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Biomedical subjects

Steven M Wright

Publications and source records attributed to Steven M Wright.

13 recordsLinked to original sources
PubMed2006

Racial variations in quality of care and outcomes in an ambulatory heart failure cohort.

BACKGROUND: Few recent studies have demonstrated similar quality of care for hospitalized black and white patients with heart failure (HF). However, systematic evaluation of racial differences in both the quality of care and outcomes is needed in the outpatient setting, where most patients with HF are treated and where care may be more fragmented. METHODS: We examined racial differences in quality-of-care measures and outcomes of 1-year mortality and hospitalization in a national cohort of 18,611 ambulatory patients with HF treated at Veterans Affairs medical centers between October 2000 and September 2002. RESULTS: Black patients were more likely to have left ventricular ejection fraction assessment than whites (risk-adjusted OR 1.29, 95% CI 1.11-1.49). In patients with left ventricular ejection fraction <40%, blacks were as likely as whites to be on treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (risk-adjusted OR 1.06, 95% CI 0.85-1.33) and beta-blockers (risk-adjusted OR 0.92, 95% CI 0.79-1.07). However, black patients more frequently had uncontrolled hypertension and were more likely to be hospitalized for any cause (OR 1.20, 95% CI 1.08-1.33) or for HF (OR 1.43, 95% CI 1.23-1.66), although 1-year mortality did not differ by race (OR 1.03, 95% CI 0.89-1.20). CONCLUSIONS: In a financially "equal access" health care system, the quality of outpatient HF care assessed by select quality measures and 1-year mortality was similar in black compared to white patients. However, blacks were more likely to be hospitalized, especially with HF. Identifying and targeting potentially modifiable factors such as uncontrolled hypertension in black patients may narrow the racial gap in hospitalizations.

Adrenergic beta-Antagonists↗
PubMed2006

Veterans Health Administration patients' use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals.

OBJECTIVE: We sought to quantify Veterans Health Administration (VA) patients' utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n=6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals. RESULTS: VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal. CONCLUSIONS: For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.

Angioplasty, Balloon, Coronary↗
PubMed2006

Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC's emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement. OBJECTIVE: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO. DESIGN: Six Sigma Project with pre-post design. PARTICIPANTS: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals. MEASUREMENTS: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire. RESULTS: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products. CONCLUSIONS: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC's evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.

Centers for Disease Control and Prevention, U.S.↗
PubMed2006

Patient satisfaction of female and male users of Veterans Health Administration services.

OBJECTIVE: To compare patient satisfaction of male and female users of Veterans Health Administration (VHA) services. DESIGN: Cross-sectional study based on secondary analysis of data from VHA's Survey of Healthcare Experiences of Patients (SHEP). PATIENTS: National random sample of 107,995 outpatients and 112,817 inpatients in FY2004. MEASURES: Patient's ratings of overall quality (OQ) and unique dimensions of satisfaction. Sociodemographic and health-related patient attributes. ANALYSIS: Bivariate unadjusted analyses of the association between gender and other patient attributes and the outcomes of OQ and dimensions of satisfaction were conducted followed by multivariate analyses for each outcome, adjusting for demographic and health variables. RESULTS: Significant differences between female and male reporting of satisfaction were found in the unadjusted analyses with males showing greater levels of satisfaction than females (P<.05). These differences disappeared or became smaller for both outpatient and inpatient services, after adjusting for covariates. For 6 of the inpatient dimensions (Transitions, Physical Comfort, Involvement Family and Friends, Courtesy, Coordination, and Access) males had higher satisfaction than females after statistical adjustment. CONCLUSIONS: After adjustment for patient attributes, female VHA outpatients report similar OQ with VHA services as male patients. The fact that some inpatient dimensions of satisfaction continued to show effects favoring males even after adjustment suggests areas for continued focus in improving health care quality. Covariate adjustment is essential for evaluating satisfaction with health care services. Breaking down overall satisfaction into independent aspects of services is useful. The SHEP survey has provided a useful tool for evaluating and improving satisfaction among its VHA veteran users.

Adult↗
PubMed2005

64-channel array coil for single echo acquisition magnetic resonance imaging.

A 64-channel array coil for magnetic resonance imaging (MRI) has been designed and constructed. The coil was built to enable the testing of a new imaging method, single echo acquisition (SEA) MRI, in which an independent full image is acquired with every echo. This is accomplished by entirely eliminating phase encoding and instead using the spatial information obtained from an array of very narrow, long, parallel coils. The planar pair element design proved to be key in achieving well-localized field sensitivity patterns and isolated elements, the crucial requirements for performing SEA. The matching and tuning of the array elements were accomplished on the coil array printed circuit board using varactor diodes biased over the RF lines. The array was successfully used to obtain SEA images as well as conventional partially parallel images at unprecedented acceleration factors.

Calibration↗
PubMed2005

Veterans Health Administration and Medicare outpatient health care utilization by older rural and urban New England veterans.

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.

Aged↗
PubMed2003

Hospital use and survival among Veterans Affairs beneficiaries.

BACKGROUND: Initiatives to reduce hospital care were part of the reorganization of the Department of Veterans Affairs (VA) medical care system undertaken in the mid-1990s. We examined changes in the use of VA health services and survival from 1994 through 1998 among VA beneficiaries with serious chronic diseases. We postulated that if access to hospital care was reduced too much, or if decreased hospital use was not offset by improvements in ambulatory care, urgent care visits would increase or survival rates would fall. METHODS: We tracked changes in risk-adjusted VA bed-day rates, rates of medical visits, rates of visits for testing and consultation, and rates of urgent care visits per patient-year among VA beneficiaries in nine disease cohorts (a total of 342,300 beneficiaries). Trends in non-VA hospital use by VA beneficiaries 65 years of age or older who were enrolled in fee-for-service Medicare were also studied. VA and Medicare vital-status data were used to calculate one-year survival rates. RESULTS: From 1994 through 1998, VA bed-day rates fell by 50 percent, rates of medical-clinic visits and visits for testing and consultation increased moderately, and rates of urgent care visits fell by 35 percent. The sharp decline in the use of VA hospitals was not compensated for by increases in the use of Medicare-reimbursed non-VA hospital care by veterans eligible for both VA care and Medicare, and the use of non-VA hospitals actually declined in four cohorts. The survival rates were essentially unchanged over the study period. CONCLUSIONS: The marked decline in VA hospital use from 1994 through 1998 did not curtail access to needed services and was not associated with serious consequences for chronically ill VA beneficiaries.

Chronic Disease↗
PubMed2002

Simulation-based investigation of partially parallel imaging with a linear array at high accelerations.

Partially parallel imaging strategies such as SMASH, SENSE, and PILS rely on the sensitivity distribution of phased array RF coils to reduce MRI imaging time. Using an N-element phased array, these techniques allow maximum accelerations, L, such that L < or = N, with acceleration defined as the factor by which scan time is reduced in comparison to traditional, fully gradient encoded acquisitions. As N increases in modern MRI facilities or using special hardware extensions, its role as the primary limitation in partially parallel imaging will be reduced and other limiting factors will become dominant. Two such factors include available SNR and the variation of sensitivity distributions with imaging depth. Simulations have been conducted to evaluate the impact of slice depth and noise on partially parallel reconstructions for the case of a square linear array of overlapped elements that are parallel to the imaging plane. Results indicate that even when sensitivity distributions are exactly known, the linear surface array can only provide high accelerations over a limited imaging depth due to changing suitability of the sensitivity distributions for partially parallel reconstruction. This work emphasizes the importance of simulations for target-based partially parallel array design.

Computer Simulation↗
PubMed2002

A desktop magnetic resonance imaging system.

Modern magnetic resonance imaging (MRI) systems consist of several complex, high cost subsystems. The cost and complexity of these systems often makes them impractical for use as routine laboratory instruments, limiting their use to hospitals and dedicated laboratories. However, advances in the consumer electronics industry have led to the widespread availability of inexpensive radio-frequency integrated circuits with exceptional abilities. We have developed a small, low-cost MR system derived from these new components. When combined with inexpensive desktop magnets, this type of MR scanner has the promise of becoming standard laboratory equipment for both research and education. This paper describes the development of a prototype desktop MR scanner utilizing a 0.21 T permanent magnet with an imaging region of approximately 2 cm diameter. The system uses commercially available components where possible and is programmed in LabVIEW software. Results from 3D data sets of resolution phantoms and fixed, newborn mice demonstrate the capability of this system to obtain useful images from a system constructed for approximately $13,500.

Animals↗
PubMed2002

Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction.

OBJECTIVES: The goal of this study was to assess racial differences in process of care and outcome for acute myocardial infarction in the VA health care system. DESIGN: Retrospective cohort study using clinical data. SETTING: Eighty-one acute care VA hospitals. PATIENTS: Four thousand seven hundred sixty veterans discharged with a confirmed diagnosis of acute myocardial infarction. The analysis was restricted to 606 black and 4005 white patients. MAIN OUTCOME MEASURES: Comparison of use of guideline-based medications, invasive cardiac procedures, and all-cause mortality at 30 days, 1 year, and 3 years. RESULTS: Black patients were equally likely to receive beta-blockers, more likely than white patients to receive aspirin (86.8% vs. 82.0%; P <0.05), and marginally more likely to receive angiotensin converting enzyme inhibitors (55.7% vs. 49.6%; P = 0.07) at the time of discharge. In contrast, black patients were less likely than white patients to receive thrombolytic therapy at the time of arrival (32.4% vs. 48.2%; P <0.01). There was no significant difference in refusal of angiography or percutaneous transluminal coronary angioplasty between black patients and white patients, or in crude rates of either of these procedures. There was also no difference overall in the percentage of patients who refused coronary artery bypass graft surgery. However, black patients were less likely than white patients to undergo bypass surgery (6.9% vs. 12.5% by 90 days; P <0.001). Black patients remained less likely to undergo bypass surgery even when high-risk specific coronary anatomy subgroups were examined. There was no difference in mortality in the two groups. CONCLUSIONS: In this integrated health care system, no significant racial disparities in use of noninterventional therapies, diagnostic coronary angiography, or short- or long-term mortality was found. Disparities in use of thrombolytic therapy and coronary artery bypass surgery existed, however, even after accounting for differences in clinical indications for treatment and patient refusals. Further work should assess the role of the medical interaction and physician behavior in racial disparities in use of health care.

Adrenergic beta-Antagonists↗
PubMed2002

Iterative RF pulse refinement for magnetic resonance imaging.

Selective RF pulses are needed for many applications in magnetic resonance imaging (MRI). The waveform required to produce a desired excitation profile is, to first-order, its Fourier transform. This approximation is most valid for small tip angles and the quality and accuracy of such excitations decreases with increasing tip angle. Since large-tip-angle excitations are required in most types of imaging, a better synthesis technique is necessary. While a variety of analytical and numerical synthesis techniques based on solution of the Bloch equations are available, these techniques fail to consider the effect of the physical scanner hardware and are often accompanied by computational complexity. We present a technique for selective RF pulse refinement which uses real-time feedback techniques in lieu of a solution to the Bloch equations. Physical experiments are conducted to demonstrate the effectiveness of this algorithm and an extension to pulses of 90 degrees is investigated.

Algorithms↗
PubMedDate not supplied

Utilization of VA and Medicare services by Medicare-eligible veterans: the impact of additional access points in a rural setting.

The Veterans Health Administration (VA) has recently established community-based outpatient clinics (CBOCs) to improve access to primary care. In our study we sought to understand the relationship between the degree to which older, Medicare-eligible veterans use CBOCs and their utilization of health services through both the VA and Medicare. We wanted to limit our analysis to a largely rural setting in which patients have greater healthcare needs and where we expected to find that the availability of CBOCs significantly improved access to VA healthcare. Therefore, we identified 47,209 patients who lived in the largely rural states of northern New England and were enrolied in the VA in 1997, 1998, and 1999. We used a merged VA/Medicare dataset to determine utilization in the VA and the private sector and to categorize patients into three segments: those who used only CBOCs for VA primary care, those who used only VA medical centers for VA primary care, and those who used both. For all three groups, we found that VA patients obtained an increasing amount of their care in the private sector, which was funded by Medicare. VA patients who obtained all of their VA primary care services through CBOCs relied on the private sector for most of their specialty and inpatient care needs. Our findings suggest that, in this rural New England setting, improved access to VA care through CBOCs appears to provide complementary, not substitutive, services. Analyses of the efficiency of adding access points to healthcare systems should be conducted, with particular emphasis on examining the possibilities of encroachment, worsened coordination of care, and potential health services overuse.

Eligibility Determination↗