PubMed Health⌕ Search

Biomedical subjects

R G Holloway

Publications and source records attributed to R G Holloway.

12 recordsLinked to original sources
PubMed1998

Carotid endarterectomy trends in the patterns and outcomes of care at academic medical centers, 1990 through 1995.

OBJECTIVE: To evaluate whether the patterns of inpatient care and patient characteristics have changed for patients undergoing a carotid endarterectomy across a group of academic medical centers from 1990 through 1995. If changes occurred, we investigated whether they had an impact on patient outcomes. DESIGN: Retrospective evaluation of patients undergoing a carotid endarterectomy using a hospital discharge data set compiled by the Academic Medical Center Consortium. SETTING: Ten academic medical centers. PATIENTS: A total of 7019 hospital admissions for patients who had 1 carotid endarterectomy performed as a principal procedure from January 1990 to December 1995. MAIN OUTCOME MEASURES: Trends in patient demographics, comorbidities, length of stay, days in the intensive care unit, and inpatient cerebral arteriogram use were determined. Patient outcomes included inpatient mortality, discharge to an institution, 30-day readmission rate, and selected diagnoses (postoperative hemorrhage, infection, or seizure; acute myocardial infarction; or cranial nerve palsy) and postprocedure diagnostic tests (computed tomography and magnetic resonance imaging of the head and electroencephalogram) indicative of complications. RESULTS: Over the 6-year study period, the number of carotid endarterectomies performed more than doubled and the percentage of hospital admissions for patients 65 years or older increased from 65% to 75%. The mean and median length of stay halved and the percentage of admissions with transfers to the intensive care unit decreased from 56% to 26% of cases. In addition, the percentage of cases with a cerebral arteriogram during the same admission but prior to the day of the carotid endarterectomy decreased from 52% to 27%. There were no trends in inpatient mortality, discharge to an institution, or 30-day readmission rate. There were no significant trends indicative of poorer quality of care as measured by the frequency of secondary diagnoses or postprocedure diagnostic test use. CONCLUSIONS: Despite dramatic changes that have occurred in patient characteristics and in hospital management practices for patients undergoing a carotid endarterectomy from 1990 to 1995, we were unable to detect any measurable impact on patient outcomes. These data have implications for monitoring and evaluating the impact of systemwide change on the overall quality of care for patients undergoing a carotid endarterectomy.

Academic Medical Centers↗
PubMed1997

The cost-effectiveness of magnetic resonance imaging for patients with equivocal neurological symptoms.

OBJECTIVE: To determine the incremental cost-effectiveness of magnetic resonance imaging (MRI) and computed tomography (CT) in young adults presenting with equivocal neurological signs and symptoms. DESIGNS AND METHODS: A decision analysis of long-term survival using accuracy data from a diagnostic technology assessment of MRI and CT in patients with suspected multiple sclerosis, information from the medical literature, and clinical assumptions. MAIN RESULTS: In the baseline analysis, at 30% likelihood of an underlying neurologic disease, MRI use has an incremental cost of $101,670 for each additional quality-adjusted life-year saved compared with $20,290 for CT use. As the probability of disease increases, further MRI use becomes a cost-effective alternative costing $30,000 for each quality-adjusted life-year saved. If a negative MRI result provides reassurance, the incremental costs of immediate MRI use decreases and falls below $25,000 for each quality-adjusted life-year saved no matter the likelihood of disease. CONCLUSIONS: For most individuals with neurological symptoms or signs, CT imaging is cost-effective while MR imaging is not. The cost-effectiveness of MRI use, however, improves as the likelihood of an underlying neurological disease increases. For selected patients who highly value diagnostic information, MRI is a reasonable and cost-effective use of medical resources when even the likelihood of disease is quite low (5%).

Adult↗
PubMed1996

Cost-effectiveness analysis: what is it and how will it influence neurology.

Cost-effectiveness analysis (CEA) refers to a set of research methods that consider the resources consumed by a medical technology in decisions about how best to use the technology. This analytic method is an evolving, controversial, and often misunderstood field in health services research. The basic set of principles underlying CEA is deceptively simple, but sufficient methodological challenges and controversies exist that have, thus far, limited its use in the development of health policy and in bedside decision making. Nonetheless, neurologists like other specialty groups may feel concerned that the results from such analyses may prove unfavorable to their specialty and the patients they serve. This article reviews the fundamental notions surrounding CEA, provides examples from the literature with particular relevance to the neurological community, and highlights critical issues for neurologists regarding the future of CEA.

Cost-Benefit Analysis↗
PubMed1996

Intracranial mass lesions in acquired immunodeficiency syndrome: using decision analysis to determine the effectiveness of stereotactic brain biopsy.

We studied the effectiveness of performing a stereotactic brain biopsy in the individual with acquired immunodeficiency syndrome (AIDS) and an intracranial mass lesion who failed 2 weeks of antitoxoplasmosis therapy. We used a decision analysis to compare two different treatment strategies: biopsy and no biopsy. The analysis estimates the average life expectancy for each choice and investigates the sensitivity of these results by varying parameters within the model. In the base case analysis (diagnostic yield of biopsy, 0.89; operative mortality, 0.015; life expectancy of lymphoma untreated and treated, 42 and 120 days), the life expectancy of the biopsy strategy was 98 days compared with 67 days for the no-biopsy strategy, for a net survival benefit of 31 days. Sensitivity analyses revealed that the life expectancy of the biopsy strategy remained greater than the no-biopsy strategy for a wide range of variable specifications. The net survival benefit, however, was sensitive to the diagnostic success rate, the operative mortality, the likelihood of a lymphoma diagnosis, and the life expectancy of patients being diagnosed and treated for lymphoma. These data allow AIDS patients and physicians to learn more about the potential outcomes of the alternative management strategies when an individual fails to respond to empiric antitoxoplasmosis therapy.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Inpatient costs of specific cerebrovascular events at five academic medical centers.

We estimated the hospital costs for patients with different cerebrovascular events and applied patient and administrative variables to explain the variance of the cost estimates with particular attention to the relationship between patient age and cost. The study sample was drawn from an administrative data set of all hospital discharges from five academic medical centers for the 1992 calendar year. Using International Classification of Diseases (ICD-9-CM) primary diagnosis codes, cases were classified into cerebrovascular subgroups: subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), ischemic cerebral infarction (ICI), and transient ischemic attack (TIA). The ICD-9-driven data file was supplemented with billing data containing inpatient charges reported in UB-82 format. Costs were imputed by applying Medicare charge-to-cost ratios and regional wage adjustments to the billing data. We estimated relationships between inpatient costs and a number of demographic and administrative variables. A statistically significant difference was found between cerebrovascular subgroups for both the mean cost per discharge (p<0.01) and the mean cost of an inpatient day (p<0.01). The mean cost per discharge for each subgroup was as follows: SAH, $39,994 (n=218); ICH, $21,535 (n=258); ICI, $9,882 (n=908); TIA, $4,653 (n=303). Likewise, the mean cost per inpatient day was as follows: SAH, $2,215; ICH, $1,396; ICI, $1,036; TIA, $1,117. Length of stay as a measure of resource use was strongly predictive of inpatient cost, explaining 72 to 82% of the variation in cost. Demographic variables (i.e., age, gender, race, insurance status), however, revealed virtually no predictive power, accounting for less than 10% of the variance in each of the four subgroups. There are substantial differences in the patient-level cost of hospital services for stroke-related events. After controlling for the type of cerebrovascular event, basic demographic variables and insurance status (including Medicare) contribute little to the total cost of inpatient care. More important factor include stroke severity, social factors, and clinical practice variations.

Academic Medical Centers↗
PubMed1995

Headache and the human immunodeficiency virus type 1 infection.

This review focuses on the prevalence, causes, evaluation, and treatment of headache in individuals infected with human immunodeficiency virus type 1 (HIV-1). Headaches, one of the commonest medical complaints in the general population, occur frequently in patients infected with the HIV-1. HIV-related headaches can occur at any time during the infection: at seroconversion, during the incubation period, in patients with symptomatic HIV-1 infection, or after an AIDS-defining illness. Causes of HIV-related headaches include HIV-1 itself, opportunistic conditions, or HIV-specific medications. Migraines, tension-type headaches, depression, and substance abuse enter into the differential diagnosis, particularly in the early stages of disease. The headaches seen in this population reflect a complex web of interactions imposed by immune competency, multiple etiologies, treatments, and premorbid conditions. Prompt recognition and early treatment of headache is essential since it may improve quality of life and, depending on the diagnosis, prolong survival. Physicians need to be alert and adaptable when assessing HIV-infected individuals with headache since multiple causes can exist in the same patient and new syndromes, complications, and investigational drugs are continually being identified.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Structure of the gene for cartilage matrix protein, a modular protein of the extracellular matrix. Exon/intron organization, unusual splice sites, and relation to alpha chains of beta 2 integrins, von Willebrand factor, complement factors B and C2, and epidermal growth factor.

The entire gene for chicken cartilage matrix protein (CMP) has been isolated and characterized by restriction mapping, electron microscopy, nuclease S1 mapping, and sequence analysis. The gene, which is present in a single copy in the chicken genome, is 18 kilobase pairs long and comprises eight exons and seven introns. It has two transcription initiation sites, 8 base pairs from each other. A sequence very homologous to the consensus nuclear factor III binding-site sequence, a CAT- and a TATA-like sequence are found in the promoter region and ATTAAA is used as a polyadenylation signal. The nucleotide sequence defines a primary translation product of 493 amino acids which consists of a 23-amino acid signal peptide and two large repeated domains connected by an epidermal growth factor module. Amino acid sequences homologous to those of the repeated domains are present in the type A repeats of von Willebrand factor, complement factors B and C2, and in the alpha chains of the integrins Mac-1, p150,95, and LFA-1. The exon-intron structure indicates that the CMP gene may have arisen by exon duplication and exon shuffling during evolution. The GT-AG splice rule cannot be applied for the excision of the last intron of the CMP pre-mRNA. The donor splice site of intron G is basically different from the consensus sequence indicating that a novel type of splicing mechanism might exist in cartilage.

Amino Acid Sequence↗