Biomedical subjects

Arlene S Ash

Publications and source records attributed to Arlene S Ash.

22 records · Page 2Linked to original sources

PubMed2002

Does more "appropriateness" explain higher rates of cardiac procedures among patients hospitalized with coronary heart disease?

BACKGROUND: There have been few studies of the extent to which differences in the pool of patients being managed might account for geographic variations in treatment rates. OBJECTIVE: For two cardiac procedures, cardiac catheterization and revascularization, we evaluate the hypothesis that differences in "the percentage of patients for whom the procedure is appropriate" is a factor explaining variations in use rates among those hospitalized with coronary heart disease (CHD). RESEARCH DESIGN: Based on hospital utilization patterns in Massachusetts in 1990, we created 70 small geographic areas. Using 1992 Massachusetts Peer Review Organization data, areas were ranked from highest to lowest based on (empirical-Bayes-adjusted) hospitalization rates for each procedure. One thousand seven hundred four cases from 43 hospitals were sampled, roughly half each from high and low use areas. Half had a procedure and half were candidates for the same procedure but did not have it. For each procedure, medical records were reviewed to determine whether the procedure was (or, for those not having it, would have been) appropriate, based on criteria developed using a modified Delphi approach. RESULTS: Among those having either procedure, appropriateness rates were similar in high and low rate areas (P = 0.59 for catheterization and P = 0.30 for revascularization). However, among candidates for either procedure who did not have it, appropriateness for performing the procedure was greater in high-rate areas (41.4% vs. 32.1%, P = 0.05 for catheterization; 71.2% vs. 57.2%, P = 0.003, for revascularization). CONCLUSION: Among those hospitalized with CHD, appropriateness rates for two cardiac procedures are higher in areas with higher use rates.

Aged↗

PubMedDate not supplied

Hypertension control: how well are we doing?

BACKGROUND: We compared blood pressure (BP) control in a recent cohort of hypertensive military veterans with BP control in a previous cohort and examined whether hypertension treatment practices, as defined by the frequency of antihypertensive medication dosage increases, have changed over time. METHODS: We abstracted 1999 outpatient chart data including visit type, BP measurements, comorbidities, and medication use for 981 randomly selected hypertensive veterans. We examined overall BP control and control in subgroups with diabetes mellitus and renal disease, and compared results with those of a sample of 800 veterans studied from 1990 to 1995. We also compared the frequency of antihypertensive medication dosage increases in the 2 samples. RESULTS: Mean BPs were significantly lower in 1999. The mean systolic drop was 3.1 mm Hg and reached 13.7 mm Hg for the subgroups with diabetes and renal disease. Even larger decreases were seen in mean diastolic BPs. In 1999, 57% of patients had BP measurements of 140/90 mm Hg or higher, vs 69% of patients in the 1990-1995 study (P<.001). In 1999, the BP control of patients with diabetes was similar to that of patients without diabetes, as 60% of the former had BP measurements of 140/90 mm Hg or higher. Patients with renal disease had better control than those without, however, as only 43% had BP measurements of 140/90 mm Hg or higher. When comparing samples, patients with diabetes, renal disease, or both had better BP control in 1999 than their counterparts in the 1990-1995 study (P<.003 in all cases). In 1999, more medical visits were associated with medication dosage increases than in the 1990-1995 study. CONCLUSIONS: Although overall BP control has improved, BP measurements still exceeded recommended levels in most patients. For patients with diabetes and renal disease BP was much better controlled in the more recent sample. However, BP control of patients with diabetes was similar to that of patients without diabetes, and not in agreement with the guideline-recommended tighter control. Thus, room for improvement remains, especially in this subgroup.

Aged↗

PubMedDate not supplied

Depression management in medical clinics: does healthcare sector make a difference?

Medical providers often fail to treat depression. We examined whether treatment is more aggressive in a setting with accessible mental health resources, the Veterans Health Administration (VA). VA and non-VA primary care physicians and medical specialists viewed a videotape vignette portraying a patient meeting criteria for major depression and then answered interviewer-administered questions about management. We found that 24% of VA versus 15% of non-VA physicians would initiate guideline-recommended treatment (antidepressants or mental health referral, or both) (P = .09). Among those who identified depression as likely, 42% of VA versus 19% of non-VA physicians would treat (P = .002): 23% versus 3% recommended mental health referral (P < .001) and 21% versus 17% an antidepressant (P = .67). Although many patients with major depression may not receive guideline-recommended management, VA physicians do initiate mental health referral more often than do non-VA physicians. Access to mental health services may prove valuable in the campaign to increase physician adherence to depression clinical guidelines.

Adult↗

PubMedDate not supplied

Identifying hypertension-related comorbidities from administrative data: what's the optimal approach?

The objective was to determine the best strategy for identifying outpatients with hypertension-related diagnoses using Veterans Affairs (VA) administrative databases. We reviewed 1176 outpatient charts from 10 VA sites in 1999, taking the presence of 11 diagnoses relevant to hypertension management as the "gold standard" for identifying the comorbidity. We calculated agreement, sensitivity, and specificity for the chart versus several administrative data-based algorithms. Using 1999 data and requiring 1 administrative diagnosis, observed agreement ranged from 0.98 (atrial fibrillation) to 0.85 (hyperlipidemia), and kappas were generally high. Sensitivity varied from 38% (tobacco use) to 97% (diabetes); specificity exceeded 91% for 10 of 11 diagnoses. Requiring 2 years of data and 2 diagnoses improved most measures, with minimal sensitivity decrease. Agreement between the database and charts was good. Administrative data varied in its ability to identify all patients with a given diagnosis but identified accurately those without. The best strategy for case-finding required 2 diagnoses in a 2-year period.

Algorithms↗