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

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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Is there a Persian Gulf War syndrome? Evidence from a large population-based survey of veterans and nondeployed controls

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AMERICAN JOURNAL OF MEDICINE 2000年第9期108卷 695-704页

作者： Doebbeling, BN Clarke, WR Watson, D Torner, JC Woolson, RF Voelker, MD Barrett, DH Schwartz, DA Univ Iowa Coll Med Dept Internal Med Iowa City IA 52242 USA Iowa City Vet Affairs Med Ctr Iowa City IA USA Iowa City Vet Affairs Med Ctr Iowa City IA USA Univ Iowa Coll Publ Hlth Dept Biostat Iowa City IA USA Univ Iowa Dept Psychol Iowa City IA 52242 USA Ctr Dis Control & Prevent Div Environm Hazards & Hlth Effects Natl Ctr Environm Hlth Atlanta GA USA Univ Iowa Coll Publ Hlth Dept Environm & Occupat Hlth Iowa City IA USA

PURPOSE: Concerns have been raised about whether veterans of the Gulf War have a medical illness of uncertain etiology. We surveyed veterans to look for evidence of an illness that was unique to those deployed to the Persian Gulf and was not seen in comparable military controls. SUBJECTS AND METHODS: A population-based sample of veterans (n = 1,896 from 889 units) deployed to the Persian Gulf and other Gulf War-era controls (n = 1799 from 893 units) who did not serve in the Gulf were surveyed in 1995-1996. Seventy-six percent of eligible subjects, including 91% of located subjects, answered questions about commonly reported and potentially important symptoms. We used factor analysis, a statistical technique that can identify patterns of related responses, on a random subset of the deployed veterans to identify latent patterns of symptoms. The results from this derivation sample were compared with those obtained from a separate validation sample of deployed veterans, as well as the nondeployed controls, to determine whether the results were replicable and unique. RESULTS: One half (50%) of the deployed veterans and 14% of the nondeployed controls reported health problems that they attributed to military service during 1990-1991. Compared with the nondeployed controls, the deployed veterans had significantly greater prevalences of 123 of 137 (90%) symptoms;none was significantly lower. Factor analysis identified three replicable symptom factors (or patterns) in the deployed veterans (convergent correlations greater than or equal to 0.85). However, these patterns were also highly replicable in the nondeployed controls (convergent correlations of 0.95 to 0.98). The three factors also accounted for similar proportions of the common variance among the deployed veterans (35%) and nondeployed controls (30%). CONCLUSIONS: The increased prevalence of nearly every symptom assessed from all bodily organ systems among the Gulf War veterans is difficult to explain pathophysiologi

关键词：病例对照研究因素分析统计学健康状况中东军事人员/统计学和数值数据波斯湾综合征人群监测患病率可重复性结果美国/流行病学退伍军人/统计学和数值数据战争成年人女(雌)性人类男(雄)性

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Epidemiology of hepatitis C virus infection in American Veterans

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AMERICAN JOURNAL OF GASTROENTEROLOGY 2000年第3期95卷 740-747页

作者： Cheung, RC VA Palo Alto Hlth Care Syst Div Gastroenterol Palo Alto CA 94304 USA Stanford Univ Sch Med Stanford CA 94305 USA

OBJECTIVE: This study reports the findings of hepatitis C virus (HCV) infection in a large Department of Veterans Affairs Health Care System in suburban Northern California. METHODS: All veterans who had anti-HCV (EIA II) tested during a 6-yr period (7/92 to 6/98) were included in this study. To estimate the seroprevalence of anti-HCV among our population, 126 consecutive bloodborne pathogen exposure accidents were studied. RESULTS: Of 8558 veterans tested for anti-HCV (EIA II), 2985 (35%) veterans were positive with a mean age of 48.4 yr (range, 28-89 yr). Sixty percent were between the age of 41 and 50 yr. Risk factors for HCV infection identified in 409 consecutive veterans were intravenous drug abuse (81%), unknown (11%), blood transfusion (3%), sexual/ household contact (2%), transfusion and intravenous drug use (2%), and tattoo (1%). Of 215 consecutive anti-HCV-positive veterans whose sera were tested by polymerase chain reaction, 96% were viremic. The most common HCV genotypes were 1a (50.5%), 1b (22.8%), 3a (12.1%), 2b (9.7%), 2a (1.9%), undetermined (1.9%), and mixed infection (1%). Veterans infected with genotype Ib were significantly alder. Among 126 consecutive bloodborne pathogen exposure accidents, hepatitis C serology was available for 72 index veterans involved in the accidents and 18% were positive. CONCLUSIONS: We found the epidemiology of hepatitis C infection was different in the veteran population when compared to other published data on nonveterans. Hepatitis C infection was much more common among veteran, within a very narrow age distribution and intravenous drug use was the major risk factor. (Am J Gastroenterol 2000;95: 740-747. (C) 2000 by Am. Cell. of Gastroenterology).

关键词：血传病原体横断面研究基因型肝炎病毒属/遗传学肝炎丙型/传播肝炎丙型慢性/流行病学肝炎丙型慢性/病毒学发病率危险因素美国/流行病学退伍军人/统计学和数值数据病毒血症/流行病学病毒血症/病毒学成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Hepatitis c in African Americans: Summary of a workshop

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GASTROENTEROLOGY 2000年第5期119卷 1385-+页

作者： Howell, C Jeffers, L Hoofnagle, JH Univ Maryland Sch Med Div Gastroenterol & Hepatol Baltimore MD 21201 USA Univ Miami Sch Med Ctr Liver Dis Miami FL USA Vet Adm Med Ctr Miami FL 33125 USA NIDDKD Div Digest Dis & Nutr NIH Bethesda MD 20892 USA

GASTROENTEROLOGY 2000;119:1385-1396

关键词：非洲裔美国人/统计学和数值数据抗病毒药/治疗应用癌肝细胞/流行病学癌肝细胞/病毒学丙型肝炎慢性/流行病学丙型肝炎慢性/病因学丙型肝炎慢性/病理生理学丙型肝炎慢性/治疗发病率干扰素类/治疗应用肝肿瘤/流行病学肝肿瘤/病毒学肝移植患病率利巴韦林/治疗应用物质滥用静脉内/并发症美国退伍军人/统计学和数值数据人类

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Prevalence of dyspepsia, heartburn, and peptic ulcer disease in veterans

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AMERICAN JOURNAL OF GASTROENTEROLOGY 1999年第8期94卷 2086-2093页

作者： Dominitz, JA Provenzale, D VA Puget Sound Hlth Care Syst Seattle Div 111GI Dept Med Div Gastroenterol Seattle WA 98108 USA Univ Washington Sch Med Seattle WA USA Vet Affairs Med Ctr Hlth Serv Res & Dev Durham NC 27705 USA Duke Univ Med Ctr Dept Med Div Gastroenterol Durham NC 27710 USA

OBJECTIVE: Medications used to treat gastrointestinal symptoms account for a substantial share of pharmacy expenses for veterans affairs medical centers. Prior studies have shown that the prevalence of peptic ulcer disease is higher in veterans than in nonveterans. Our aim was to determine the prevalence of upper gastrointestinal symptoms among patients seeking health care in the Department of Veterans Affairs outpatient clinics. METHODS: A total of 1582 veterans completed a previously validated bowel symptom questionnaire in the following clinics: gastroenterology (n = 693), walk-in (n = 403), general medicine (n = 379), and women's health (n = 107). RESULTS: Overall response was 78%. Dyspepsia was reported in 30%, 37%, 44%, and 53% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Heartburn, at least weekly, was reported in 21%, 21%, 28%, and 40% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Prior peptic ulcer disease (PUD) was reported in 29%, 26%, 22%, and 44% of patients in general medicine, walk-in, women's health, and gastroenterology clinics, respectively. Dyspepsia, heartburn, and PUD were significantly associated with increased physician visits and lower general health. CONCLUSIONS: Dyspepsia and heartburn are common symptoms among veterans. Lifetime prevalence of PUD is high among veterans. Gastrointestinal symptoms have a significant impact on health care utilization and general health. These prevalence estimates provide a basis for studies of resource utilization and for cost-effectiveness analyses of the treatment of gastrointestinal disorders in the veteran population. Moreover, the high prevalence of symptoms helps to explain the high utilization of gastrointestinal medications. (Am J Gastroenterol 1999;94:2086-2093. (C) 1999 by Am. Coll. of Gastroenterology).

关键词：费用效益分析横断面研究消化不良/经济学消化不良/流行病学卫生资源/经济学卫生资源/利用胃灼热/经济学胃灼热/流行病学发病率北卡罗来纳消化性溃疡/经济学消化性溃疡/流行病学转诊和会诊/经济学转诊和会诊/利用退伍军人/统计学和数值数据成年人老年人女(雌)性人类男(雄)性中年人

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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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Racial variation in the use of laparoscopic cholecystectomy in the Department of Veterans Affairs Medical System

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JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 1999年第6期188卷 604-622页

作者： Arozullah, AM Ferreira, MR Bennett, RL Gilman, S Henderson, WG Daley, J Khuri, S Bennett, CL Vet Affairs Med Ctr Cooperat Studies Program Coordinating Ctr 151K Hines IL 60141 USA Brockton W Roxbury Vet Affairs Med Ctr W Roxbury MA USA Northwestern Univ Sch Med Dept Med Chicago IL 60611 USA Univ Chicago Robert Wood Johnson Clin Scholars Program Chicago IL 60637 USA VA Employee Educ Syst Long Beach CA USA Harvard Univ Sch Med Boston MA USA Beth Israel Deaconess Med Ctr Div Gen Med & Primary Care Boston MA USA Brigham & Womens Hosp Boston MA 02115 USA Northwestern Univ Sch Med VA Chicago Hlth Care Syst Lakeside Div Chicago IL USA

Background: While studies have found racial differences in the rates of use of established invasive cardiac and cerebrovascular procedures, no study has evaluated racial variation in the rates of adoption of new surgical procedures. For patients undergoing laparoscopic cholecystectomy, the procedure represents a new and safe option that shortens the duration of postoperative hospitalization by almost one week. In this study, we evaluated whether, in the equal access Veterans Affairs (VA) medical system, the rate of adoption of this procedure and improvements in the duration of postoperative hospitalization differed between African-American and Caucasian patients. Study Design: Data were obtained from two sources-administrative claims fries and prospectively compiled clinical data from medical records and patient interviews. In both data sets, frequency of use, length of stay, and outcomes for African-American and Caucasian patients undergoing minimally invasive and open gallbladder surgery were analyzed for the first four years of use of the procedure in the VA system (1992 to 1995). Results: Analyses based on claims files indicated that, after adjustment for potentially confounding variables, African-American patients who underwent cholecystectomy in VA medical centers were 25% less likely to undergo a minimally invasive cholecystectomy during the first 4 years of use of the new procedure (adjusted odds ratio, 0.74;95% confidence interval, 0.66-0.83). Shortening of the average postoperative length of stay from 9 days or more in the prelaparoscopic era to less than 4.5 days for patients undergoing the laparoscopic procedure occurred in the first year for Caucasian patients, but did not occur until the fourth year for African-American patients (p < 0.001). The overall difference in postoperative length of stay between African-American and Caucasian patients more than doubled from 1.7 days before introduction of laparoscopic cholecystectomy to 3.8 days in the fourth y

关键词：非洲裔美国人/统计学和数值数据胆囊切除术/死亡率胆囊切除术/利用胆囊切除术腹腔镜/死亡率胆囊切除术腹腔镜/利用共病现象欧洲大陆世系人群/统计学和数值数据医院死亡率医院退伍军人/统计学和数值数据住院时间比值比美国美国退伍军人事务部成年人老年人女(雌)性人类男(雄)性中年人

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Doing battle with HCV

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AMERICAN JOURNAL OF GASTROENTEROLOGY 2000年第3期95卷 582-583页

作者： Fimmel, CJ St Louis VA Med Ctr St Louis MO 63125 USA

Hepatitis C virus (HCV) infection has emerged as a major health care problem in the US veteran population. The growing awareness of its importance is reflected in the recent mandate by the Department of Veterans Affairs to perform HCV testing on all veterans at risk for the disease (1) and to manage patients according to the Center for Disease Control and Prevention guidelines (2). Interferon/ribavirin combination therapy is available to VA patients, and Congress has earmarked $230 million for HCV diagnosis and treatment for the year 2000 VA budget. Gastroenterologists practicing in the VA system have noticed a drastic increase in HCV-related morbidity over the past years. However, the full impact of the disease is unknown. This is due to the lack of epidemiological data that would allow one to estimate the number of affected patients and to calculate the HCV-related expenditures. The study by Ramsey Cheung in this issue of the American Journal of Gastroenterology (3) provides a first systematic and detailed report on HCV antibody seroprevalence, risk factors, genotypes, and age distribution of infected patients. The data were obtained in a retrospective analysis of the Palo Alto VA Healthcare system. Over a period of 6 yr, (1992-1998), approximately one-fifth of the approximately 40,000 veterans living in this predominantly suburban area were tested for HCV antibodies by a second generation ELISA assay. The test was positive in 2985 subjects, corresponding to a point prevalence of 35%. The overwhelming majority of these patients were found to be viremic, as confirmed by PCR analysis. As pointed out by the authors, the high rate of seropositivity is likely to be affected by selection and referral bias, as patients were tested based on the presence of HCV risk factors or abnormal liver tests. To obtain a more representative seroprevalence rate, the author measured HCV antibodies in 126 consecutive patients involved in blood-borne exposure accidents and obtained a pre

关键词：抗病毒药/经济学抗病毒药/治疗应用横断面研究药费支出药物疗法联合肝炎丙型慢性/药物疗法肝炎丙型慢性/经济学肝炎丙型慢性/流行病学干扰素类/经济学干扰素类/治疗应用利巴韦林/经济学利巴韦林/治疗应用美国退伍军人/统计学和数值数据人类

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Birth defects prevalence among infants of Persian Gulf War veterans born in Hawaii, 1989-1993

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TERATOLOGY 2000年第4期62卷 195-204页

作者： Araneta, MRG Destiche, DA Schlangen, KM Merz, RD Forrester, MB Gray, GC USN Hlth Res Ctr DoD Ctr Deployment Hlth Res San Diego CA 92186 USA Hawaii Birth Defects Program Honolulu HI 96817 USA Texas Birth Defects Monitoring Div Austin TX 78756 USA

Background: Gulf War veterans (GWVs) have expressed concern about possible teratogenic exposures. However, epidemiologic studies on birth defects prevalence among their progeny have been limited to military hospitals, anomalies diagnosed among newborns, or self-reported data. To measure the prevalence of selected birth defects among infants of GWVs and nondeployed veterans (NDVs) in Hawaii, using birth defects surveillance records. Methods: Personal identifiers of 684,645 GWVs and 1,587,102 NDVs and their families were matched against birth certificate records of 99,545 live births reported to the State of Hawaii Department of Health between 1989 and 1993 to identify births to military personnel. These births were matched with records from the Hawaii Birth Defects Program. Results: A total of 17,182 military infants (3,717 GWV infants and 13,465 NDV infants) were identified. Of these, 367 infants (2.14/100 live births) were identified with one or more of 48 major birth defects diagnoses. The prevalence of the 48 birth defects were similar for GWV and NDV infants during the prewar and postwar periods, and among GWV infants who were conceived before and after the Gulf war. Conclusions: The results must be interpreted with caution because of the small number of affected infants in each birth defects category. This study demonstrated the feasibility of measuring birth defects prevalence among military infants through multiple data linkage. Further, it included live births to parents who had separated from the military, births in civilian hospitals, and birth defects diagnosed through the first year of life. Published 2000 Wiley-Liss, ***

关键词：畸形/流行病学病例对照研究夏威夷/流行病学中东军事人员/统计学和数值数据人群监测妊娠结局患病率退伍军人/统计学和数值数据战争成年人女(雌)性人类婴儿新生男(雄)性妊娠

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Health status in VA patients: Results from the Veterans Health Study

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AMERICAN JOURNAL OF MEDICAL QUALITY 1999年第1期14卷 28-38页

作者： Kazis, LE Ren, XS Lee, A Skinner, K Rogers, W Clarke, J Miller, DR Edith Nourse Rogers Mem Vet Adm Hosp VA Hlth Serv Res & Dev Field Program 152 Ctr Hlth Qual Outcomes & Econ Res Hlth Outcomes Sect Bedford MA 01730 USA New England Med Ctr Hlth Inst Boston MA 02215 USA

Recently, the Veterans Administration (VA) Under Secretary for Health has designated functional status as one of the domains of value for the system, given its increasing importance for clinical care. The Veterans Health Study (VHS) was designed to assist the VA in monitoring out comes and measuring the case mix of patients who use the Vk The Veterans SF-36 (short form functional status assessment for veterans) was administered to 2425 veterans receiving ambulatory care. Measures of the Veterans SF 36 were strongly correlated with sociodemographics and morbidities of the veterans. Young veterans had poorer mental health status than older veterans. Veterans who used ambulatory care in the VHS reported lower levels of health status, reflecting more disease than a non VA civilian population. These measures of health are important indicators of the disease burden or case mix of the patients and are pertinent to health systems such as the VA for resource allocation decisions and as outcomes of care.

关键词：门诊医疗设施/利用波士顿诊断相关患者组健康状况最小二乘法分析前瞻性研究美国美国退伍军人事务部/利用退伍军人/统计学和数值数据成年人老年人老年人 80以上人类男(雄)性中年人

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