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Biomedical subjects

Chester B Good

Publications and source records attributed to Chester B Good.

At least 19 recordsLinked to original sources
PubMed2006

Rate and predictors of treatment prescription for hepatitis C.

BACKGROUND: The true treatment rate for hepatitis C virus (HCV) in veterans is unknown. AIM: To determine the treatment prescription rates and predictors of treatment prescription for HCV in a large national population. METHODS: The Department of Veterans Affairs National Patient Care Database (NPCD) was used to identify all HCV-infected people between the fiscal years 1999 and 2003 using the International classification of diseases, 9th revision codes. Demographic information, medical and psychiatric comorbidities, and drug and alcohol use diagnoses were retrieved. Pharmacy data were retrieved from the Department of Veterans Affairs Pharmacy Benefits Management (PBM) database. Logistic regression analysis was used to determine the predictors of treatment for HCV in HCV. RESULTS: 113 927 veterans in the Department of Veterans Affairs care with a diagnosis of HCV were identified. The treatment prescription rate for HCV was 11.8%. Patients not prescribed treatment were older, more likely to be from minority races, have more alcohol and drug misuse, and have medical and psychiatric comorbid conditions. In a multivariate logistic regression model, the following factors were predictive of non-treatment for HCV: increasing age (odds ratio (OR) 0.77 for each 5-year increase in age; 95% confidence interval (CI) 0.76 to 0.78); black race (OR 0.64; 95% CI 0.6 to 0.68); Hispanic race (OR 0.88; 95% CI 0.8 to 0.96); alcohol abuse and dependence (OR 0.62; 95% CI 0.59 to 0.65); drug abuse and dependence (OR 0.78; 95% CI 0.74 to 0.82); anaemia (OR 0.18; 95% CI 0.16 to 0.21); hepatitis B infection (OR 0.72; 95% CI 0.62 to 0.83); coronary artery disease (OR 0.9; 95% CI 0.85 to 0.97); stroke (OR 0.75; 95% CI 0.67 to 0.85); bipolar disorder (OR 0.64; 95% CI 0.58 to 0.70); major depression (OR 0.72; 95% CI 0.67 to 0.77); mild depression (OR 0.56; 95% CI 0.53 to 0.59); and schizophrenia (OR 0.71; 95% CI 0.65 to 0.77). The following factors were associated with a higher likelihood of treatment prescription for HCV: liver cirrhosis (OR 1.6; 95% CI 1.5 to 1.7); and diabetes (OR 1.07; 95% CI 1.02 to 1.12). CONCLUSIONS: A small number of HCV-infected veterans were prescribed treatment for HCV. Non-treatment is associated with increasing age, non-white race, drug and alcohol abuse, and dependence and comorbid illnesses. Reasons for non-treatment need further study.

Age Factors↗
PubMed2006

Noncardiac surgery and the risk of death and other cardiovascular events in patients with hypertrophic cardiomyopathy.

BACKGROUND: There is a paucity of reports evaluating the perioperative risk of noncardiac surgery in patients with hypertrophic cardiomyopathy (HCM). HYPOTHESIS: The study was undertaken to evaluate the incidence of acute myocardial infarction (MI) and all-cause inhospital mortality following noncardiac surgery in patients with HCM. METHODS: We searched the National Hospital Discharge Survey database for patients with a diagnosis of HCM who had undergone noncardiac surgery. Cases were matched by age, gender, and year of surgery. Death or acute MI were used as endpoints for analysis. RESULTS: From 1996 to 2002, 227 patients with HCM were matched with 554 controls (representing national estimates of 25,874 HCM and 50,326 controls patients). Patients with HCM were more likely than controls to have a history of atrial fibrillation (22.7 vs. 10.6%, p < 0.001) and of congestive heart failure (CHF) (24.2 vs. 14.1%, p < 0.001). The in-hospital incidence of death or MI was higher in patients with HCM than in controls (6.7 vs. 2.5%, p < 0.001 for death and 2.2 vs. 0.3%, p < 0.001 for MI). After correcting for age, gender, race, presence of hypertension, diabetes mellitus, history of coronary artery-disease, history of CHF, atrial fibrillation, and ventricular arrhythmias in a multivariate binary logistic regression model, the presence of HCM increased the odds of death by 61% (odds ratio [OR] = 1.61, 95% confidence interval [CI] 1.46-1.77, p < 0.001), and almost tripled the odds of the combined endpoint of death or MI (OR = 2.82, 95% CI 2.59-3.07, p < 0.001). CONCLUSION: The presence of HCM significantly increases the risk of death and MI associated with noncardiac surgery. Patients with HCM undergoing elective procedures may require more careful preoperative assessment and perioperative monitoring. The impact of the severity of HCM on outcomes of noncardiac surgery needs further study.

Aged↗
PubMed2005

Perioperative risk of noncardiac surgery associated with aortic stenosis.

The perioperative risk of noncardiac surgery in patients with aortic stenosis (AS) remains ill-defined, and the few studies published have reported conflicting results. A sample of patients from the National Hospital Discharge Survey database diagnosed with AS who underwent any noncardiac surgical procedure was searched. Patients who underwent any cardiac surgery were excluded. Patients with AS were matched by decile of age and surgical risk for twice as many controls. A discharge diagnosis of acute myocardial infarction (AMI) and death was used as the end points for analysis. From 1996 to 2002, 5,149 patients with a diagnosis of AS had undergone noncardiac surgery and were matched with 10,284 controls. The incidence of AMI was greater in patients with AS than in controls (3.86% vs 2.03%, p <0.001). After correcting for gender and the presence of coronary artery disease, hypertension, and diabetes mellitus in a multivariate logistic regression model, the presence of AS was associated with an increased likelihood of AMI (odds ratio 1.55, 95% confidence interval 1.27 to 1.90, p <0.001). There was no significantly increased risk for death in patients with AS versus controls. In the era of more intense perioperative medical management of patients who undergo noncardiac surgery, the presence of AS increases the risk for perioperative AMI but not overall mortality. The impact of the actual severity of AS on outcomes with noncardiac surgery needs further study.

Aged↗
PubMed2005

Effect of both elevated troponin-I and peripheral white blood cell count on prognosis in patients with suspected myocardial injury.

We found a high white blood cell count (>11,000/mul) to be of additive prognostic value to high troponin-I levels in predicting risk of recurrent nonfatal myocardial infarctions and all-cause mortality in patients who present with acute coronary syndromes and non-ST-elevation myocardial infarctions. A high troponin-I level or white blood cell count increased the odds ratio of an event to 2.2 (95% confidence interval 1.0 to 4.73, p = 0.05), but high values for the 2 markers increased the odds ratio to 4.5 (95% confidence interval 1.42 to 14.21, p = 0.01).

Aged↗
PubMed2005

Racial variations in treatment and outcomes of black and white patients with high-risk non-ST-elevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?).

BACKGROUND: Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non-ST-segment elevation acute coronary syndromes (NSTE ACS) and how different treatments affect outcomes. METHODS AND RESULTS: Using data from 400 US hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative, we identified black and white patients with high-risk NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes). After adjustment for demographics and medical comorbidity, we compared the use of therapies recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS and outcomes by race. Our study included 37,813 (87.3%) white and 5504 (12.7%) black patients. Black patients were younger; were more likely to have hypertension, diabetes, heart failure, and renal insufficiency; and were less likely to have insurance coverage or primary cardiology care. Black patients had a similar or higher likelihood than whites of receiving older ACS treatments such as aspirin, beta-blockers, or ACE inhibitors but were significantly less likely to receive newer ACS therapies, including acute glycoprotein IIb/IIIa inhibitors, acute and discharge clopidogrel, and statin therapy at discharge. Blacks were also less likely to receive cardiac catheterization, revascularization procedures, or smoking cessation counseling. Acute risk-adjusted outcomes were similar between black and white patients. CONCLUSIONS: Black patients with NSTE ACS were less likely than whites to receive many evidence-based treatments, particularly those that are costly or newer. Longitudinal studies are needed to assess the long-term impact of these treatment disparities on clinical outcomes.

Black or African American↗
PubMed2005

The evolving use of cost-effectiveness analysis in formulary management within the Department of Veterans Affairs.

The Veterans Health Administration (VHA) runs the largest integrated healthcare system in the nation. Formulary management within VHA primarily involves 3 national groups: the Medical Advisory Panel, the Veterans Integrated Service Network Formulary Leaders, and the Pharmacy Benefits Management Strategic Healthcare Group. Together, these groups manage the VHA national drug formulary with a goal of providing a comprehensive, safe, and cost-effective pharmacy benefit for veterans. Traditionally, VHA has relied on cost-minimization analyses in formulary decisions. More recently, VHA has emphasized the use of cost-effectiveness data, especially for newer, costly drugs. In addition to including this data in drug monographs, the VHA has begun requiring formal cost-effectiveness analysis from manufacturers of selected pharmaceuticals. VHA has also requested that clinically relevant information such as quality of life plus mortality benefit be made available from industry so that internal cost analyses can be performed. It is hoped that by setting the expectation that cost-effectiveness will be formally considered in all VHA formulary decisions, the pharmaceutical industry and others will be stimulated to collect and report data that enables these analyses. We believe that if other organizations also place an emphasis on economic evaluations, industry and the public will be more accepting of decisions that incorporate cost considerations.

Cost-Benefit Analysis↗
PubMed2005

Bleeding Risk Index in an anticoagulation clinic. Assessment by indication and implications for care.

BACKGROUND: The Outpatient Bleeding Risk Index (BRI) prospectively classified patients who were at high, intermediate, or low risk for warfarin-related major bleeding. However, there are only 2 published validation studies of the index and neither included veterans. OBJECTIVE: To determine the accuracy of the BRI in patients attending a Veterans Affairs (VA) anticoagulation clinic and to specifically evaluate the accuracy of the BRI in patients with atrial fibrillation. DESIGN: Retrospective cohort study. PATIENTS AND MEASUREMENTS: Using the BRI, all patients managed by the Anticoagulation Clinic between January 1, 2001 and December 31, 2002 were classified as high, intermediate, or low risk for major bleeding. Bleeds were identified via quality-assurance reports. Poisson regression was used to determine whether there was an association between the index and the development of bleeding. RESULTS: The rate of major bleeding was 10.6%, 2.5%, and 0.8% per patient-year of warfarin in the high-, intermediate-, and low-risk groups, respectively. Patients in the high-risk category had 14 times the rate of major bleeding of those in the low-risk group (incidence rate ratio (IRR) 14; 95% confidence interval (CI), 1.9 to 104.7). The rate of major bleeding was significantly different between the high- and intermediate-risk categories (P<.001). Among those with atrial fibrillation, patients in the high-risk category had 6 times the major bleeding rate of those in the intermediate- and low-risk groups combined (IRR=6; 95% CI, 2.4 to 15.3). CONCLUSIONS: The BRI discriminates between high- and intermediate-risk patients in a VA anticoagulation clinic, including those with atrial fibrillation.

Aged↗
PubMed2005

How does depression influence diabetes medication adherence in older patients?

OBJECTIVE: Using various measures (electronic monitoring, patient/provider report, pharmacy data), the authors assessed the association between depression and diabetes medication adherence among older patients with Type 2 diabetes. METHODS: Patients completed a baseline survey on depression (Patient Health Questionnaire) and were given electronic monitoring caps (EMCs) to use with their oral hypoglycemic medication. At the time of the patient baseline survey, providers completed a survey on their patients' overall medication adherence. Upon returning the caps after 30 days, patients completed a survey on their overall medication adherence. EMC adherence was defined as percent of days out of 30 with correct number of doses. Using pharmacy refill data from the patient baseline through 1 year later, they defined adherence as the percentage of days with adequate medication, based on days' supply across refill periods. RESULTS: Of 203 patients (mean age: 67 years), 10% (N=19) were depressed. Depressed patients were less likely to self-report good adherence and had a lower median percentage of days with adequate medication coverage (on the basis of pharmacy refill data). After adjustment for alcohol use, cognitive impairment, age, and other medication use, depression was still negatively associated with adequate adherence, according to patient report and pharmacy data. Depression showed no associated with adherence on the basis of provider or EMC data. CONCLUSIONS: Depression was independently associated with inadequate medication adherence on the basis of patient self-report and pharmacy data.

Adult↗
PubMed2005

Racial differences in the treatment of veterans with bipolar disorder.

OBJECTIVES: The authors examined whether African Americans, compared with whites, received guideline-concordant care for bipolar I disorder. METHODS: A retrospective analysis was conducted of data for patients who received a diagnosis of bipolar I disorder in fiscal year 2001 and received care in facilities in the Department of Veterans Affairs (VA) mid-Atlantic region. Indicators of guideline-concordant care were based on prescription data and data on utilization of inpatient and outpatient services from VA databases. RESULTS: A total of 2,316 patients with a diagnosis of bipolar I disorder were identified. Their mean age was 52 years; 9.4 percent (N=218) were women, and 13.1 percent (N=303) were African American. Overall, mood stabilizers were prescribed for 74.6 percent (N=1,728) of the patients; 67.1 percent (N=1,554) had an outpatient mental health visit within 90 days after the index diagnosis, and 54.3 percent (N=1,258) had an outpatient visit within 30 days after discharge from a psychiatric hospitalization. Multivariate logistic regression analyses with adjustment for sociodemographic and facility factors revealed that African Americans were less likely than whites to have an outpatient follow-up visit within 90 days after the index diagnosis. Race was not associated with receipt of mood stabilizers or use of outpatient services after a hospital discharge. CONCLUSIONS: Although a majority of patients received guideline-concordant care for bipolar disorder, potential gaps in continuity of outpatient care may exist for African-American patients.

Black or African American↗
PubMed2005

Pharmacy benefits management in the Veterans Health Administration: 1995 to 2003.

The Department of Veterans Affairs (VA) Pharmacy Benefits Management Strategic Healthcare Group (VA PBM) oversees the formulary for the entire VA system, which serves more than 4 million veterans and provides more than 108 million prescriptions per year. Since its establishment in 1995, the VA PBM has managed pharmaceuticals and pharmaceutical-related policies, including drug safety and efficacy evaluations, pharmacologic management algorithms, and criteria for drug use. These evidence-based practices promote, optimize, and assist VA providers with the safe and appropriate use of pharmaceuticals while allowing for formulary decisions that can result in substantial cost savings. The VA PBM also has utilized various contracting techniques to standardize generic agents as well as specific drugs and drug classes (eg, antihistamines, angiotensin-converting enzyme inhibitors, alpha-blockers, and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins]). These methods have enabled the VA to save approximately dollar 1.5 billion since 1996 even as drug expenditures continued to rise from roughly dollar 1 billion in fiscal year (FY) 1996 to more than dollar 3 billion in FY 2003. Furthermore, the VA PBM has established an outcomes research section to undertake quality-improvement and safety initiatives that ultimately monitor and determine the clinical impact of formulary decisions on the VA system nationwide. The experiences of this pharmacy benefits program, including clinical and contracting processes/procedures and their impact on the VA healthcare system, are described.

Clinical Pharmacy Information Systems↗
PubMed2004

Incidence and severity of potential drug-dietary supplement interactions in primary care patients: an exploratory study of 2 outpatient practices.

BACKGROUND: To explore the incidence and severity of potential interactions between prescription medications and dietary supplements. METHODS: A survey was conducted on dietary supplement use in 458 veteran outpatients currently taking prescription medications. Self-reported dietary supplement use was cross-referenced with each patient's prescription medication list, and potential interactions were identified from several tertiary sources and medical literature searches. RESULTS: One hundred ninety-seven patients (43%) were currently taking at least 1 dietary supplement with prescription medication(s). The most common products included vitamins and minerals, garlic, Ginkgo biloba, saw palmetto, and ginseng. Among these, 89 (45%) had a potential for drug-dietary supplement interactions of any significance. Most of these interactions (n = 84 [94%]) were not serious based on limited available evidence, giving an incidence of 6% (5/89) of potentially severe interactions among patients taking interacting drugs and dietary supplements and 3% (5/197) among patients taking coincident dietary supplements and medications. CONCLUSIONS: Although the use of dietary supplements appears to be very common among patients who also take prescription medications, most potential drug-dietary supplement interactions found were not serious. However, literature support was sparse at best. Health care providers should continue to inquire about dietary supplement use and consider the potential for interactions, regardless of their severity.

Dietary Supplements↗
PubMed2004

Physician satisfaction with formulary policies: is it access to formulary or nonformulary drugs that matters most?

OBJECTIVE: To assess physician satisfaction with Department of Veterans Affairs (VA) formulary policies and to examine the correlation between physician satisfaction and perceived access to formulary and nonformulary medications. STUDY DESIGN: Cross-sectional survey with specific questions on access to formulary and nonformulary medications. Statistical analyses included assessment of associations between physician satisfaction and various measures of access. PARTICIPANTS AND METHODS: Initial sample of 4015 staff physicians working in VA healthcare facilities. Responses were received from 1812 (49%) of the 3682 physicians in the final eligible sample population. RESULTS: Most clinicians (72%) reported that their local formulary covered more than 90% of the medications they wanted to prescribe. Most (73%) agreed that drug restrictions were important to contain costs, and 86% agreed that it was important for VA to choose "best-value" drugs. Respondents reported an 89% approval rate for nonformulary drugs, though 31% indicated that approvals routinely took 3 or more days. We found strong associations between physician satisfaction and self-reported approval rates for nonformulary drugs (P = .001), timely approval of nonformulary requests (P < .001), and percentage of nonformulary prescriptions as a proportion of overall prescriptions at a regional level (P< .01). There was no significant correlation between physician satisfaction and number of medications added to regional formularies or with drug costs per unique patient. CONCLUSIONS: VA physicians were generally supportive of VA formulary policies including choosing best-value drugs to control pharmaceutical expenditures. Nevertheless, access to nonformulary drugs and timely approval of requests for nonformulary medications were strong predictors of clinician satisfaction and support for cost-containment measures.

Attitude of Health Personnel↗
PubMed2003

Equal effectiveness of older traditional antibiotics and newer broad-spectrum antibiotics in treating patients with acute exacerbations of chronic bronchitis.

BACKGROUND: Choice of antibiotic therapy for acute exacerbations of chronic bronchitis (AECB) is important because of cost and concerns about development of resistance. METHODS: A retrospective cohort study was conducted in outpatients with chronic obstructive pulmonary disease and documented AECB treated with antibiotics. RESULTS: We compared outcomes and costs of AECB treated with first-line antibiotics having partial coverage against organisms associated with AECB (eg, amoxicillin), first-line antibiotics with full coverage against organisms associated with AECB (eg, sulfamethoxazole-trimethoprim), and newer broad-spectrum antibiotics (eg, azithromycin). There were no significant differences among the three antibiotic groups in failure rate, hospitalization rate, or time until subsequent AECB. Pharmacy costs were significantly less with first-line antibiotics (3.18 dollars +/- 0.64, 3.00 dollars +/- 0.48, and 36.70 dollars +/- 16.29, respectively; P < 0.0001), but there was no significant difference among all three groups with regard to total costs. CONCLUSION: We found no difference in outcome between older traditional antibiotics with adequate coverage against organisms associated with AECB and newer broad-spectrum antibiotics.

Acute Disease↗