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Performance of a general location model with an ignorable missing-data assumption in a multivariate mental health services study

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STATISTICS IN MEDICINE 1999年第22期18卷 3123-3135页

作者： Belin, TR Hu, MY Young, AS Grusky, O Univ Calif Los Angeles Ctr Hlth Sci Deot Psychiat & Biobehavioral Sci Los Angeles CA 90095 USA Univ Calif Los Angeles Ctr Hlth Sci Dept Biostat Los Angeles CA 90095 USA Univ Calif Los Angeles Ctr Hlth Sci Dept Stat Los Angeles CA 90095 USA Univ Calif Los Angeles Ctr Hlth Sci Dept Sociol Los Angeles CA 90095 USA

In a study of the impact of case management teams in a publicly funded mental health programme, mental health patients were interviewed about a variety of outcomes suggestive of successful community adaptation, such as support from family and friends and avoidance of legal problems. Because outcome data were missing for a number of patients, a follow-up study was carried out to obtain this information form previous non-responders whenever possible. Because the data of interest were multivariate and included both continuous and categorical variables, a candidate approach for handling incomplete data in the absence of follow-up data would have been to fit a general location model, presumably with log-linear constraints on cell probabilities to avoid overfitting of the data. Here, we use available follow-up data to investigate the performance of a series of general location models with ignorable non-response. We note some problems with this approach and embed the discussion of this example in a broader consideration of the role of ignorable and non-ignorable models in applied research. Copyright (C) 1999 John Wiley & Sons, Ltd.

关键词：随访研究卫生服务易得程度/统计学和数值数据健康调查采访(主题) Markov链精神卫生服务/统计学和数值数据模型统计学蒙特卡罗法多元分析女(雌)性人类男(雄)性

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Is specialty care associated with improved survival of patients with congestive heart failure?

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AMERICAN HEART JOURNAL 2003年第2期145卷 300-309页

作者： Indridason, OS Coffman, CJ Oddone, EZ Durham Vet Affairs Med Ctr Ctr Hlth Serv Res Primary Care Durham NC 27705 USA Duke Univ Med Ctr Div Gen Internal Med Durham NC USA Duke Univ Med Ctr Div Nephrol Dept Med Durham NC 27706 USA

Background Implementation of the complex treatment strategies that have been shown to improve survival of patients with congestive heart failure (CHF) may require certain expertise. We wanted to examine the association between pattern of outpatient care and survival of patients with CHF. Methods In a retrospective cohort study conducted with national Veterans Health Administration (VHA) databases, we examined the association between the pattern of outpatient care and survival in 11,661 patients discharged from VA hospitals between October 1, 1991, and September 30, 1992, with the primary diagnosis of CHF (cohort 1). Patients were divided into 4 groups, on the basis of their pattern of outpatient care over a 12-month period after discharge: 1) general medicine clinic visits only (GM-only);2) cardiology clinic visits only (CARD-only);3) general medicine and cardiology (MIXED) clinic visits;and 4) neither general medicine nor cardiology clinic visits (no-GM/CARD). We used the Cox proportional hazards model to evaluate 1-year survival, controlling for clinical and demographic factors. Consistency of our results was examined by performing identical analysis on a cohort of patients discharged from VHA hospitals between October 1, 1994, and September 30, 1995 (cohort 2, n 10, 141). Results The overall 1-year mortality rate was 23% in the primary cohort. The unadjusted mortality rate was highest for patients in the no-GM/CARD follow up (29%) and lowest for patients in the MIXED group (19%). By use of the MIXED group as reference and adjusting for important clinical and demographic factors, the risk of death (risk ratio [95% CI]) was 1.12 (0.94-1.34) in the CARD-only group, 1.26 (1.15-1.38) in the GM-only group, and 1.48 (1.28-172) in the no-GM/CARD group. Cohort-2 results were consistent with cohort 1 for most covariates, and significant survival differences were again found between GM-only and the MIXED group (1.25 [1.14-1.37]). Conclusions We found an improved survival as

关键词：心脏病学/标准心脏病学/统计学和数值数据临床工作能力队列研究数据库事实型家庭医学/标准家庭医学/统计学和数值数据卫生服务易得程度/统计学和数值数据医院退伍军人/标准结果评价(卫生保健) 门诊部医院/标准病人出院预后比例危险度模型存活率美国/流行病学老年人人类男(雄)性

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Severity of coronary artery disease in black and white male veterans and likelihood of revascularization

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AMERICAN HEART JOURNAL 2000年第5期139卷 840-847页

作者： Peniston, RL Lu, DY Papademetriou, V Fletcher, RD Dept Vet Adm Med Ctr Div Cardiothorac Surg Washington DC USA Dept Vet Adm Med Ctr Div Cardiol Washington DC USA Howard Univ Coll Med Washington DC USA Georgetown Univ Sch Med Washington DC USA George Washington Univ Sch Med & Hlth Sci Washington DC 20052 USA

Background Many reports in the literature have found the use of invasive cardiac procedures in black patients to be less common than in white patients. These reports tend to have small numbers of black patients compared with white patients or rely on the information contained in claims or administrative data. Methods and Results Cardiac catheterization reports were reviewed in a Veterans Administration hospital that serves a large number of black patients. After review of the medical histories and hemodynamic and angiographic findings in 726 black and 734 white male veterans, data were collected to determine recommended and actual therapy. Death was assessed after a 4- to 10-year follow-vp period. White patients were more likely to have significant coronary artery lesions than black patients. Multivariate analysis showed that the likelihood of patients actually having percutaneous transluminal coronary angioplasty or coronary artery bypass surgery did not differ by ethnicity when controlling for disease extent or severity. Coronary artery bypass surgery was associated with decreased mortality rates for both black and white patients. Although short-term death in blacks was not different from whites, blacks had an increased long-term risk for death. Conclusions After coronary angiography, black veterans and white veterans appear to undergo revascularization procedures related to the severity of disease. The decreased long-term life expectancy of black men as compared with whites is not necessarily explained by the presence of or treatment for coronary artery disease in this population.

关键词：非洲大陆世系人群冠心病/人种学冠心病/死亡率冠心病/治疗文化交叉比较欧洲大陆世系人群随访研究卫生服务易得程度/统计学和数值数据心肌血管重建术/统计学和数值数据回顾性研究危险因素存活率分析退伍军人/统计学和数值数据老年人人类男(雄)性中年人

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Race and sex differences in the management of coronary artery disease

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AMERICAN HEART JOURNAL 2000年第5期139卷 848-857页

作者： Sheifer, SE Escarce, JJ Schulman, KA Duke Clin Res Inst Ctr Clin & Genet Econ Durham NC 27715 USA Georgetown Univ Med Ctr Dept Med Div Cardiol Washington DC 20007 USA RAND Corp Hlth Sci Program Santa Monica CA USA

Although numerous studies have documented race and sex differences in the treatment of coronary artery disease, the available analyses have not been comprehensively evaluated. In this review, we summarize prior estimates of race and sex disparities in the utilization of standard tests and therapies, and we evaluate studies of factors that may contribute to gaps in care. The studies presented consistently demonstrate that blacks and women with coronary artery disease, compared with whites and men, are substantially less likely to receive standard interventions. Studies also indicate that racial differences relate in part to socioeconomic Factors, process-of-care variables, and patient preferences, whereas sex differences relate in part to clinical factors. In both cases, however, our understanding is limited by deficiencies in currently available datasets. Moreover, factors that have been shown to contribute to race and sex disparities in medical care fail to explain them fully. In both cases, physician decisionmaking appears to contribute as well, suggesting that subconscious biases may contribute to treatment disparities. We conclude by proposing initiatives to remedy race and sex disparities in medical care. Efforts should focus on increasing physician aware ness of this problem. Studies should gather data that are currently unavailable for analysis, including detailed clinical variables and patient-level socioeconomic information. Finally, novel quality assurance programs, designed to evaluate and improve the care of blacks and women with coronary artery disease, should be promptly undertaken.

关键词：非洲大陆世系人群冠心病/人种学冠心病/死亡率冠心病/治疗欧洲大陆世系人群卫生服务易得程度/统计学和数值数据心肌血管重建术/统计学和数值数据偏见存活率分析美国利用情况审核女(雌)性人类男(雄)性

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Prevalence of self-reported heart failure among US adults: Results from the 1999 National Health Interview Survey

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AMERICAN HEART JOURNAL 2003年第1期146卷 121-128页

作者： Ni, H CDCP Div Hlth Interview Stat Natl Ctr Hlth Stat Hyattsville MD 20782 USA

Objective The objective of the present study was to determine the prevalence of self-reported heart failure among US adults. Methods Data from the 1999 National Health Interview Survey were analyzed. A total of 30,801 sampled adults aged 18 years were given a list of major medical conditions, which included heart failure (HF), and asked if they had ever been told by a doctor or other health professional that they had any of the conditions. Analyses were conducted with the use of SUDAAN software to account for the complex sample design. Results An estimated 2.4 million adults had been told by a doctor or other health professional that they had HF. The prevalence of self-reported HF for age groups 18 to 39, 40 to 64, 65 to 74, and 75 to 105 years were 0.1%, 1.1%, 3.6%, and 5.5%, respectively. HF was most prevalent among ever-smokers, obese persons, and persons aged 65 years. No difference was found in the prevalence of self-reported HF between black and white persons. The most common comorbid conditions for those with HF were hypertension, coronary heart disease, and diabetes. Compared with those without HF, the elderly persons with HF were 8 times as likely to have severe mobility difficulties and 2 to 3 times as likely to have severe depression. Half of the elderly persons with HF had been hospitalized, visited an emergency room, or had > 10 clinic visits in the past year. Black patients were more likely than white patients to have been unable to pay for prescription medicine and to have seen a medical specialist during the past year. Conclusions This nationally representative survey indicates that an estimated 2.4 million adults had been told by a doctor or other health professional that they had heart failure. Black patients with HF were less likely than white patients to have received the needed care.

关键词：非洲裔美国人/统计学和数值数据年龄分布心排血量低/流行病学心排血量低/人种学欧洲大陆世系人群/统计学和数值数据卫生服务易得程度/统计学和数值数据卫生服务需求/统计学和数值数据健康调查患病率性别分布统计数据美国/流行病学成年人老年人老年人 80以上人类中年人

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Is there differential access to carotid endarterectomy based on gender?

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ANNALS OF VASCULAR SURGERY 2000年第4期14卷 340-342页

作者： DiBardino, D Vicente, DC Kazmers, A Harper Grace Hosp Div Vasc Surg Detroit MI 48201 USA Wayne State Univ Div Vasc Surg Detroit MI 48201 USA

The purpose of this study was to determine whether there was differential access to carotid endarterectomy (CEA) based on gender at our institution. In 1995, the year after ACAS results were published, 1774 carotid duplex studies were performed in our vascular laboratory in 765 men and 1009 women. The incidence of 50-99% carotid stenosis was 13% (n = 235) overall and did not differ between men (13.3%;102/765) and women (13.2%;133/1009). The frequency that patients subsequently underwent CEA was determined to assess whether men with significant carotid stenosis were more likely to undergo CEA than women. Attempts were made to contact patients with 50-99% stenosis directly. Data were available for 101 patients (41 men, 60 women) with 50-99% carotid stenosis diagnosed by carotid duplex. There was conflicting information regarding the possibility of gender bias in the selection of candidates for CEA: logistic regression analysis suggested that disease severity dictated surgical intervention, however, a significantly lower percentage of women with ICA/CCA peak systolic ratios greater than or equal to 2.9 underwent CEA. This study cannot refute the possibility that gender bias existed in the selection of patients for CEA. DOI: 10.1007/s100169910078.

关键词：颈动脉狭窄/流行病学颈动脉狭窄/外科学颈动脉内膜切除术/统计学和数值数据卫生服务易得程度/统计学和数值数据密执安病人遴选偏见性别比率女(雌)性人类男(雄)性

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Variations in the use of cardiac procedures in the Veterans Health Administration

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AMERICAN HEART JOURNAL 1999年第4期137卷 706-713页

作者： Mirvis, DM Graney, MJ Univ Tennessee Dept Prevent Med Memphis TN 38105 USA Univ Tennessee Dept Med Memphis TN 38105 USA Dept Vet Affairs Med Ctr Memphis TN USA

Background Considerable variability exists in the use of cardiac procedures for patients with heart disease. One cause for this variability is the availability of local facilities to perform these procedures. This study was initiated to identify health system features that are related to rates of catheterization, percutaneous coronary angioplasty, and coronary artery bypass graft surgery in the Veterans Affairs health care system in which structured referral systems are intended to compensate for variation in local resource availability Methods Medical records of 30,901 patients admitted to a Veterans Affairs medical center with coronary artery disease were analyzed. Odds ratios (OR) and 95% confidence intervals (CI) for undergoing each procedure, based on clinical variables (age, sex, race, coronary artery disease type, and a computed comorbidity score), and local Veterans Affairs facility features (geographic region, primary service area size, and hospital complexity) were estimated by logistic regression. Results Regression models demonstrated significant associations between the odds of undergoing each procedure and medical center geographic and complexity features, after adjustment for clinical variables. Associations included the presence of a cardiac catheterization laboratory For undergoing catheterization (OR 1.86, CI 1.76 to 1.95) and the presence of a cardiac surgical program for angioplasty (OR 1.46, CI 1.36 to 1.57) and bypass grafting (OR 1.43, CI 1.34 to 1.53). Including health system variables in addition to clinical variables in the regression models improved the discriminating ability of the models by 44.2% to 51.4%. Conclusions Geographic location and the complexity of the local Veterans Affairs hospital are important determinants of the use of cardiac procedures in the Veterans Affairs health care system, even though referral networks are intended to correct for local differences in hospital complexity.

关键词：血管成形术经腔经皮冠状动脉/利用置信区间冠状动脉分流术/利用卫生服务易得程度/统计学和数值数据心脏导管插入术/利用医院退伍军人/统计学和数值数据医院退伍军人/利用 Logistic模型病案心肌缺血/外科学比值比医师诊疗模式/统计学和数值数据美国美国退伍军人事务部利用情况审核/统计学和数值数据老年人女(雌)性人类男(雄)性中年人

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Understanding racial differences in cardiovascular care and outcomes: Issues for the new millennium

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AMERICAN HEART JOURNAL 2000年第5期139卷 764-766页

作者： East, MA Peterson, ED Duke Clin Res Inst Durham NC USA

In 1984, Oberman and Cutter1 reported that black cardiac patients treated at the University of Alabama were less likely to undergo cardiac catheterization or bypass surgery than their white counterparts. That same year, Haywood2 found that blacks enrolled in a large -blocker trial had higher long-term mortality rates than whites. Over the ensuing 15 years, dozens of papers have confirmed that racial differences in cardiac care are nearly ubiquitous in the US healthcare system.1,3-23 Similarly, most,4,24 but not all,25 subsequent studies have found that blacks with coronary disease generally have lower long-term survival rates than whites.

关键词：非洲大陆世系人群冠心病/人种学冠心病/死亡率文化交叉比较欧洲大陆世系人群预测卫生服务易得程度/统计学和数值数据心肌血管重建术/统计学和数值数据危险因素存活率分析美国退伍军人/统计学和数值数据老年人人类男(雄)性中年人

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The struck-off mystery

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JOURNAL OF THE ROYAL SOCIETY OF MEDICINE 1999年第11期92卷 608-608页

作者： McKinley, RK Dixon-Woods, M Univ Leicester Leicester Gen Hosp Dept Gen Practice & Primary Hlth Care Leicester LE5 4PW Leics England Univ Leicester Dept Epidemiol & Publ Hlth Leicester LE1 6TP Leics England

Observations on ward rounds suggested that psychiatric patients might be at special risk of removal from their general practitioner's list. Little has been published on why patients are struck off and our first attempt at investigation was by direct appeals for patients. This drew a small and unsatisfactory sample. We then asked two family health services authorities to distribute questionnaires to struck-off patients. One agreed, but later withdrew cooperation. There is a danger that struck-off patients will become an underclass excluded from primary care. We propose anonymous collection of information by health authorities, so that policy can be reviewed if necessary.

关键词：社区精神病学/组织和管理数据收集/方法英格兰家庭医学/组织和管理卫生服务易得程度/统计学和数值数据医生病人关系诊疗准则(主题) 医生拒绝医治/统计学和数值数据人类

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Access to care for rural Medicare beneficiaries

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JOURNAL OF RURAL HEALTH 2000年第1期16卷 31-42页

作者： Stearns, SC Slifkin, RT Edin, HM Univ N Carolina Dept Hlth Policy & Adm Chapel Hill NC 27599 USA Univ N Carolina Program Hlth Care Econ & Finance Cecil G Sheps Ctr Hlth Serv Res Chapel Hill NC 27599 USA

This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self-reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems;instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self-reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self-reported access, satisfaction and utilization than does rural residence per se.

关键词：残疾人/统计学和数值数据卫生服务易得程度/统计学和数值数据纵向研究 Medicare/统计学和数值数据 Medicare/利用病人满意度/统计学和数值数据回归分析农村人口/统计学和数值数据美国/流行病学市区人口/统计学和数值数据老年人老年人 80以上女(雌)性人类男(雄)性中年人

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