Biomedical subjects

R D Horner

Publications and source records attributed to R D Horner.

At least 37 records · Page 2Linked to original sources

PubMed1999

Race, presenting signs and symptoms, use of carotid artery imaging, and appropriateness of carotid endarterectomy.

BACKGROUND AND PURPOSE: We sought to determine whether there are racial differences in use of carotid artery imaging after controlling for clinical factors and to ascertain racial differences in presenting signs and symptoms and overall appropriateness for carotid endarterectomy (CE). METHODS: We performed a retrospective cohort study of 803 patients older than 45 years, hospitalized between 1991 and 1994 at any of 4 Veterans Affairs Medical Centers, with a discharge diagnosis of transient ischemic attack or ischemic stroke. Clinical data were abstracted from the medical record, including presenting symptoms, diagnostic test results, and use of surgical procedures. Appropriateness for CE was determined according to RAND criteria. RESULTS: Black patients were more likely than white patients to present with stroke (78% versus 55%) but less likely to present with transient ischemic attack (22% versus 45%; P=0.001). There was no racial difference in medical comorbidity or preoperative risk. Black patients were less likely to have an imaging study of their carotid arteries (67% versus 79%; P=0.001). Race remained an independent predictor of imaging after adjustment for clinical factors (odds ratio=1.50; 95% CI, 1.06 to 2.13). Because of higher prevalence of significant carotid artery stenosis, whites were significantly more likely than blacks to be assessed as appropriate candidates for surgery with the use of RAND criteria (18% versus 4%; P=0.001). CONCLUSIONS: Use of carotid artery imaging, a critical step in determining eligibility for CE, is influenced by the patient's race after controlling for clinical presentation. Adjustment for appropriateness of CE reduces but does not eliminate the importance of race.

Black or African American↗

PubMed1999

New horizons in stroke rehabilitation research.

To promote health services research in stroke rehabilitation, we gathered information about stroke rehabilitation structures, processes, and outcomes (SPO), using extant databases and the Donabedian theoretical model of health services evaluation. We found that, in the United States, over S3.6 billion was spent by third-party payers in 1992 on rehabilitation, including stroke. Total disability-related costs now amount to over $170 billion per year. However, there are few studies identifying cost-effective stroke rehabilitation practices. Existing studies indicate that the organizational structure of rehabilitation influences stroke outcomes, but it is less clear exactly what organizational practices constitute optimal stroke rehabilitation. Data about specific, beneficial rehabilitation processes are scanty for stroke. There are a number of valid and reliable outcome measures pertinent to stroke rehabilitation health services research. We conclude that health services research in stroke rehabilitation is sparse. To be more informative, rehabilitation health services research should be guided by the SPO model.

Cost-Benefit Analysis↗

PubMed1998

Racial variation in cancer care: a case study of prostate cancer.

Prostate cancer is one of several cancers that affects U.S. racial and ethnic groups differently with Blacks experiencing a higher incidence and mortality rate than Whites. Observational studies indicate that black patients with prostate cancer are less likely to receive definitive therapy. This pattern of care appears to be attributable primarily to the later clinical stage of disease at presentation; socioeconomic considerations as such relate to access to care (e.g., ability to pay) appear to play a lesser role. Other patient related factors, for example, preferences for certain therapies, have not been well studied; consequently, their ability to explain racial variations in use of therapies for this disease is unclear. Potential areas for future research should focus on the reasons for the detection of the disease at a later clinical stage and, hence, with worse prognosis.

Ethnicity↗

PubMed1998

The reliability of a self-reported measure of disease, impairment, and function in persons with spinal cord dysfunction.

OBJECTIVE: To develop a self-report instrument that would provide information about the different levels of the disablement process, and that (1) was suitable for persons with spinal cord disease (SCD), (2) could be completed quickly, (3) could be mailed, (4) had acceptable reliability, and (5) would be clinically useful. STUDY DESIGN: Test-retest using a convenience sample. METHODS: Review of the literature and an expert panel were used to develop the instrument. It was mailed to 49,458 individuals in June 1995 and a second mailing was done in August 1995. A subset of 725 individuals who responded to both mailings was used to examine the instrument's test-retest reliability. RESULTS: The instrument has a 4th grade reading level and has questions on causal disease, disease severity, impairment, activities of daily living (including a self-reported version of the Functional Independence Measure, the SRFM), and resource utilization. Individual item test-retest reliability was high for a mailed questionnaire; all kappa coefficients were near or above .60 and most were over .70. Intraclass correlation coefficient for the SRFM was .90 and internal consistency (Chronbach's alpha) was .96. CONCLUSION: This instrument provides a new, rapid way to obtain information relative to the differing levels of the disablement process.

Activities of Daily Living↗

PubMed1998

Benzodiazepine use and cognitive function among community-dwelling elderly.

OBJECTIVE: To evaluate the relation between benzodiazepine use and cognitive function among community-dwelling elderly. METHODS: This prospective cohort study included 2765 self-reporting subjects from the Duke Established Populations for Epidemiologic Studies of the Elderly. The subjects were cognitively intact at baseline (1986-1987) and alive at follow-up data collection 3 years later. Cognitive function was assessed with the Short Portable Mental Status Questionnaire (unimpaired versus impaired and change in score) and on the basis of the number of errors on the individual domains of the Orientation-Memory-Concentration Test. Benzodiazepine use was determined during in-home interviews and classified by dose, half-life, and duration. Covariates included demographic characteristics, health status, and health behaviors. RESULTS: After control for covariates, current users of benzodiazepine made more errors on the memory test (beta coefficient, 0.35; 95% confidence interval [CI], 0.10 to 0.61) than nonusers. Further assessment of the negative effects on memory among current users suggested a dose response in which users taking the recommended or higher dose made more errors (beta coefficient, 0.57; 95% CI, 0.26 to 0.88) and a duration response in which long-term users made more errors (beta coefficient, 0.39; 95% CI, 0.05 to 0.73) than nonusers. Users of agents with long half-lives and users of agents with short half-lives both had increased memory impairment (beta coefficient, 0.32; 95% CI, 0.01 to 0.64 and beta coefficient, 0.38; 95% CI, 0.02 to 0.75, respectively) relative to nonusers. Previous benzodiazepine use was unrelated to memory problems, and current and previous benzodiazepine use was unrelated to level of cognitive functioning as measured with the other 4 tests. CONCLUSIONS: The results suggested that current benzodiazepine use, especially in recommended or higher doses, is associated with worse memory among community-dwelling elderly.

Aged↗

PubMed1998

Developing a national registry of veterans with spinal cord dysfunction: experiences and implications.

We describe the development of a registry of veterans with spinal cord dysfunction who have been treated within the Department of Veterans Affairs health care facilities. The registry departs from the function and structure of traditional registries by a more extensive utilization of advances in computer technology; in particular, by its reliance upon computerized record linkage and by its association with a set of computer-based clinical management and reporting tools. We discuss some of the applications of the registry to research for persons with spinal cord dysfunction as well as implications that our experiences provide for developing other registries of persons with disabilities.

Humans↗

PubMed1998

Variations in intensive care unit utilization for patients with human immunodeficiency virus-related Pneumocystis carinii pneumonia: importance of hospital characteristics and geographic location.

OBJECTIVE: To determine whether intensive care unit (ICU) use and outcomes for patients with human immunodeficiency virus (HIV)-related Pneumocystis carinii pneumonia vary by hospital characteristics and geographic location. DESIGN: Retrospective review of the medical records of 2,174 patients with HIV-related P. carinii pneumonia. SETTING: Random sample of 73 private, nine public, and 14 Veterans Affairs hospitals in five cities (Chicago, New York, Los Angeles, Miami, and Durham, NC). PATIENTS: Stratified random sample of patients hospitalized with HIV-related P. carinii pneumonia from 1987 to 1990. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 2,174 patients with P. carinii pneumonia, 398 (18%) patients received care in an ICU. ICU utilization varied significantly by patient and hospital characteristics, as well by as geographic location. Non-Hispanic whites, patients with Medicaid, and patients with a prior acquired immunodeficiency syndrome-defining illness were the least likely to receive care in an ICU. Patients in county- or state-owned hospitals and patients in hospitals with more P. carinii pneumonia-experience were also less likely to be cared for in an ICU. These differences in ICU utilization persisted when controlling for severity of illness, as well as other patient characteristics. Significant geographic variation in ICU utilization persisted after controlling for patient and hospital characteristics. Survival to hospital discharge after an ICU stay was significantly higher for patients without a prior acquired immunodeficiency syndrome-defining illness and for patients in hospitals with more P. carinii pneumonia experience. CONCLUSIONS: We found significant variations in ICU utilization by hospital characteristics and geographic location that remained significant after controlling for severity of illness and patient sociodemographic characteristics. Hospital and geographic variations in ICU utilization may make it difficult to generalize ICU outcomes across different hospitals.

AIDS-Related Opportunistic Infections↗

PubMed1998

Is use of mechanical ventilation a reasonable proxy indicator for coma among Medicare patients hospitalized for acute stroke?

OBJECTIVE: To ascertain whether use of mechanical ventilation on admission to the hospital is a proxy indicator of coma (i.e., very severe stroke) among acute stroke patients. METHODS: A secondary analysis of data from a medical record review on a nationally representative sample of 2,824 Medicare patients, ages 65 years or older, who were hospitalized for stroke in 1982-1983 or 1985-1986 in 297 acute care hospitals in 30 areas within five geographically dispersed states. RESULTS: Use of mechanical ventilation on the first day of hospitalization was significantly associated with level of consciousness on admission: < 2 percent of noncomatose patients versus 17.5 percent of comatose (p < .001). With a high specificity and high likelihood ratio for a positive test, use of mechanical ventilation on the first day of hospitalization ruled-in coma. It was also significantly associated with severity of illness, prognostic indicators (i.e., admission through the emergency room, admission to intensive care, and having a "do-not-resuscitate" order written during the hospital stay), and with in-hospital death. Adjusting for patient demographics, stroke type, comorbidity, and process of care, early initiation of mechanical ventilation remained significantly associated with both coma and in-hospital death. CONCLUSIONS: A stroke patient's use of mechanical ventilation on the first day of hospitalization is a valid proxy indicator of level of consciousness.

Aged↗

PubMed1998

Understanding racial variation in the use of carotid endarterectomy: the role of aversion to surgery.

Previous studies indicate that African-American patients undergo carotid endarterectomy at one fourth the rate of white patients. This study was undertaken to determine if differences in aversion to carotid endarterectomy might account for some of the racial difference in utilization of this procedure. A sample of 185 African-American and white patients was selected from a cohort of patients hospitalized for stroke or transient ischemic attack at four Veterans Affairs medical centers. Of these patients, 115 (62%) were able to be contacted by telephone and 95 (83%) agreed to be interviewed. The interview included assessments of functional status, patient preferences for their current health status, and risk aversion to a hypothetical carotid endarterectomy. Patients from both racial groups were similar in age, marital status, level of education, and comorbid medical illnesses. All respondents were male. Functional status for both groups was high and not statistically different. There were no significant racial differences in patients' perceptions of their current health state. However, African-American patients expressed more aversion to the hypothetical surgery than whites. The median excess risk of death accepted to avoid surgery was 20% for African Americans versus 2.5% for whites. These results indicate that racial differences in the utilization of carotid endarterectomy may be due in part to differences in patients' levels of aversion to this surgery.

Black or African American↗

PubMed1997

Primary care clinicians' performance for detecting actinic keratoses and skin cancer.

BACKGROUND: If skin cancer screening is to become widely adopted, its effectiveness depends on the ability of primary care clinicians to detect cutaneous malignancies. OBJECTIVE: To assess primary care clinicians' proficiency for detecting skin cancers and actinic keratoses in a clinic population. METHODS: A convenience sample of 190 white male patients aged 40 years or older presenting to a university-affiliated Veterans Affairs general internal medicine or dermatology clinic were included in the study. Each patient was independently examined by a primary care clinician and a dermatologist to measure interobserver agreement. We compared the ability of primary care clinicians to diagnose actinic keratoses and skin cancers using dermatologists' examinations as a pragmatic reference standard. RESULTS: Agreement was moderate as to whether a patient had single actinic keratosis (kappa, 0.36; 95% confidence interval [CI], 0.22-0.50), multiple actinic keratoses (kappa, 0.48; 95% CI, 0.34-0.61), or skin cancer (kappa, 0.48; 95% CI, 0.34-0.62). Agreement decreased when individual lesions were the unit of analysis. When the patient was the unit of analysis, primary care clinicians identified the presence of skin cancer with a sensitivity of 57% (95% CI, 44%-68%), specificity of 88% (95% CI, 81%-93%), positive likelihood ratio of 4.9 (95% CI, 3.0-8.3), and negative likelihood ratio of 0.48 (95% CI, 0.35-0.63). When the lesion was the unit of analysis the sensitivity was 38% (95% CI, 29%-47%), the specificity was 95% (95% CI, 93%-96%), the positive likelihood ratio was 7.1 (95% CI, 4.8-10.3), and the negative likelihood ratio was 0.66 (95% CI, 0.56-0.75). CONCLUSIONS: Examinations performed by primary care clinicians for diagnosing skin cancer lacked sensitivity. Without improved diagnostic skills, primary care clinicians' examinations may be ineffective as a screening test.

Adult↗

PubMed1997

Relation of prescription nonsteroidal antiinflammatory drug use to cognitive function among community-dwelling elderly.

PURPOSE: To evaluate the relationship of nonsteroidal antiinflammatory drug (NSAID) use to level of cognitive function in community-dwelling elderly persons. METHODS: The prospective cohort study included 2765 nonproxy subjects from the Duke University Established Populations for Epidemiologic Studies of the Elderly who were cognitively intact at baseline (1986-1987) and alive at follow-up three year later. Cognitive function was assessed by the Short Portable Mental Status Questionnaire (i.e., intact vs. impaired and change in score) and by the individual domains of the Orientation-Memory-Concentration Test (i.e., number of errors). NSAID use, determined from in-home interviews, was coded for chronicity, dose, frequency of use, and prescription status. RESULTS: After controlling for demographic factors as well as health status and behavior, continuous, regularly-scheduled, prescription use of NSAID was associated with preservation of one aspect of cognitive functioning: concentration (beta coefficient, 0.29; 95% confidence interval [CI] -0.54 to -0.04, indicating fewer errors). However, no consistent dose-response relationship was found. Current and prior NSAID use was unrelated to level of cognitive functioning across all five measures; among current users, those taking moderate or high doses (beta coefficient, 0.41; 95% CI, 0.08 to 0.74) made more errors on the memory test compared with those taking low doses (beta coefficient 0.03; 95% CI, -.85 to 0.91). CONCLUSIONS: These results suggest no substantial or consistent protective effect of prescription NSAID use on cognitive function in community-dwelling elderly. However, recent use at higher doses may be associated with memory deterioration in this population.

Aged↗

PubMed1997

Racial differences in the utilization of inpatient rehabilitation services among elderly stroke patients.

BACKGROUND AND PURPOSE: We undertook this study to ascertain whether elderly black and white patients who are hospitalized for stroke utilize inpatient physical and occupational therapy (PT/OT) services differently, adjusting for characteristics associated with use of these services. METHODS: We retrospectively reviewed medical records regarding the care received by a nationally representative sample of 2497 black and white Medicare patients, aged 65 years of older, who were hospitalized at any of 297 acute-care hospitals located in 30 communities within five states. RESULTS: Compared with whites, black stroke patients were younger and more likely to have Medicaid coverage, have an ischemic stroke, and have a motor deficit noted at the time of admission. There was no difference in either sex or level of consciousness on admission. Overall, a larger proportion of black stroke patients used inpatient PT/OT at some point during the hospitalization (66.3% versus 55.8%; P < .01). However, after adjustment for characteristics associated with use of PT/OT, there was no racial difference in either the likelihood of inpatient PT/OT use (adjusted relative risk, 1.06; 95% confidence limits, 0.89 to 1.27; P = .42) or time to initial contact (median: blacks, 6.6 days; whites, 7.4 days; P = .42). Adjusted analyses also indicated a similarity between the racial groups in the number of inpatient PT/OT days overall or as a proportion of the hospital stay. CONCLUSIONS: Elderly black and white stroke patients who have Medicare coverage have similar patterns of use of inpatient PT/OT services.

Black or African American↗

PubMed1997

Knowledge of risk among patients at increased risk for stroke.

BACKGROUND AND PURPOSE: Patients who recognize their increased risk for stroke are more likely to engage in (and comply with) stroke prevention practices than those who do not. We describe perceived risk of stroke among a nationally diverse sample of patients at increased risk for stroke and determine whether patients' knowledge of their stroke risk varied according to patients' demographic and clinical characteristics. METHODS: Respondents were recruited from the Academic Medical Center Consortium (n = 621, five academic medical centers, inpatients of varying age); the Cardiovascular Health Study (n = 321, population-based sample of persons aged 65+ years); and United HealthCare (n = 319, five health plans, inpatients and outpatients typically younger than 65 years). The primary outcome was awareness of being at risk for stroke. RESULTS: Only 41% of respondents were aware of their increased risk for stroke (including less than one half of patients with previous minor stroke). Approximately 74% of patients who recalled being told of their increased stroke risk by a physician acknowledged this risk in comparison with 28% of patients who did not recall being informed by a physician. Younger patients, depressed patients, those in poor current health, and those with a history of TIA were most likely to be aware of their stroke risk. CONCLUSIONS: Over one half of patients at increased risk of stroke are unaware of their risk. Healthcare providers play a crucial role in communicating information about risk, and successful communication encourages adoption of stroke prevention practices. Educational messages should be targeted toward patients least likely to be aware of their risk.

Adult↗

PubMed1996

U.S. hospital care for HIV-infected persons and the role of public, private, and Veterans Administration hospitals.

Hospitals are a major provider of medical care for human immunodeficiency virus (HIV)-infected persons. Although utilization and patterns of care profiles in public and private hospitals have been evaluated for acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), one of the most costly and common severe complications of AIDS, information from Veterans Administration (VA) hospitals has not been reported previously. This article reports on inpatient care for PCP patients by obtaining data from VA, private, and public hospitals. Cost and resource utilization data were obtained from reviews of medical records, claims, and provider bills from 26 non-VA hospitals and 18 VA hospitals in 10 cities in the United States. Data on severity of illness, patterns of care, and outcomes for PCP were obtained from medical record reviews from 2,174 PCP cases treated in 82 non-VA and 14 VA hospitals in five U.S. cities. Estimates were made of the average costs and the rates of use of diagnostic tests, anti-PCP medications, and intensive care units for samples of public hospital, private hospital, and VA patients with PCP. With mean charges for a single PCP episode of $14,500 to $16,060, PCP remains one of thea most costly complications of AIDS. Although the severity of PCP illness at admission was greatest at public hospitals, the intensity of care was lowest: for frequency of cytologic diagnosis (48% at public, 62% at VA, and 66% at private hospitals), bronchoscopy (45% at public, 60% at VA, and 66% at private hospitals), and intensive care unit use (11% at public, 22% at VA, and 19% at private hospitals). In-hospital mortality rates for PCP also differed in the three types of hospitals (20% at public, 24% at VA, and 18% at private hospitals). Patterns of PCP care differ among VA, public, and private hospitals. Future studies on the HIV epidemic should include data collected from uniform data sources from VA hospitals, in addition to public and private hospitals, to provide insight on the processes of care and outcomes for HIV-infected persons.

AIDS-Related Opportunistic Infections↗

PubMed1996

Predictors of resource utilization for hospitalized patients with Pneumocystis carinii pneumonia (PCP): a summary of effects from the multi-city study of quality of PCP care.

To determine whether patient and hospital characteristics were significantly associated with variations in Pneumocystis carinii (PCP) care and outcomes, we analyzed the use of diagnostic tests, intensive care units (ICUs), anti-PCP medications for persons hospitalized with human immunodeficiency virus (HIV)-related PCP, and hospital discharge status. We conducted retrospective chart reviews of a cohort of 2,174 patients with PCP hospitalized in 1987-1990. Outcomes included process of care for PCP and in-hospital mortality rates. Persons with PCP who were more severely ill at admission were more likely to have early medical care, to receive care in an intensive care unit, and to die in hospital. After we adjusted for differences in this severity of illness, we noted that Medicaid patients, injection drug users (IDUs), and patients treated at VA or county hospitals were significantly less likely than others to have diagnostic bronchoscopies and that persons covered by Medicaid, with a previous diagnosis of acquired immunodeficiency syndrome (AIDS), who did not receive prior zidovudine (AZT) or who received care in a VA hospital had the highest chances of in-hospital death. Insurance and risk group characteristics, severity of illness, and hospital characteristics appear to be the most important determinants of the intensity and timing of medical care and outcomes among patients hospitalized with PCP.

AIDS-Related Opportunistic Infections↗

PubMed1996

Factors predicting change in prescription and nonprescription drug use in a community-residing black and white elderly population.

The current study identifies characteristics that predict change in use of prescription and nonprescription drugs over a period of 3 years. A modified health care services use model was applied to information obtained from a probability-based sample of black (n = 1778) and white (n = 1446) community-resident elderly, interviewed in 1986-1987 and 1989-1990. Analysis was by means of logistic and ordinary least-squares regression, with sample weights and design effects taken into account. The number of users and average number of prescription drugs used increased over the 3 years, and was best predicted by extent of prior drug use, older age, white race, poorer health, and number of health care visits. Conversely, nonprescription drug use declined significantly, and was best predicted by prior use, white race, and female gender. The reduced use of prescription drugs by blacks as compared to whites is of concern, suggesting that attention is needed to assure equitable access to prescription drugs.

Black or African American↗

PubMed1996

Is medication use by community-dwelling elderly people influenced by cognitive function?

To determine whether medication use differs by cognitive status among community dwelling elderly, a survey was made of a stratified random sample of 4110 black and white participants, aged 65 or older from the Duke Established Populations for Epidemiologic Studies of the Elderly in five adjacent urban and rural counties in the Piedmont area of North Carolina. Main outcome measures were usage of prescription medications, non-prescription medications, and medicines within therapeutic classes in the previous 2 weeks as determined during an in-home interview; and total number of prescription and non-prescription medicines used in the previous 2 weeks. Multivariate analyses, using weighted data adjusted for sampling design, were conducted to assess the association between drug use patterns and cognitive status, as assessed by the Short Portable Mental Status Questionnaire, while adjusting for demographic, health status, and access to health care factors. Participants with cognitive impairment (13.7% of sample) were less likely to use any prescription medications (Adjusted OR = 0.66, 95% CI = 0.48-0.90) or any non-prescription medications (Adjusted OR = 0. 71, 95% CI = 0.56-0.89) than cognitively intact subjects. Both groups took a similar number of prescription and non-prescription medications. Those who were cognitively impaired were less likely to take analgesics (Adjusted OR = 0.66, 95% CI = 0.52-0.83), but were more likely to take central nervous drugs (Adjusted OR = 1.55, 95% CI 1.18-2.04) than those who were cognitively intact. We conclude that drug use patterns by community-dwelling elderly people differ with cognitive status. Future research needs to examine medication use by specific causes of cognitive impairment.

Activities of Daily Living↗

PubMed1995

Community perceptions of adolescent health and sexuality. Results from a southern community-based project.

OBJECTIVE: To describe the attitudes about adolescent health issues, especially school-based health services, held by adults in a rural community. DESIGN: "Before-after," quasi-experimental design involving independent, cross-sectional population-based surveys in 1989 and 1992. SETTING: Rural county located in the southeastern United States. PARTICIPANTS: Probability sample of adults, 18 years and older, who were residents of the county, including 831 respondents in the first survey and 210 respondents in the second survey. INTERVENTION: County-wide public education campaign involving public service announcements on television and radio, newspaper advertisements, posters, and open-to-the-public adolescent health programs and events. MAIN OUTCOME MEASURES: Attitudes about the types of health services that should be included in a public school-based adolescent health program. RESULTS: Rural adults' attitudes toward public school-based adolescent health services were similar before and after the community-wide campaign. Respondents believed the public schools should provide teenagers with information and counseling on substance abuse, sexual activity, birth control, and the acquired immunodeficiency syndrome but should not provide primary health care or birth control products. Most adults believed that sex and acquired immunodeficiency syndrome education should begin before high school. CONCLUSIONS: A comprehensive, public school-based adolescent health program providing health information but not health services may be acceptable to this community. Adults' attitudes about adolescent health issues do not appear to have been modified by the adolescent health awareness campaign.

Adolescent↗