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Biomedical subjects

William M Tierney

Publications and source records attributed to William M Tierney.

At least 19 recordsLinked to original sources
PubMed2006

Outcomes of HIV-infected orphaned and non-orphaned children on antiretroviral therapy in western Kenya.

OBJECTIVES: Determine outcome differences between orphaned and non-orphaned children receiving antiretroviral therapy (ART). DESIGN: Retrospective review of prospectively recorded electronic data. SETTING: Nine HIV clinics in western Kenya. POPULATION: 279 children on ART enrolled between August 2002 and February 2005. MAIN MEASURES: Orphan status, CD4%, sex- and age-adjusted height (HAZ) and weight (WAZ) z scores, ART adherence, mortality. RESULTS: Median follow-up was 34 months. Cohort included 51% males and 54% orphans. At ART initiation (baseline), 71% of children had CDC clinical stage B or C disease. Median CD4% was 9% and increased dramatically the first 30 weeks of therapy, then leveled off. Parents and guardians reported perfect adherence at every visit for 75% of children. Adherence and orphan status were not significantly associated with CD4% response. Adjusted for baseline age, follow-up was significantly shorter among orphaned children (median 33 vs. 41 weeks, P = 0.096). One-year mortality was 7.1% for orphaned and 6.6% for non-orphaned children (P = 0.836). HAZ and WAZ were significantly below norm in both groups. With ART, HAZ remained stable, while WAZ tended to increase toward the norm, especially among non-orphans. Orphans showed identical weight gains as non-orphans the first 70 weeks after start of ART but experienced reductions afterwards. CONCLUSIONS: Good ART adherence is possible in western rural Kenya. ART for HIV-infected children produced substantial and sustainable CD4% improvement. Orphan status was not associated with worse short-term outcomes but may be a factor for long-term therapy response. ART alone may not be sufficient to reverse significant developmental lags in the HIV-positive pediatric population.

Adolescent↗
PubMed2006

A comparison of traditional and Rasch cut points for assessing clinically important change in health-related quality of life among patients with asthma.

BACKGROUND: Patient-perceived change in health-related quality of life (HRQoL) domains has often been classified using a 15-point patient transition rating scale. However, traditional change levels of trivial ( - 1, 0, or 1), minimal (2, 3 or - 2, - 3), moderate (4, 5 or - 4, - 5) and large (6, 7 or - 6, - 7) on this scale have been arbitrarily defined and originally assumed that change related to an improvement was the same as that for a decline. OBJECTIVE: To compare traditional and Rasch partial credit model-derived cut points and the mean changes for each change categorization when assessing clinically important change in asthma-specific HRQoL. METHODS: Our sample included 396 asthmatic outpatients who completed bimonthly telephone interviews on the Asthma Quality of Life Questionnaire and transition rating items over 1 year of participation. We employed item response theory in a novel approach to identify cut points on domain-specific HRQoL change data and transition ratings. After determining natural cut points for minimal, moderate, and large differences on the transition rating anchor, we calculated mean changes under change categorizations for both improvements and declines for the two transition rating classification approaches. RESULTS: Although traditional and Rasch categorizations for small, moderate, and large changes slightly differed and displayed a lack of symmetry between improvements and declines, nearly all mean changes between classification approaches were comparable. CONCLUSIONS: In this study, traditional transition rating cut points remain suitable to assess HRQoL clinical significance in outpatients with asthma.

Adult↗
PubMed2006

Physician-estimated disease severity in patients with chronic heart or lung disease: a cross-sectional analysis.

BACKGROUND: We evaluated how well physicians' global estimates of disease severity correspond to more specific physician-rated disease variables as well as patients' self-rated health and other patient variables. METHODS: We analyzed baseline data from 1662 primary care patients with chronic cardiac or pulmonary disease who were enrolled in a longitudinal study of health-related quality of life (HRQoL). Each patient's primary physician rated overall disease severity, estimated the two-year risk of hospitalization and mortality, and reported the use of disease-specific medications, tests, and subspecialty referrals. Patient variables included sociodemographic characteristics, psychosocial factors, self-rated health, and both generic and disease-specific HRQoL. RESULTS: Physicians rated 40% of their patients "about average", 30% "worse", and 30% "better" than the typical patient seen with the specific target disorder. The physician's global estimate of disease severity was strongly associated (P < 0.001) with each of the five more specific elements of physician-rated disease severity, but only marginally associated with patient self-rated health. Multivariable regression identified a set of patient variables that explained 16.4% of the variance in physician-rated disease severity. CONCLUSION: Physicians' global ratings may provide disease severity and prognostic information unique from and complementary to patient self-rated health and HRQoL measures. The elements influencing physician-rated disease severity and its predictive validity for clinical outcomes warrant prospective investigation.

Adult↗
PubMed2006

Pancreatic metastasis of tall cell variant of papillary thyroid carcinoma: diagnosis by endoscopic ultrasound-guided fine needle aspiration.

CONTEXT: The incidence of tall cell variant of papillary thyroid carcinoma that has metastasized to the pancreas is extremely rare. There has been only one previously reported case of pancreatic metastasis of the tall cell variant of papillary thyroid carcinoma. CASE REPORT: We present the case of a patient who presented with tall cell variant of papillary thyroid carcinoma with metastasis to the pancreas detected and confirmed cytologically by EUS-FNA after finding of the CT scan were equivocal. DISCUSSION: EUS-FNA is a powerful new tool that can be used for the detection and diagnosis of primary and metastatic lesions of the pancreas.

Biopsy, Fine-Needle↗
PubMed2006

A computer-based medical record system and personal digital assistants to assess and follow patients with respiratory tract infections visiting a rural Kenyan health centre.

BACKGROUND: Clinical research can be facilitated by the use of informatics tools. We used an existing electronic medical record (EMR) system and personal data assistants (PDAs) to assess the characteristics and outcomes of patients with acute respiratory illnesses (ARIs) visiting a Kenyan rural health center. METHODS: We modified the existing EMR to include details on patients with ARIs. The EMR database was then used to identify patients with ARIs who were prospectively followed up by a research assistant who rode a bicycle to patients' homes and entered data into a PDA. RESULTS: A total of 2986 clinic visits for 2009 adult patients with respiratory infections were registered in the database between August 2002 and January 2005; 433 patients were selected for outcome assessments. These patients were followed up in the villages and assessed at 7 and 30 days later. Complete follow-up data were obtained on 381 patients (88%) and merged with data from the enrollment visit's electronic medical records and subsequent health center visits to assess duration of illness and complications. Symptoms improved at 7 and 30 days, but a substantial minority of patients had persistent symptoms. Eleven percent of patients sought additional care for their respiratory infection. CONCLUSION: EMRs and PDA are useful tools for performing prospective clinical research in resource constrained developing countries.

Acute Disease↗
PubMed2006

Viewpoint: a pragmatic approach to constructing a minimum data set for care of patients with HIV in developing countries.

Providing quality health care requires access to continuous patient data that developing countries often lack. A panel of medical informatics specialists, clinical human immunodeficiency virus (HIV) specialists, and program managers suggests a minimum data set for supporting the management and monitoring of patients with HIV and their care programs in developing countries. The proposed minimum data set consists of data for registration and scheduling, monitoring and improving practice management, and describing clinical encounters and clinical care. Data should be numeric or coded using standard definitions and minimal free text. To enhance accuracy, efficiency, and availability, data should be recorded electronically by those generating them. Data elements must be sufficiently detailed to support clinical algorithms/guidelines and aggregation into broader categories for consumption by higher level users (e.g., national and international health care agencies). The proposed minimum data set will evolve over time as funding increases, care protocols change, and additional tests and treatments become available for HIV-infected patients in developing countries.

Databases, Factual↗
PubMed2006

Viability and effectiveness of large-scale HIV treatment initiatives in sub-Saharan Africa: experience from western Kenya.

OBJECTIVES: To determine the clinical and immunological outcomes of a cohort of HIV-infected patients receiving antiretroviral therapy. DESIGN: Retrospective study of prospectively collected data from consecutively enrolled adult HIV-infected patients in eight HIV clinics in western Kenya. METHODS: CD4 cell counts, weight, mortality, loss to follow-up and adherence to antiretroviral therapy were collected for the 2059 HIV-positive non-pregnant adult patients treated with antiretroviral drugs between November 2001 and February 2005. RESULTS: Median duration of follow-up after initiation of antiretroviral therapy was 40 weeks (95% confidence interval, 38-43); 111 patients (5.4%) were documented as deceased and 505 (24.5%) were lost to follow-up. Among 1766 (86%) evaluated for adherence to their antiretroviral regimen, 78% reported perfect adherence at every visit. Although patients with and without perfect adherence gained weight, patients with less than perfect adherence gained 1.04 kg less weight than those reporting perfect adherence (P = 0.059). CD4 cell counts increased by a mean of 109 cells/microl during the first 6 weeks of therapy and increased more slowly thereafter, resulting in overall CD4 cell count increases of 160, 225 and 297 cells/microl at 12, 24, and 36 months respectively. At 1 year, a mean increase of 170 cells/microl was seen among patients reporting perfect adherence compared with 123 cells/microl among those reporting some missed doses (P < 0.001). CONCLUSIONS: Antiretroviral treatment of adult Kenyans in this cohort resulted in significant and persistent clinical and immunological benefit. These findings document the viability and effectiveness of large-scale HIV treatment initiatives in resource-limited settings.

Adult↗
PubMed2006

The independent correlation between high-density lipoprotein cholesterol and subsequent major adverse coronary events.

BACKGROUND: There is substantial evidence from clinical trials that lowering low-density lipoprotein cholesterol (LDL-C) reduces cardiovascular risk. There is less evidence for the salutatory effects of raising high-density lipoprotein cholesterol (HDL-C). The predictive strength of an initial HDL-C measurement and its change over time for major adverse coronary events is not well understood. METHODS: We identified a cohort of all 6928 patients in an urban primary care practice who had two or more lipid measurements between January 1985 and December 1997. We used bivariable and multivariable (Cox proportional hazards) techniques to identify independent predictors of subsequent major adverse coronary events (hospitalization for myocardial infarction or acute coronary syndrome) after the second set of lipid measurements. RESULTS: The time between first and second lipid measurements averaged 2.6 years. During a mean of 5.1 +/- 3.2 years of observation after their second lipid measurements, 2167 (31%) patients had an acute coronary event. Patients having events were significantly older, more often white, male, and smokers and more often had antecedent diabetes, hypertension, coronary heart disease, and myocardial infarctions. Adjusting for covariates, a 10-mg/dL higher initial HDL-C was associated with an 11% (95% CI 7%-14%) lower risk of coronary events. A 10-mg/dL increase in HDL-C between lipid measurements was associated with a 7% (95% CI 3%-10%) lower risk of events. Neither initial or change in triglycerides nor LDL-C predicted subsequent coronary events. CONCLUSION: High-density lipoprotein cholesterol measurements and change in HDL-C predicted major adverse coronary events in this urban practice, which provides support studying interventions targeting HDL-C for cardiovascular risk reduction.

Adult↗
PubMed2006

Interpreting quality-of-life data: methods for community consensus in asthma.

BACKGROUND: Change in health-related quality of life (HRQoL) is an important outcome in asthma treatment. Patient and provider consensus on how to determine thresholds for identifying important improvements and declines, however, has not been achieved. OBJECTIVE: To search for consensus in clinically important difference (CID) thresholds for HRQoL change from 3 points of view: (1) an expert panel of physicians who treat patients with asthma and measure the HRQoL of their patients, (2) asthmatic patients, and (3) the primary care physicians (PCPs) of these asthmatic patients. METHODS: The expert panel used Delphi and consensus methods to agree on CID levels for the Asthma Quality of Life Questionnaire and the Medical Outcomes Study 36-Item Short-Form Health Survey, version 2.0. A total of 396 patients attending midwestern primary care clinic sites completed these interviews bimonthly for 1 year. The 46 PCPs treating these patients completed baseline assessments on each patient's asthma and then evaluated the change in each patient's condition at subsequent office visits during the next year. RESULTS: The patient-perceived estimates were consistent with results of previous studies but were notably lower than those derived from the expert panel and the PCPs. The Short-Form Health Survey generally did not provide sufficient sensitivity to detect important changes. CONCLUSIONS: Although consensus on the interpretation of change in HRQoL measures was not achieved, this evidence-based approach demonstrates the value of patient and physician perspectives and the need for improved dialogue and understanding to optimize the HRQoL of patients with asthma.

Adult↗
PubMed2006

Priorities and strategies for the implementation of integrated informatics and communications technology to improve evidence-based practice.

The U.S. health care system is one of the world's most advanced systems. Yet, the health care system suffers from unexplained practice variations, major gaps between evidence and practice, and suboptimal quality. Although information processing, communication, and management are key to health care delivery and considerable evidence links information/communication technology (IT) to improvements in patient safety and quality of care, the health care system has a longstanding gap in its investment. In the Crossing the Quality Chasm and Building a Better Delivery System reports, The Institute of Medicine and National Academy of Engineering identified IT integration as critical to improving health care delivery systems. This paper reviews the state of IT use in the U.S. health care system, its role in facilitating evidence-based practices, and identifies key attributes of an ideal IT infrastructure and issues surrounding IT implementation. We also examine structural, financial, policy-related, cultural, and organizational barriers to IT implementation for evidence-based practice and strategies to overcome them.

Diffusion of Innovation↗
PubMed2005

Effect of CPOE user interface design on user-initiated access to educational and patient information during clinical care.

OBJECTIVE: Authors evaluated whether displaying context sensitive links to infrequently accessed educational materials and patient information via the user interface of an inpatient computerized care provider order entry (CPOE) system would affect access rates to the materials. DESIGN: The CPOE of Vanderbilt University Hospital (VUH) included "baseline" clinical decision support advice for safety and quality. Authors augmented this with seven new primarily educational decision support features. A prospective, randomized, controlled trial compared clinicians' utilization rates for the new materials via two interfaces. Control subjects could access study-related decision support from a menu in the standard CPOE interface. Intervention subjects received active notification when study-related decision support was available through context sensitive, visibly highlighted, selectable hyperlinks. MEASUREMENTS: Rates of opportunities to access and utilization of study-related decision support materials from April 1999 through March 2000 on seven VUH Internal Medicine wards. RESULTS: During 4,466 intervention subject-days, there were 240,504 (53.9/subject-day) opportunities for study-related decision support, while during 3,397 control subject-days, there were 178,235 (52.5/subject-day) opportunities for such decision support, respectively (p = 0.11). Individual intervention subjects accessed the decision support features at least once on 3.8% of subject-days logged on (278 responses); controls accessed it at least once on 0.6% of subject-days (18 responses), with a response rate ratio adjusted for decision support frequency of 9.17 (95% confidence interval 4.6-18, p < 0.0005). On average, intervention subjects accessed study-related decision support materials once every 16 days individually and once every 1.26 days in aggregate. CONCLUSION: Highlighting availability of context-sensitive educational materials and patient information through visible hyperlinks significantly increased utilization rates for study-related decision support when compared to "standard" VUH CPOE methods, although absolute response rates were low.

Decision Making, Computer-Assisted↗
PubMed2005

An electronic medical record system for ambulatory care of HIV-infected patients in Kenya.

Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Africa. Electronic medical records (EMRs) can aid in documenting care, monitoring drug adherence and response to therapy, and providing data for quality improvement and research. Faculty at Moi University in Kenya and Indiana and University in the USA opened adult and pediatric HIV clinics in a national referral hospital, a district hospital, and six rural health centers in western Kenya using a newly developed EMR to support comprehensive outpatient HIV/AIDS care. Demographic, clinical, and HIV risk data, diagnostic test results, and treatment information are recorded on paper encounter forms and hand-entered into a central database that prints summary flowsheets and reminders for appropriate testing and treatment. There are separate modules for monitoring the Antenatal Clinic and Pharmacy. The EMR was designed with input from clinicians who understand the local community and constraints of providing care in resource poor settings. To date, the EMR contains more than 30,000 visit records for more than 4000 patients, almost half taking antiretroviral drugs. We describe the development and structure of this EMR and plans for future development that include wireless connections, tablet computers, and migration to a Web-based platform.

Ambulatory Care↗
PubMed2005

Provider response to computer-based care suggestions for chronic heart failure.

OBJECTIVES: We sought to assess the responses of providers to recommendations generated by a computer-management system for chronic heart failure (CHF). METHODS: This study is an analysis of primary care providers' responses to evidence-based computer-generated suggestions regarding patients with CHF at one center of a randomized trial. The trial randomized primary care providers from 2 VA Medical Centers to receive care suggestions regarding patients with CHF, with or without inclusion of patient symptom data obtained from pre-visit questionnaires. At one center, providers were asked to respond to the suggestions with hand-written comments and a numerical agreement scale. RESULTS: Providers responded to 774 care suggestions (62% of the 1246 delivered). They agreed with 41%, had major disagreements with 12%, and had minor disagreements with 22%. For 7% of the care suggestions, providers asked to not see it again for that patient. The most common reasons for major or minor disagreements were a belief that the suggestion was wrong or unnecessary (45%) or would not be tolerated by the patient (32%). External barriers to implementation of guidelines, lack of guideline awareness, or disagreement with guidelines were uncommon reasons cited by providers in this study. CONCLUSIONS: Providers agreed with less than half of computer-generated care suggestions from evidence-based CHF guidelines, most often because the suggestions were felt to be inapplicable to their patients or unlikely to be tolerated.

Attitude of Health Personnel↗
PubMed2005

Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial.

OBJECTIVE: Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations. STUDY SETTING: Inner-city academic general internal medicine practice. STUDY DESIGN: Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 x 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls. DATA EXTRACTION/COLLECTION METHODS: Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires. PRINCIPAL FINDINGS: During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed. CONCLUSIONS: Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease.

Academic Medical Centers↗
PubMed2005

A comparison of clinically important differences in health-related quality of life for patients with chronic lung disease, asthma, or heart disease.

OBJECTIVE: On the eight scales of the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), Version 2, we compared the clinically important difference (CID) thresholds for change over time developed by three separate expert panels of physicians with experience in quality of life assessment among patients with chronic obstructive pulmonary disease (COPD), asthma, and heart disease. STUDY DESIGN: We used a modified Delphi technique combined with a face-to-face panel meeting within each disease to organize and conduct the consensus process among the expert panelists, who were familiar with the assessment and evaluations of health-related quality of life (HRQL) measures among patients with the panel-specific disease. PRINCIPAL FINDINGS: Each of the expert panels first determined the magnitude of the smallest numerically possible change on each SF-36 scale, referred to as a state change, and then built their CIDs from this metric. All three panels attained consensus on the scale changes that constituted small, moderate, and large clinically important SF-36 change scores. The CIDs established by the heart disease panel were generally greater than the CIDs agreed on by the asthma and COPD panels. CONCLUSIONS: These panel-derived thresholds reflect possible differences in disease management among the represented panel-specific diseases, and are all greater than the minimal CID thresholds previously developed for the SF-36 scales among patients with arthritis. If confirmed among patients with the relevant diseases and those patients' physicians, these disease-specific CIDs could assist both researchers and practicing clinicians in the use and interpretation of HRQL changes over time.

Asthma↗