Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes.

Objective: Percutaneous endoscopic gastrostomy (PEG) tube placement is the preferred method for long-term enteral feeding of patients who are unable to take food by mouth. Despite the widespread acceptance of the procedure, no large-scale study of the long-term outcomes of patients receiving PEG tubes has been reported. The objective of this study was to determine the survival of patients in whom PEG tubes are placed.

Long-term follow-up of symptomatic HIV-infected patients originally randomized to early versus later zidovudine treatment; report of a Veterans Affairs Cooperative Study. VA Cooperative Study Group on AIDS Treatment.

Following a 4-year controlled trial comparing early and later zidovudine treatment, we conducted an additional 3-year follow-up. Of the original 338 patients, 275 participated. Clinical outcome measures were AIDS and death.

Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial. Results of a pilot study.

The reasons why many patients seemingly benefit from arthroscopic treatment of osteoarthritis of the knee remain obscure. The purpose of this pilot study was to determine if a placebo effect might play a role in arthroscopic treatment of this condition. After giving full informed consent, including full knowledge of the possibility and nature of a placebo surgery, five subjects were randomized to a placebo arthroscopy group, three subjects were randomized to an arthroscopic lavage group, and two subjects were randomized to a standard arthroscopic debridement group.

Using administrative databases to evaluate the quality of medical care: a conceptual framework.

Health care is consuming an ever larger share of national resources in the United States. Measures to contain costs and evidence of unexplained variation in patient outcomes have led to concern about inadequacy in the quality of health care. As a measure of quality, the evaluation of hospitals through analysis of their discharge databases has been suggested because of the scope and economy offered by this methodology.

The association between the quality of inpatient care and early readmission.

Objective: To determine whether the quality of care during a hospital stay is associated with unplanned readmission within 14 days.

Design: Case-control study.

Setting: 12 Veterans Affairs hospitals.

Outpatient surgical utilization in Veterans Affairs hospitals, 1981-1989.

In the 1980s, there was a large increase in the percentage of surgical operations performed in the United States without an overnight hospital admission. This shift may have been related to changes in reimbursement for outpatient surgery; studies of this relationship have had conflicting results. The Department of Veterans Affairs (VA) has a budgeting strategy significantly different from reimbursement strategies used by nonfederal hospitals.

Selecting disease-outcome pairs for monitoring the quality of hospital care.

Health care payors and providers are increasingly monitoring hospital discharge data bases for adverse events as markers for quality of care. The principal criticisms of these analyses have focused on the impediments to risk adjustment posed by the incompleteness and inaccuracy of the data bases. However, efforts to address the inadequacies of the data bases will not correct deficiencies of the analytic process.

A method of developing and weighting explicit process of care criteria for quality assessment.

The use of explicit criteria to evaluate how well processes of care conform to accepted standards is a key method of quality assessment. Synthesizing four decades of literature, we devised an inexpensive, 6-step method of developing reliable, content-valid, explicit process criteria. This paper describes the method using a set of congestive heart failure criteria.

Changes in VA hospital use 1980-1990.

During the 1980s several changes occurred within and outside the Veterans Affairs medical system which may have affected levels of Veterans Affairs (VA) hospital use. We performed a secondary analysis of the 1980-1990 national VA hospital discharge database and Veteran Population Files to examine trends in VA hospital use and to assess effects of the aging of the veteran population. Between 1980 and 1990 discharges increased by 7% despite a 6% drop in the number of veterans.

The association between residents' work-rounds styles and the process and outcome of medical care.

Objective: To determine whether the manner in which residents conduct work rounds is associated with the adequacy of their care processes and the outcomes of their patients.

Methods: Two types of data were collected: time and motion data for residents (n = 12) during work rounds, and clinical and outcome data for the patients they cared for during the observation period (n = 211). Five residents were classified as data gatherers because they spent twice as much time gathering clinical data about their patients as they spent engaging in other activities.

Prediction of rates of inbreeding in populations undergoing index selection.

For populations undergoing mass selection, previous studies have shown that the rate of inbreeding is directly related to the mean and variance of long-term contributions from ancestors to descendants, and thus prediction of the rate of inbreeding can be achieved via the prediction of long-term contributions. In this paper, it is shown that the same relationship between the rate of inbreeding and long-term contributions is found when selection is based on an index of individual and sib records (index selection) and where sib records may be influenced by a common environment. In these situations, rates of inbreeding may be considerably higher than under mass selection.

Calculation of prediction error variances using sparse matrix methods.

The use of exact and approximate algorithms to calculate prediction error variances using sparse matrix methods are demonstrated for an individual animal effect including maternal effects. One exact algorithm is substantially faster than two others. An approximation of the best exact method gave an acceptable level of reliabilities and reduced the computation by a factor of approximately fifty compared with the exact computation and is routine in national beef evaluation in Britain.

Predicting the outcomes of human immunodeficiency virus infection. How well are we doing.

An important determinant of patient outcomes is illness severity, which must be classified to guide clinical decision making and evaluate the effectiveness of diagnostic and therapeutic interventions. Currently, no widely accepted framework for grading illness severity in human immunodeficiency virus-infected patients exists. The best known classification systems for human immunodeficiency virus infection (Centers for Disease Control and Prevention; Walter Reed) are not based on illness severity, and provide stages that are not all inclusive so that a large number of persons cannot be classified (Walter Reed).

Variation in hemodialysis patient compliance according to demographic characteristics.

Patient noncompliance with treatment regime undermines the effectiveness of medical care, resulting in an unpredictable progression of the primary disease and a greater likelihood of complications. Hemodialysis patients are well suited for studying noncompliance because their treatment is prolonged and intensive, and medical regimens are clear cut and easily determined with objective measures. Moreover, noncompliant behavior by these patients not only endangers their life in the long run, but also results in negative effects within a day or two.

Effect of HIV transmission category and CD4 count on the occurrence of diarrhea in HIV-infected patients.

This study was designed to assess the relative contributions of HIV transmission category and immunodeficiency to the risk of HIV-related diarrhea. We reviewed the medical records of 169 HIV-infected non-AIDS patients seen between 1986 and 1990 at the Houston VA Special Medicine Clinic. The prevalence of diarrhea at any given clinic visit ranged from 3% to 7%.

Forecasting areawide hospital utilization: a comparison of five univariate time series techniques.

Time series analysis is one of the methods health services researchers, managers and planners have to examine and predict utilization over time. The focus of this study is univariate time series techniques, which model the change in a dependent variable over time, using time as the only independent variable. These techniques can be used with administrative healthcare databases, which typically contain reliable, time-specific utilization variables, but may lack adequate numbers of variables needed for behavioral or economic modeling.

The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery.

Objectives: To determine the incidence of and risk factors for perioperative myocardial infarction with noncardiac surgery and to test the accuracy of a risk stratification system.

Design: Prospective cohort study.

Setting: A large urban Veterans Affairs hospital.

A simple clinical staging system that predicts progression to AIDS using CD4 count, oral thrush, and night sweats.

Objective: To develop a simple clinical staging system based on CD4 count and clinical variables that predicts progression to AIDS in HIV-infected non-AIDS patients.

Design: Retrospective cohort study.

Setting: A primary care outpatient clinic for HIV-infected patients at a VA Medical Center.

The impact of economic considerations on clinical decisionmaking: the case of thrombolytic therapy.

This study examines the intravenous use of two thrombolytic agents [streptokinase (SK) and tissue plasminogen activator (tPA)] in the acute phase of myocardial infarction (MI). These two agents have very different costs and offer an excellent opportunity to study both the impact of economic factors on clinical decisionmaking and the potential for cost savings by limiting the use of expensive new therapeutic agents. A nationwide survey of the 5,792 acute care general hospitals listed in the American Hospital Association's 1988 data file was responded to by 2,651 hospitals (46%) and revealed that 2,384 of these responding hospitals (90%) were using thrombolytic therapy.

The frequency and significance of ECG changes after transurethral prostate resection.

Although many clinicians routinely recommend a base-line preoperative electrocardiogram (ECG) and obtain frequent postoperative ECGs to screen for myocardial infarction or ischemia, the diagnostic utility of screening perioperative ECGs is unknown. The present analysis evaluates the sensitivity and specificity of the perioperative ECG and examines its value as a predictor of early postoperative cardiac events and outcomes during the postoperative year. ECGs obtained preoperatively and on the first 3 postoperative days in 206 men undergoing transurethral prostate resection were analyzed using the Minnesota Code.

Confocal microscopic detection of human immunodeficiency virus RNA-producing cells.

A central anomaly in the pathogenesis of AIDS is that few actively infected CD4+ cells (1 in 10(4)-10(5) have been detected in the peripheral blood, even though dramatic depletion (often greater than 90%) of CD4+ cells is the hallmark of disease progression. A sensitive, 35S-based human immunodeficiency virus (HIV) RNA in situ hybridization technique was coupled with a new detection method, confocal laser scanning microscopy, to examine transcriptionally active HIV-infected cells from individuals at different disease stages. In 35 symptomatic HIV-infected individuals (AIDS and AIDS related complex), an average of 1 in 350 mononuclear cells produced HIV RNA.

Methods for predicting rates of inbreeding in selected populations.

In selected populations, families superior for the selected trait are likely to contribute more offspring to the next generation than inferior families and, as a consequence, the rate of inbreeding is likely to be higher in selected populations than in randomly mated populations of the same structure. Methods to predict rates of inbreeding in selected populations are discussed. The method of Burrows based on probabilities of coselection is reappraised in conjunction with the transition matrix method of Woolliams.

Acute and chronic effects of propranolol on extinction of rewarded running in the rat.

Three experiments examined the effect of propranolol injected IP on a series of 16 extinction trials at 24-hour intertrial intervals after continuously rewarded running. In Experiment I, propranolol (1, 5 or 10 mg/kg) was injected, in different groups, shortly before or shortly after each extinction trial, but without effect. In Experiment II, the same doses were injected daily for 18 days preceding extinction, to allow longer for any long-term drug effect to accumulate.