of care. This model can be used to describe the interactions among these factors and their impact on health outcomes and equity of services among racial and ethnic groups. We present a modified version of the IOM model that incorporates the features of other access models and highlights barriers and mediators that are relevant for interventions designed to eliminate disparities in U.S. health care. We also suggest that interventions to eliminate disparities and achieve equity in health care services be considered within the broader context of improving quality of care. Some health service intervention studies have shown improvements in the health of disadvantaged groups. If properly designed and implemented, these interventions could be used to reduce health disparities. Successful features of interventions include the use of multifaceted, intense approaches, culturally and linguistically appropriate methods, improved access to care, tailoring, the establishment of partnerships with stakeholders, and community involvement. However, in order to be effective in reducing disparities in health care and health status, important limitations of previous studies need to be addressed, including the lack of control groups, nonrandom assignment of subjects to experimental interventions, and use of health outcome measures that are not validated. Interventions might be improved by targeting high-risk populations, focusing on the most important contributing factors, including measures of appropriateness and quality of care and health outcomes, and prioritizing dissemination efforts.

Ethnicity↗
PubMed2002

Cost-quality trade-offs in dialysis care: a national survey of dialysis facility administrators.

Dialysis facilities face important trade-offs between cost and quality under constrained capitated reimbursement. How management at dialysis facilities makes decisions affecting cost and quality of care and views opportunities and threats is unknown. We conducted a national survey of dialysis facility administrators. We asked administrators what changes they would make in response to increases or decreases in reimbursement, their views on linking dialysis care payment to quality-of-care measures, and their views on providing patients with treatment options and outcomes information. One hundred fifty-seven of 280 dialysis facility administrators (56%) responded. If dialysis reimbursement were to increase by 20%, the five most common responses were to: improve patient education programs (62% of respondents), improve facility amenities (42%), purchase new equipment (30%), provide more money for staff salaries (28%), and increase number of nursing staff (21%). Conversely, if dialysis reimbursement were to decrease by 20%, the most common responses were to: limit staff salary (45% of respondents), decrease nursing staff (41%), not replace dialysis equipment (43%), increase dialyzer reuse (37%), and return less to investors (36%). Differences in rank order of responses were observed according to professional training of the administrator and profit status of the facility. Administrators uniformly believe that it is very acceptable to provide facility-specific outcomes data to the public, as well as information on modalities of treatment provided by facilities. However, administrators varied in their views regarding whether reimbursement should be based on quality by using a process-of-care measure, such as the average dose of dialysis, or an outcome-of-care measure, such as case-mix-adjusted mortality rates. We conclude that increases in facility reimbursement generally would be used by dialysis facility administrators for the benefit of patients, whereas decreases (or inflation erosion) in payment rates might compromise staffing. US dialysis administrators support sharing treatment options and outcomes information with patients, but appear to be ambivalent with regard to linking reimbursement to adequacy of dialysis or patient outcomes. These results have important implications regarding proposed changes in the US capitated dialysis payment rate and current efforts to empower consumers of dialysis care.

Adult↗
PubMed2002

Comorbidity and other factors associated with modality selection in incident dialysis patients: the CHOICE Study. Choices for Healthy Outcomes in Caring for End-Stage Renal Disease.

Case-mix factors influence both the selection of dialysis modality and outcomes in end-stage renal disease (ESRD). A detailed characterization of the case-mix differences between peritoneal dialysis (PD) and hemodialysis (HD) patients at the onset of dialysis therapy has not been performed, despite the importance of accounting for baseline differences in future comparisons of outcomes across modality groups. We compared baseline characteristics of 279 PD and 759 HD patients enrolled in the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Cohort Study, a prospective study of incident dialysis patients. Comorbidity was assessed using the Index of Coexistent Diseases (ICED), consisting of a medical record review of 19 medical conditions and an observer-based assessment of 11 physical functions. ICED scores range from 0 to 3, with higher levels reflecting more severe comorbidity. Comorbidity was less severe in PD patients than in HD patients: the proportions of patients with ICED 0-1, ICED 2, and ICED 3 were 52%, 26%, and 22%, respectively, among the PD patients and 30%, 39%, and 31%, respectively, among the HD patients (P < 0.001). After controlling for all other factors, the differences in comorbidity remained significant. As compared with patients with ICED 0-1, the odds of being treated with PD for patients with ICED 2 and ICED 3 were less (odds ratio [OR] and 95% confidence intervals) 0.31 (0.17 to 0.56) and 0.50 (0.28 to 0.90), respectively. The number and severity of comorbid conditions at the onset of ESRD is significantly lower in patients choosing PD, independent of other factors influencing modality selection. The increased survival of PD patients reported in recent studies may simply reflect the self- or physician-directed selection of healthier patients to PD. Adjustment for case-mix differences in patients treated with PD versus HD is essential to the assessment of the independent effect of the dialysis modality on outcomes.

Aged↗
PubMed2002

Understanding disparities in donor behavior: race and gender differences in willingness to donate blood and cadaveric organs.

BACKGROUND: Recent efforts to recruit blood and organ donors have only marginally improved demographic disparities in willingness to donate. Few studies have examined which factors are most important in explaining race and gender disparities in willingness to donate. OBJECTIVES: To assess race and gender differences in willingness to donate blood and cadaveric organs, and to determine the extent to which several factors (including sociodemographic characteristics and attitudes about religion and mistrust of hospitals) might explain differences in willingness to donate. RESEARCH DESIGN: Cross-sectional telephone survey of Maryland households contacted via random-digit dialing. MEASURES: Past blood donation, organ-donor status on driver's license, and measures of medical mistrust and religious and spiritual salience. SUBJECTS: Persons age 18 to 75 living in the Baltimore, Maryland metropolitan area. RESULTS: Of 385 respondents (84% of randomized households), 114 were black females, 46 were black males, 110 were white females, and 69 were white males. Before adjustment, black females were least willing to donate blood (41%), and black males were least willing to become cadaveric donors (19%) among all race-gender groups. Adjustment for respondent concerns about mistrust of hospitals and discrimination in hospitals explained most differences in willingness to donate blood, whereas adjustment for respondents' beliefs regarding the importance of spirituality and religion explained most differences in willingness to donate cadaveric organs. CONCLUSIONS: Both race and gender are important identifiers of those less willing to donate. To maximize efficiency, donor recruitment efforts should focus on race-gender groups with lowest levels of willingness. Potential donor concerns regarding mistrust in hospitals and religion/spirituality may serve as important issues to address when developing programs to improve donation rates.

Adult↗
PubMed2002

Is health plan employer data and information set performance associated with withdrawal from medicare managed care?

BACKGROUND: Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some plans claim that providing higher quality care raises costs, lowers profits, and spurs withdrawal because plans cannot sustain high quality care under current payment levels. OBJECTIVE: To assess whether higher performance by Medicare health plans on quality indicators was associated with withdrawal. DESIGN: Retrospective cohort study. SUBJECTS: Taking each county where a contract was active as a unit of analysis, Medicare managed care plans active in 2310 contract-county combinations in 1997 were studied and followed for 3 years. MEASURES: Independent variables were scores on six indicators from the Health Plan Employer Data and Information Set (HEDIS) for each contract, collapsed into two summary measures: clinical and ambulatory care access. Separate Cox proportional hazards regressions were used for each indicator, and each summary measure, to assess the association of HEDIS performance with our outcome measure, time-to-withdrawal from Medicare. Multiple potential confounders were adjusted for. RESULTS: Of 2310 managed care contract-county combinations, 877 (38%) withdrew. The proportion of contract-counties with high scores on the summary clinical quality measure that withdrew was one-fifth that for low scorers (4.2% vs. 20.5%). For summary ambulatory care access performance, the corresponding ratio was two-fifths (12.8% vs. 32.0%). Lower payments were associated with higher withdrawal risk, but also higher clinical and ambulatory care access quality performance. In separate multivariable analyses controlling for confounders, both high clinical performance (HR, 0.18; 95% CI, 0.08-0.42) and high ambulatory care access performance (HR, 0.53; 95% CI, 0.27-1.07) were independently associated with lower withdrawal risk. CONCLUSIONS: Health plans continuing to provide care to Medicare beneficiaries have higher average performance on HEDIS clinical and ambulatory care access measures than plans that withdrew.

Adult↗
PubMed2002

Traditional cardiovascular disease risk factors in dialysis patients compared with the general population: the CHOICE Study.

Although atherosclerotic cardiovascular disease (ASCVD) risk in end-stage renal disease (ESRD) is 5 to 30 times that of the general population, few data exist comparing ASCVD risk factors among new dialysis patients to the general population. This cross-sectional study of 1041 dialysis patients describes the prevalence of ASCVD risk factors at the beginning of ESRD compared with estimates of ASCVD risk factors in the adult US population derived from the Third National Health and Nutrition Examination (NHANES III). CHOICE Study participants had a high prevalence of diabetes (54%), hypertension (96%), left ventricular hypertrophy by electrocardiogram (EKG) criteria (22%), low physical activity (80%), hypertriglyceridemia (36%), and low HDL cholesterol (33%). CHOICE participants were more likely to be older, black, and male than NHANES III participants. After adjustment for age, race, gender, and ASCVD (defined as myocardial infarction, revascularization procedure, stroke, carotid endarterectomy, and amputation in CHOICE; and as myocardial infarction and stroke in NHANES III), the prevalence of diabetes, hypertension, left ventricular hypertrophy by EKG, low physical activity, low HDL cholesterol, and hypertriglyceridemia were still more common in CHOICE participants. Smoking, obesity, hypercholesterolemia, and high LDL cholesterol, however, were less common in CHOICE than NHANES III participants. The projected 5-yr ASCVD risk based on the Framingham Risk Equation among those older than 40 yr without ASCVD was higher in CHOICE Study participants (13%) than in the NHANES III participants (6%). In summary, many ASCVD risk factors are more prevalent in ESRD than in the general population and may explain some, but probably not all, of the increased ASCVD risk in ESRD.

Cardiovascular Diseases↗
PubMed2002

Excess risk of chronic kidney disease among African-American versus white subjects in the United States: a population-based study of potential explanatory factors.

African Americans experience higher rates of chronic kidney disease (CKD) than do whites. It was hypothesized that racial differences in modifiable factors would account for much of the excess risk of CKD. A cohort study of 9082 African-American and white adults of age 30 to 74 yr, who participated in the Second National Health and Nutrition Examination Survey in 1976 to 1980 and were monitored for vital status through 1992 in the Second National Health and Nutrition Examination Survey Mortality Study, was conducted. Incident CKD was defined as treated CKD cases (ascertained by linkage to the Medicare Registry) and deaths related to kidney disease. The incidence of all-cause CKD was 2.7 times higher among African Americans, compared with whites. Adjustment for sociodemographic factors decreased the relative risk (RR) to 2.49, explaining 12% of the excess risk of CKD among African Americans. Further adjustment for lifestyle factors explained 24% of the excess risk, whereas adjustment for clinical factors alone explained 32%. Simultaneous adjustment for sociodemographic, lifestyle, and clinical factors attenuated the RR to 1.95 (95% confidence interval, 1.05 to 3.63), explaining 44% of the excess risk. Although the excess risk of CKD among African Americans was much greater among middle-age adults (30 to 59 yr of age; RR = 4.23, statistically significant) than among older adults (60 to 74 yr of age; RR = 1.27), indicating an interaction between race and age, the same patterns of explanatory factors were observed for the two age groups. Nearly one-half of the excess risk of CKD among African-American adults can be explained on the basis of potentially modifiable risk factors; however, much of the excess risk remains unexplained.

Age Distribution↗
PubMed2002

The adoption of ablation therapy for Barrett's esophagus: a cohort study of gastroenterologists.

OBJECTIVES: Although ablation therapy may be useful in the treatment of Barrett's esophagus. evidence of effectiveness is scarce, and little is known about current utilization of ablation. We aimed to determine whether the use of ablation was increasing in a cohort of gastroenterologists, and to identify physician beliefs and characteristics associated with ablation use. METHODS: We surveyed a national sample of gastroenterologists about ablation use, with an 18-month follow-up. The self-administered instrument included questions about demographic characteristics, attitudes about ablation therapy, and prior experience with ablation. Case scenarios were also included. We used logistic regression to identify factors associated with the use of ablation in patients with Barrett's esophagus. RESULTS: Two hundred seventy-nine (50.3% of those eligible) responded to the baseline survey. Few agreed that ablation lowers the risk of adenocarcinoma (15%) or is supported by the medical literature (19%). However, 25% of respondents reportedly had used ablation at baseline, and this increased to 36% in the follow-up survey (p = 0.0003). The use of ablation was significantly associated with physician age greater than 54 yr (odds ratio [OR] = 2.77, 95% CI = 1.04-7.37) and the belief that ablation was used by colleagues (OR = 13.27, 95% CI = 4.44-39.64) or decreases medical costs (OR = 5.07, 95% CI = 1.00-25.74). CONCLUSIONS: Although few gastroenterologists agreed that ablation is effective, a significant proportion had adopted its use. There was a significant increase in ablation use during our study period, and the characteristic that was most strongly associated with ablation use was the belief that colleagues used it.

Adult↗