Biomedical subjects

R J Gurley

Publications and source records attributed to R J Gurley.

8 recordsLinked to original sources

PubMed1997

Insurance type and satisfaction with medical care among HIV-infected men.

Patient satisfaction is a valuable indicator of the quality of medical care. We assessed the impact of type of health insurance on satisfaction with seven aspects of medical care among 593 HIV-infected men without AIDS, drawn from three sites in San Francisco, California and Denver, Colorado. After adjustment for site of medical care, patient age, race, income, education, and CD4 lymphocyte count, there were few differences in satisfaction between men with fee-for-service and those with managed care insurance. Men with fee-for-service insurance were significantly more satisfied with their interpersonal relations with their clinicians (p = 0.01) but less satisfied with their finances (p = 0.0001) than persons with managed care. Uninsured men were significantly less satisfied with several aspects of care than insured persons. There were no significant differences in satisfaction between men with managed care and those with public insurance. HIV-infected persons who have a choice of insurance should carefully weigh their options, recognizing the implicit trade-offs between types of insurance. Those who choose fee-for-service insurance can expect to be more satisfied with interpersonal relations with their medical providers but less satisfied with financial aspects of their plans. Efforts to address the low satisfaction of uninsured persons are needed.

Adult↗

PubMed1997

Meeting the service needs of HIV-infected persons: is the Ryan White CARE Act succeeding?

To evaluate the success of the Ryan White CARE Act in meeting HIV-related service needs, we surveyed HIV-infected clients (n = 1,056) at San Francisco CARE-funded agencies. Most CARE clients were male (85.1%), 51.7% were nonwhite, 84.9% were uninsured or underinsured, and 43.9% had a most recent CD4+ count < 200 cells. The most common HIV risk groups were gay/ bisexual male noninjection drug user (IDU) (53.3%) and gay/bisexual male IDU (22.1%). Health care needs were high for medical (85.5%), dental (70.2%), and mental health care (69.7%); need for basic necessities was great for food (57.2%) and living expenses (55.5%). Unmet health care needs were common for dental care (41.0%), home health care (39.9%), and alternative therapies (38.6%); unmet needs for basic necessities were frequent for childcare (59.5%), household help (52.3%), and transportation (47.9%). Unmet needs for medical care (5.8%) and food (14.7%) were low. Poor persons, those with dependents, and gay/bisexual male IDUs had greater unmet needs. Women and racial/ethnic minorities did not consistently have greater unmet needs. The CARE Act is serving those it intended to reach, is successfully meeting two important service needs, and has equalized access to services for women and racial/ethnic minorities. Remaining unmet needs require continued funding and strategies to increase access to care.

Adult↗

PubMed1997

Projected cost-effectiveness of primary angioplasty for acute myocardial infarction.

OBJECTIVES: This study sought to evaluate the cost-effectiveness of primary angioplasty for acute myocardial infarction under varying assumptions about effectiveness, existing facilities and staffing and volume of services. BACKGROUND: Primary angioplasty for acute myocardial infarction has reduced mortality in some studies, but its actual effectiveness may vary, and most U.S. hospitals do not have cardiac catheterization laboratories. Projections of cost-effectiveness in various settings are needed for decisions about adoption. METHODS: We created a decision analytic model to compare three policies: primary angioplasty, intravenous thrombolysis and no intervention. Probabilities of health outcomes were taken from randomized trials (base case efficacy assumptions) and community-based studies (effectiveness assumptions). The base case analysis assumed that a hospital with an existing laboratory with night/weekend staffing coverage admitted 200 patients with a myocardial infarction annually. In alternative scenarios, a new laboratory was built, and its capacity for elective procedures was either 1) needed or 2) redundant with existing laboratories. RESULTS: Under base case efficacy assumptions, primary angioplasty resulted in cost savings compared with thrombolysis and had a cost of $12,000/quality-adjusted life-year (QALY) saved compared with no intervention. In sensitivity analyses, when there was an existing cardiac catheterization laboratory at a hospital with > or = 200 patients with a myocardial infarction annually, primary angioplasty had a cost of < $30,000/QALY saved under a wide range of assumptions. However, the cost/QALY saved increased sharply under effectiveness assumptions when the hospital had < 150 patients with a myocardial infarction annually or when a redundant laboratory was built. CONCLUSIONS: At hospitals with an existing cardiac catheterization laboratory, primary angioplasty for acute myocardial infarction would be cost-effective relative to other medical interventions under a wide range of assumptions. The procedure's relative cost-ineffectiveness at low volumes or redundant laboratories supports regionalization of cardiac services in urban areas. However, approaches to overcoming competitive barriers and close monitoring of outcomes and costs will be needed.

Angioplasty, Balloon, Coronary↗

PubMed1996

Persons found in their homes helpless or dead.

BACKGROUND: Health care providers and providers of emergency services are sometimes called to help with people who are found alone in their homes either helpless or dead. It is not known who is at risk for being found helpless or dead, what the mortality rates are among those found alive, or how frequently this situation occurs. METHODS: We conducted a population-based study of patients who were found in their homes either helpless or dead. Over 12 weeks, paramedics employed by the city of San Francisco identified 387 such events involving 367 persons. We obtained information on these patients from the emergency-medical-services department or the hospitals to which they were taken and determined their outcomes. RESULTS: The median age of the persons found helpless or dead was 73 years; 51 percent were women. The frequency of such incidents increased sharply with age, from a rate of 3 per 1000 per year among those 60 to 64 years of age to 27 per 1000 per year among those 85 years of age or older. The highest rate was among men 85 years and older who were living alone (123 per 1000 per year). In 23 percent of the cases, the person was found dead; an additional 5 percent died in the hospital. Thus, total mortality was 28 percent. Of the patients found alive, 62 percent were admitted to the hospital. The average hospital stay was eight days, and 52 percent of those admitted required intensive care. Of the survivors, 62 percent were unable to return to living independently. The total mortality was 67 percent for patients who were estimated to have been helpless for more than 72 hours, as compared with 12 percent for those who had been helpless for less than 1 hour. CONCLUSIONS: For elderly people who live alone, becoming incapacitated and unable to get help is a common event, which usually marks the end of their ability to live independently.

Accidental Falls↗

PubMed1996

Primary angioplasty and thrombolysis for acute myocardial infarction: an evidence summary.

Coronary angioplasty is being increasingly used as the primary treatment for patients with acute myocardial infarction, but controversy remains over its potential adoption in preference to thrombolysis as standard care. This report summarizes the published evidence on health outcomes after primary angioplasty compared with thrombolysis or no intervention for patients with acute myocardial infarction. The data tables presented provide the scientific groundwork to assist physicians and other policy-makers in deciding which interventions to provide for broad populations of patients.

Adolescent↗

PubMed1996

Initial cost of primary angioplasty for acute myocardial infarction.

OBJECTIVES: We sought to evaluate the initial economic cost of primary angioplasty for acute myocardial infarction under varying assumptions about whether a cardiac catheterization laboratory exists, whether services are provided during night and weekend hours and how cardiovascular surgical backup is arranged. BACKGROUND: Primary angioplasty for acute myocardial infarction has resulted in clinical outcomes superior or equal to those obtained with thrombolysis in recent studies, but its future implementation depends greatly on its cost and cost-effectiveness. There is a gap in knowledge about the true economic costs of this procedure, and understanding costs under a variety of hypothetic scenarios is important in planning whether and how the procedure should be offered to broad groups of patients. METHODS: A generalizable spreadsheet model was constructed to calculate the cost of primary angioplasty at a single hospital with assumptions based on data from a large nonprofit health maintenance organization (Kaiser Permanente). The following baseline assumptions were made: 1) A total of 200 patients with myocardial infarction presented to the hospital each year; 2) primary angioplasty was offered for 10 years; 3) the hospital had a cardiac catheterization laboratory; 4) costs of night call for technical personnel and cardiovascular surgical backup were already covered. Other scenarios were modeled to represent different assumptions about existing resources. RESULTS: Under the baseline assumptions, primary angioplasty cost $1,597/procedure. If night call for technical personnel were a new expense, the average cost would be > or = $3,206. If a new cardiac catheterization laboratory needed to be built, costs would range from $3,866 to $14,339/procedure, depending on how cardiovascular surgical backup was provided. Results were sensitive to assumptions about the annual volume of myocardial infarctions, the number of years the procedure was offered and the costs of labor, construction and equipment. CONCLUSIONS: The initial cost of providing primary angioplasty for acute myocardial infarction varies greatly, depending on the setting in which it is provided. To provide information for clinical policy decisions, a cost-effectiveness model is needed that combines these initial costs with data on survival, quality of life and rates and costs of subsequent cardiac procedures.

Angioplasty, Balloon, Coronary↗

PubMed1989

CD4+ lymphocyte function with early human immunodeficiency virus infection.

The pathogenesis of cellular immune deficiency following human immunodeficiency virus (HIV) infection could result from quantitative and/or qualitative dysfunction of the CD4+ lymphocyte population. To better characterize the T-cell response to soluble antigen with HIV infection, we have isolated peripheral blood lymphocytes and purified populations of CD4+ lymphocytes from healthy HIV antibody-positive subjects, patients with acquired immunodeficiency syndrome (AIDS)-related complex (ARC), and healthy HIV antibody-negative controls. T-lymphocyte function was determined by proliferative response to lectin (phytohemagglutinin), phorbol 12-myristate 13-acetate (PMA), calcium ionophore, purified recombinant HIV envelope gp120, tetanus toxoid antigen, and tetanus toxoid antigen in the presence of recombinant gp120 or purified recombinant soluble CD4. PBLs and CD4+ lymphocytes from asymptomatic HIV-infected subjects responded equally well to lectin, PMA, and/or calcium ionophore and to tetanus toxoid as cells from uninfected control subjects. The cells that proliferated in response to a soluble antigenic stimulus did not respond to gp120. Cells from subjects with ARC had a selective antigen recognition defect independent of the number of CD4+ lymphocytes. Recombinant gp120 inhibited CD4+ lymphocyte proliferation to antigenic stimulus by 30-40%. Recombinant soluble CD4, a proposed therapeutic for HIV, had no effect on T-cell response to antigen. A selective antigen recognition response was not compromised early in HIV infection but was compromised in subjects with ARC. Inhibition of proliferation to tetanus toxoid by gp120 suggests that HIV may affect major histocompatibility complex II restricted antigen recognition independent of CD4+ cell loss.

AIDS-Related Complex↗

PubMedDate not supplied

Medicinal marijuana: a comprehensive review.

Considerable controversy exists regarding the role of marijuana as a therapeutic agent; however, many practitioners are taught very little about existing marijuana data. The authors therefore undertook a comprehensive literature review of the topic. References were identified using textbooks, review and opinion articles, and a primary literature review in MEDLINE. Sources were included in this review based primarily on the quality of the data. Some data exists that lends credence to many of the claims about marijuana's properties. In general, however, the body of literature about marijuana is extremely poor in quality. Marijuana and/or its components may help alleviate suffering in patients with a variety of serious illnesses. Health care providers can best minimize short term adverse consequences and drug interactions for terminally ill patients by having a thorough understanding of the pharmacology of marijuana, potential adverse reactions, infection risks, and drug interactions (along with on-going monitoring of the patient). For chronic conditions, the significance and risk of short and long term adverse effects must be weighed against the desired benefit. Patients who are best suited to medicinal marijuana will be those who will gain substantial benefit to offset these risks, and who have failed a well-documented, compliant and comprehensive approach to standard therapies.

Cannabis↗