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Bayes J, Palencia J, Wardle J. Complementary and Integrative Medicine Prevalence and Utilization in International Military and Veteran Settings and Communities: A Systematic Review. Mil Med 2024; 189:e1318-e1335. [PMID: 37847545 DOI: 10.1093/milmed/usad392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/06/2023] [Accepted: 09/21/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Active duty military personnel and veterans have unique and complex health needs, with the high demands of military life often leading to chronic physical and mental health conditions. Complementary and integrative medicine (CIM) could be a possible solution to this problem. Some military health systems have started integrating CIM into health care delivery. However, there has been no systematic evaluation of the prevalence and utilization of CIM in military and veteran populations globally. MATERIALS AND METHODS A Preferred Reporting Items For Systematic Reviews and Meta-Analysis Protocols protocol was used to systematically search for original research assessing the prevalence and utilization of CIM among active serving military or veterans. CINAHL, MEDLINE, Scopus, and AMED databases were searched up to February 3, 2023. RESULTS A total of 27 studies met the inclusion criteria and were included in this review. The overall quality of evidence was high with a low risk of bias. Utilization of CIM varied. The lowest utilization demonstrated that only 1.9% of services delivered by military health system were CIM. The majority of studies found utilization rates between 30% and 80%, with some studies reporting use as high as 90%. The most commonly used CIM therapies included chiropractic care, massage, mindfulness/meditation, and acupuncture. Utilization of CIM products was high and ranged from 32% to 87%. The most frequently used products were dietary supplements, particularly multivitamins and minerals and protein supplements/amino acids. The use of herbal products was high among veterans ranging from 10% to 79%. CONCLUSIONS The high demand for CIM by military personnel and veterans has important implications for policy, funding allocation, and integration of these services into clinical practice, particularly by countries not currently doing so. Further research is needed to assess the implementation of CIM into real-world settings to explore barriers and facilitators for their use in clinical practice and, by extension, their integration into the wider health care system.
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Affiliation(s)
- Jessica Bayes
- National Centre for Naturopathic Medicine (NCNM), Faculty of Health, Southern Cross University, East Lismore, NSW 2480, Australia
| | - John Palencia
- National Centre for Naturopathic Medicine (NCNM), Faculty of Health, Southern Cross University, East Lismore, NSW 2480, Australia
| | - Jon Wardle
- National Centre for Naturopathic Medicine (NCNM), Faculty of Health, Southern Cross University, East Lismore, NSW 2480, Australia
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Malkawi AM, Meertens RM, Kremers SPJ, van der Borgh-Sleddens EFC, Picknell GC, Al Shehhi M. Correlates of Dietary Behaviors Among Young Emirati Males Completing Compulsory Military Service. Mil Med 2023; 188:3488-3495. [PMID: 35674290 DOI: 10.1093/milmed/usac150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/28/2022] [Accepted: 05/18/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION It is important to understand the correlates of different dietary behaviors in a military context in the United Arab Emirates (UAE) to guide intervention development to prevent and treat obesity as it has a significant impact at the country and regional level. This study aimed to assess different dietary behaviors and their association with potential correlates including age, marital status, educational level, smoking status, screen time, dietary knowledge, eating self-efficacy, and general self-efficacy. MATERIALS AND METHODS The study used a cross-sectional design and included 153 (M = 25.9 years, SD = ± 3.2) military recruits completing their basic training at a single military camp in the UAE. Dietary behaviors of these recruits were measured using the Arab Teens Lifestyle Study. Other potential correlates included dietary knowledge, general self-efficacy, and eating efficacy. The ethical approval was obtained from the research ethics committee in the UAE university. RESULTS Daily intake of fruits, vegetables, and breakfast was reported by 14.4%, 25.5%, and 22.9% of the military recruits, respectively. Almost half of the recruits (46.4%) consumed sugar-sweetened drinks more than 3 times a week, 39.2% consumed fast food more than 3 times a week, and 37.3% consumed sweets/chocolates more than 3 times a week. Bivariate regression analyses revealed that eating self-efficacy was positively associated with breakfast and dairy food consumption, although it was inversely associated with sugar, fast-food, and French fries intake. Age was significantly and inversely associated with sugar, fast-food, and energy drink intake. Moreover, nutrition knowledge was significantly and positively correlated with vegetable intake and negatively correlated with energy drink consumption. Multiple regressions showed that lower age and lower eating self-efficacy were found to be the main predictors for sugar-sweetened drinks (adjusted R2 = 0.112) and fast-food intake (adjusted R2 = 0.084). Also, a higher dietary knowledge score was a predictor of vegetable intake (adjusted R2 = 0.093), although age and smoking predict energy drink intake (adjusted R2 = 0.225). CONCLUSIONS The results show that unhealthy eating patterns are common among new recruits in the UAE military. The study suggests that age, eating self-efficacy, and nutrition knowledge are the main correlates of selected dietary behaviors. Interventions are advised to target these correlates to achieve healthier dietary habits inside the military.
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Affiliation(s)
- Ahmad M Malkawi
- Department of Health Promotion, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center, Maastricht 6200 MD, The Netherland
| | - Ree M Meertens
- Department of Health Promotion, School of Nutrition and Translational Research in Metabolism, and Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht 6200 MD, The Netherlands
| | - Stef P J Kremers
- Department of Health Promotion, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center, Maastricht 6200 MD, The Netherland
| | | | - Gareth C Picknell
- Physical Readiness Department, National Service and Reserve Authority, Ministry of Defence, Abu Dhabi, UAE
| | - Mouza Al Shehhi
- 3Dimensions Physical Performance LLC, Khalifa Commercial Center, Abu Dhabi, UAE
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Monti K, Monti JD, Thomas D. Knowledge and Attitudes of Lifestyle Medicine-Based Care in a Military Community. Mil Med 2023; 188:e497-e502. [PMID: 34254645 DOI: 10.1093/milmed/usab279] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/01/2021] [Accepted: 06/29/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The Department of Defense spends more than $3 billion annually on medical costs of lifestyle-related morbidity. Military service members and veterans engage in unhealthy behaviors at a higher rate than the civilian population. Lifestyle medicine may mitigate lifestyle-related chronic diseases and increase medical readiness in the U.S. Military. However, patients' perspectives in a military community regarding a lifestyle medicine-based approach to health care have not been studied. The purpose of this study was to assess the knowledge and attitudes of and interest in lifestyle medicine-based care within a military community. MATERIALS AND METHODS Following exempt study determination from the Madigan Army Medical Center Human Protections Office (Reference No. 220092), a prospective, cross-sectional, mixed-methods survey study was conducted from September 2020 to January 2021. Volunteer subjects, including active duty service members, National Guard/Reserves service members, and military dependents, were recruited to complete the anonymous survey while seeking care at five military clinics on Joint Base Lewis-McChord, Washington. The study's outcome measures were the overall level of awareness of lifestyle medicine, ranked level of importance of seven core lifestyle domains, the level of interest in seeking care from a lifestyle medicine practitioner, and the preferred lifestyle medicine care delivery setting. Kruskal-Wallis analyses of variance were conducted for categorical outcome variables. Mean composite scores were calculated for lifestyle domain rankings. RESULTS A total of 623 respondents completed the survey with a 62.3% response rate. The majority of respondents (89.7%) lacked definitive knowledge of the field of lifestyle medicine. Food/nutrition and sleep were ranked the highest of all lifestyle domains to include in a healthcare approach in the overall sample and across all subgroups. Quitting smoking and alcohol use were ranked the lowest of importance overall and across all subgroups. The majority of respondents (65.7%) reported it was extremely or very important that lifestyle is part of the healthcare discussion with their provider. Of 614 responses, 77.6% of respondents expressed interest in a lifestyle medicine-based approach to health care, with 40.1% indicating they were extremely or very interested in this approach. A direct correlation was noted between education levels and level of interest in lifestyle medicine. Many respondents selected their primary care provider (34.6%) or a lifestyle medicine practitioner embedded in their primary care clinic (26.1%) as their preferred method of lifestyle medicine provision. A higher smoking rate was demonstrated in service members in combat arms occupational specialties. CONCLUSIONS Despite an overall low level of awareness of lifestyle medicine, most respondents expressed interest in a lifestyle medicine approach to health care, with food/nutrition and sleep ranked as the most important domains. Lower levels of education may be a potential barrier to patient willingness to engage in lifestyle medicine care. Service members in combat arms occupational specialties may represent a potential target population for smoking cessation interventions. Further research with a larger sample more proportionately inclusive of all military service branches is needed.
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Affiliation(s)
- Katrina Monti
- 1st Special Forces Group (Airborne), Joint Base Lewis-McChord, WA 98433, USA
| | - Jonathan D Monti
- Department of Clinical Investigation, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
| | - Drew Thomas
- Geneva Foundation, Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA
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Obesity in Latinx and White U.S. military veterans: prevalence, physical health, and functioning. J Psychiatr Res 2022; 155:163-170. [PMID: 36030571 DOI: 10.1016/j.jpsychires.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/03/2022] [Accepted: 08/16/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE While Latinx Americans in the general population are more likely to have obesity than non-Hispanic Whites, limited research has examined ethnic differences in obesity and its correlates among military veterans. To address this gap, we examined the prevalence, physical health and functional correlates of obesity in a population-based sample of Latinx and White U.S. military veterans. METHODS Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of veterans. Bivariate and multivariate analyses were conducted to evaluate the relation between obesity, and health and functioning measures in Latinx and White veterans. RESULTS The prevalence of obesity was significantly higher among Latinx veterans (weighted 43.6% vs. 35.5%; odds ratio (OR) = 1.4, 95% confidence interval (CI) = 1.10-1.81). While obesity was associated with a greater number of medical conditions, reduced functioning, higher somatic symptoms, and insomnia severity in both Latinx and White veterans, these differences were more pronounced in Latinx relative to White veterans, with higher rates of arthritis, liver disease, diabetes, high blood pressure and cholesterol, heart attack, stroke, migraine, and physical disability, and greater physical, mental, and psychosocial dysfunction. CONCLUSION Obesity is more prevalent in Latinx than in White U.S. veterans, and the associated elevated health and functional impairments are more pronounced in Latinx veterans. Characterization of co-occurring physical and functioning problems among Latinx and White veterans with obesity may help inform ethnically-sensitive obesity prevention and treatment efforts in this population.
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Relationships Between Dietary Intake and Weight-Related Experiential Avoidance Following Behavioral Weight-Loss Treatment. Int J Behav Med 2022; 29:104-109. [PMID: 33864234 PMCID: PMC8522188 DOI: 10.1007/s12529-021-09990-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Interventions targeting weight-related experiential avoidance (EA) and disinhibited eating (DE) may also improve diet quality. Participants with overweight/obesity and DE who recently completed a behavioral weight-loss program were randomized to receive acceptance and commitment therapy or continued behavioral weight-loss treatment. In this secondary analysis, we explored (1) change in diet quality from baseline to 6-month follow-up (FU) and (2) whether weight-related EA at baseline and (3) change in weight-related EA during treatment were related to change in diet quality from baseline to FU. METHOD Veterans (N = 68) completed food frequency questionnaires at baseline and FU, which were used to generate diet quality scores on the healthy eating index-15 (HEI-15). Weight-related EA was assessed using the Acceptance and Action Questionnaire for Weight-Related Difficulties-Revised (AAQW-R) at baseline, post-treatment, and FU. Aims were examined with mixed ANOVA analyses. RESULTS Across both treatment groups, HEI-15 scores declined from baseline to FU. Women's HEI-15 decreased by about 5 times that of men. Baseline AAWQ-R was negatively associated with change in HEI-15. Neither AAWQ-R at post-treatment nor change in AAQW-R from baseline to post-treatment was significantly associated with change in HEI-15 at FU. CONCLUSIONS Greater weight-related EA at baseline was associated with lower diet quality at FU, but change in weight-related EA during treatment did not predict change in diet quality at FU. Interventions targeting DE and weight-loss may require specific components to improve and sustain healthy dietary intake in Veterans with obesity and DE.
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Haibach JP, Hoerster KD, Dorflinger L, McAndrew LM, Cassidy DG, Goodrich DE, Bormann JE, Lowery J, Asch SM, Raffa SD, Moin T, Peterson AL, Goldstein MG, Neal-Walden T, Talcott GW, Hunter CL, Knight SJ. Research translation for military and veteran health: research, practice, policy. Transl Behav Med 2021; 11:631-641. [PMID: 32043529 DOI: 10.1093/tbm/ibz195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Military service presents unique challenges and opportunities for health care and public health. In the USA, there are over 2 million military servicemembers, 20 million veterans, and millions more military and veteran family members. Military servicemembers and eligible family members, many veterans, and retirees receive health care through the two largest learning health care systems in the USA, managed and delivered through the Departments of Defense (DoD), Veterans Affairs (VA), and contracted health care organizations. Through a network of collaborative relationships, DoD, VA, and partnering health care and research organizations (university, corporate, community, and government) accelerate research translation into best practices and policy across the USA and beyond. This article outlines military and veteran health research translation as summarized from a collaborative workshop led by experts across health care research, practice, and administration in DoD, VA, the National Institutes of Health, and affiliated universities. Key themes and recommendations for research translation are outlined in areas of: (a) stakeholder engagement and collaboration; (b) implementation science methods; and (c) funding along the translation continuum. Overall, the ability to rapidly translate research into clinical practice and policy for positive health outcomes requires collaborative relationships among many stakeholders. This includes servicemembers, veterans, and their families along with researchers, health care clinicians, and administrators, as well as policymakers and the broader population.
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Affiliation(s)
- Jeffrey P Haibach
- U.S. Department of Veterans Affairs, Washington, DC, USA.,Veteran Consulting and Research Corp., Rochester, NY, USA
| | - Katherine D Hoerster
- Research and Development Service, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | | | - Lisa M McAndrew
- War Related Illness and Injury Study Center, VA New Jersey Health care System, East Orange, NJ, USA.,Department of Educational and Counseling Psychology, University at Albany, Albany, NY, USA
| | | | - David E Goodrich
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jill E Bormann
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, USA.,Hahn School of Nursing and Health Science/Beyster Institute for Nursing Research, University of San Diego, San Diego, CA, USA
| | - Julie Lowery
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Susan D Raffa
- VA National Center for Health Promotion and Disease Prevention, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Tannaz Moin
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Alan L Peterson
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center, San Antonio, TX, USA
| | - Michael G Goldstein
- VA National Center for Health Promotion and Disease Prevention, Durham, NC, USA
| | - Tracy Neal-Walden
- Steven A. Cohen Military Family Clinic at Easterseals, Silver Spring, MD, USA
| | - Gerald W Talcott
- Center for Addiction and Prevention Research, University of Virginia, Charlottesville, VA, USA
| | - Christopher L Hunter
- Primary Care and Clinical Patient Engagement/Experience, Military Affairs, Clinical Support Division, Defense Health Agency, Falls Church, VA, USA
| | - Sara J Knight
- VA Salt Lake City Health care System, Salt Lake City, UT, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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Stearns-Yoder KA, Ryan AT, Smith AA, Forster JE, Barnes SM, Brenner LA. Acceptability and Feasibility of a Computerized Cognitive Behavioral Therapy Intervention for Depression among Veterans (Preprint). JMIR Form Res 2021; 6:e31835. [PMID: 35468088 PMCID: PMC9086870 DOI: 10.2196/31835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 12/17/2021] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kelly A Stearns-Yoder
- Veterans Affairs Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
| | - Arthur T Ryan
- Veterans Affairs Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
- Research and Development Service, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
| | - Alexandra A Smith
- Veterans Affairs Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
| | - Jeri E Forster
- Veterans Affairs Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
| | - Sean M Barnes
- Veterans Affairs Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
| | - Lisa A Brenner
- Veterans Affairs Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
- Department of Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
- Department of Neurology, University of Colorado Anschutz School of Medicine, Aurora, CO, United States
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Makridis CA, Strebel T, Marconi V, Alterovitz G. Designing COVID-19 mortality predictions to advance clinical outcomes: Evidence from the Department of Veterans Affairs. BMJ Health Care Inform 2021; 28:bmjhci-2020-100312. [PMID: 34108143 PMCID: PMC8190987 DOI: 10.1136/bmjhci-2020-100312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/17/2021] [Accepted: 03/31/2021] [Indexed: 12/21/2022] Open
Abstract
Using administrative data on all Veterans who enter Department of Veterans Affairs (VA) medical centres throughout the USA, this paper uses artificial intelligence (AI) to predict mortality rates for patients with COVID-19 between March and August 2020. First, using comprehensive data on over 10 000 Veterans’ medical history, demographics and lab results, we estimate five AI models. Our XGBoost model performs the best, producing an area under the receive operator characteristics curve (AUROC) and area under the precision-recall curve of 0.87 and 0.41, respectively. We show how focusing on the performance of the AUROC alone can lead to unreliable models. Second, through a unique collaboration with the Washington D.C. VA medical centre, we develop a dashboard that incorporates these risk factors and the contributing sources of risk, which we deploy across local VA medical centres throughout the country. Our results provide a concrete example of how AI recommendations can be made explainable and practical for clinicians and their interactions with patients.
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Affiliation(s)
- Christos A Makridis
- National Artificial Intelligence Institute at the Department of Veterans Affairs, US Department of Veterans Affairs, Washington, District of Columbia, USA .,Digital Economy Lab, Stanford University, Stanford University, Stanford, California, USA
| | - Tim Strebel
- Washington D.C. VA Medical Center, Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Vincent Marconi
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Gil Alterovitz
- National Artificial Intelligence Institute at the Department of Veterans Affairs, US Department of Veterans Affairs, Washington, District of Columbia, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Gilson ND, Papinczak ZE, Mielke GI, Haslam C, McKenna J, Brown WJ. Stepped-down intervention programs to promote self-managed physical activity in military service veterans: A systematic review of randomised controlled trials. J Sci Med Sport 2021; 24:1155-1160. [PMID: 34246553 DOI: 10.1016/j.jsams.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 04/28/2021] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES A stepped-down program is one where clients transition from the care of a health professional to self-managed care. This study reviewed the effectiveness of stepped-down interventions to promote self-managed physical activity for health in military service veterans. DESIGN Systematic review. METHODS Literature searches of 11 electronic databases were performed (up to 28th April 2020) to identify randomised controlled trials that assessed self-managed physical activity interventions in military service veterans. Data were extracted on study characteristics, intervention programs (with strategies mapped against a taxonomy of behaviour change techniques), and physical activity outcomes; secondary outcomes were physical fitness/function, psychosocial health, and cost effectiveness. Study quality was assessed using a 15-item checklist adapted from the TESTEX scale. RESULTS Searches identified 26 studies (all from the United States; N = 45 to 531 participants) representing 17 intervention programs. Studies were of good quality (M = 10.7; SD = 2.3). More than half (54%) reported positive between-group intervention effects for physical activity outcomes (mean increase of 80 min/week in self-reported physical activity at 10-12 months). Physical fitness/function outcomes improved in 38% of studies, but no studies found significant intervention effects for psychosocial health or cost effectiveness outcomes. Behaviour change techniques most frequently used to elicit physical activity changes were education, goal setting, goal review and self-monitoring. CONCLUSIONS Stepped-down programs that include specific behaviour change techniques have the potential to promote self-management of physical activity in military service veterans. Multi-national randomised controlled trials that use objective physical activity measures are needed to further build the evidence base.
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Affiliation(s)
- Nicholas D Gilson
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia.
| | - Zoe E Papinczak
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia
| | - Gregore I Mielke
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia
| | | | - James McKenna
- Active Lifestyles Research Centre, Leeds Beckett University, United Kingdom
| | - Wendy J Brown
- School of Human Movement and Nutrition Sciences, The University of Queensland, Australia
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Melcer T, Walker J, Bhatnagar V, Richard E. Clinic Use at the Departments of Defense and Veterans Affairs Following Combat Related Amputations. Mil Med 2021; 185:e244-e253. [PMID: 31247095 DOI: 10.1093/milmed/usz149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/02/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Little population-based research has described the transition from Department of Defense (DoD) to Department of Veterans Affairs (VA) healthcare following combat related amputations. The objectives were to describe (1) to what extent patients used either DoD only facilities, both DoD and VA facilities, or VA only facilities during the first 5 years postinjury, (2) which specific clinics were used and (3) clinic use among patients with different levels of amputation (upper versus lower), and among patients with early or late amputation. MATERIALS AND METHODS This was a retrospective analysis of health data extracted from the expeditionary medical encounter database (EMED) and national DoD and VA databases. Patients were 649 US service members who sustained a single major limb amputation following injuries in the Iraq and Afghanistan conflicts, 2001-2008. We compared yearly DoD and VA clinic use by patient groups with different levels of amputation (upper limb: above versus below elbow or lower limb: above versus below knee), different timing of amputation (early: within 90 days postinjury versus late: more than 90 days postinjury), military component (Active Duty versus National Guard/Reserve) and race (White versus Black). For all groups, we calculated the percentage of patients using: (1) DoD only, (2) both DoD and VA or 3) VA only clinics during each of postinjury years 1 through 5. We also calculated the percentage of patients who used specific clinics (e.g., social work, prosthetics, mental health) during each postinjury year. RESULTS During postinjury year 1, over 98% of patients used DoD only or both DoD and VA clinics. Most individuals (70% to 78%) used both DoD and VA clinics during postinjury year 1. Use of VA only clinics increased gradually between postinjury year 2 (15% to 30% of patient groups) and year 5 (75% to 88%). This gradual transition to use of VA only clinics was seen consistently across patient groups with different anatomical levels or timing of amputation, military component or race. Patients with lower levels of amputation (versus higher levels) and individuals with early amputations (versus late) transitioned earlier to VA only care. Overall, clinic use was high as 91% to 100% of all patient groups used one or more clinics (DoD or VA) during each of the first 5 years. For specific clinics, most patients used DoD facilities related to rehabilitation (physical therapy, prosthetics) or transitional care (social work) particularly during postinjury year 1. Use of most VA clinics studied (social work, primary care, prosthetics, mental health) showed a modest increase primarily after postinjury year 1 and remained stable through postinjury year 5. The results indicated apparent underuse of psychiatric/mental health and prosthetics between postinjury year 1 and 2. CONCLUSIONS The present study indicated a gradual transition from DoD to VA only healthcare which extended across 5 years following combat related amputations. Patients with lower levels of amputation or early amputation generally transitioned earlier to VA only healthcare. These results can inform medical planning to support a timely and clinically effective transition from DoD to VA healthcare.
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Affiliation(s)
- Ted Melcer
- Department of Medical Modeling, Simulation, and Mission Support, Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521
| | - Jay Walker
- Leidos Inc., 10260 Campus Point Dr, San Diego, CA 92121
| | - Vibha Bhatnagar
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161.,Department for Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093
| | - Erin Richard
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161.,Department for Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093
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Makridis CA, Zhao DY, Bejan CA, Alterovitz G. Leveraging machine learning to characterize the role of socio-economic determinants on physical health and well-being among veterans. Comput Biol Med 2021; 133:104354. [PMID: 33845269 DOI: 10.1016/j.compbiomed.2021.104354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/07/2021] [Accepted: 03/20/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION We investigate the contribution of demographic, socio-economic, and geographic characteristics as determinants of physical health and well-being to guide public health policies and preventative behavior interventions (e.g., countering coronavirus). METHODS We use machine learning to build predictive models of overall well-being and physical health among veterans as a function of these three sets of characteristics. We link Gallup's U.S. Daily Poll between 2014 and 2017 over a range of demographic and socio-economic characteristics with zipcode characteristics from the Census Bureau to build predictive models of overall and physical well-being. RESULTS Although the predictive models of overall well-being have weak performance, our classification of low levels of physical well-being performed better. Gradient boosting delivered the best results (80.2% precision, 82.4% recall, and 80.4% AUROC) with perceptions of purpose in the workplace and financial anxiety as the most predictive features. Our results suggest that additional measures of socio-economic characteristics are required to better predict physical well-being, particularly among vulnerable groups, like veterans. CONCLUSION Socio-economic characteristics explain large differences in physical and overall well-being. Effective predictive models that incorporate socio-economic data will provide opportunities to create real-time and personalized feedback to help individuals improve their quality of life.
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Affiliation(s)
- Christos A Makridis
- Stanford University Digital Economy Lab, and National Artificial Intelligence Institute at the Department of Veterans Affairs, 810 Vermont Ave NW, Washington, DC 20420, USA.
| | - David Y Zhao
- Department of Computer Science at Stanford University, Gates Computer Science Building, 353 Jane Stanford Way, Stanford, CA 94305, USA.
| | - Cosmin A Bejan
- Department Biomedical Informatics at Vanderbilt University Medical Center, 2525 West End Avenue, Nashville, TN, 37203, USA.
| | - Gil Alterovitz
- Harvard Medical School, Boston Children's Hospital, National Artificial Intelligence Institute at the Department of Veterans Affairs, 810 Vermont Ave NW, Washington, DC 20420, USA.
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12
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Gilson ND, Papinczak ZE, Mielke GI, Haslam C, Fooken J, McKenna J, Brown WJ. Effects of the Active Choices Program on Self-Managed Physical Activity and Social Connectedness in Australian Defence Force Veterans: Protocol for a Cluster-Randomized Trial. JMIR Res Protoc 2021; 10:e21911. [PMID: 33625365 PMCID: PMC7946582 DOI: 10.2196/21911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 11/16/2022] Open
Abstract
Background A stepped-down program is one in which clients transition from the care of a health professional to self-managed care. Very little is known about the effectiveness of stepped-down physical activity (PA) programs for military service veterans. Objective This study will test Active Choices, a stepped-down behavioral support program designed to help Australian Defence Force veterans and their dependents who are clients of the Department of Veterans’ Affairs, transition from treatment by an exercise physiologist or physiotherapist to self-managed PA. Methods The study is a parallel-group, randomized trial, with city-based exercise physiology or physiotherapy practices that recruit eligible Department of Veterans’ Affairs clients assigned to Active Choices or a comparison program. The study aims to recruit 52 participants (26 in each group). The Active Choices program will consist of 2 face-to-face (Weeks 1, 12) and 2 telephone (Weeks 4 and 8) consultations. During these sessions, the participant and Active Choices consultant will utilize an evidence-based resource booklet to review the key benefits of an active lifestyle, build an action plan for PA preferences, set and review goals, self-monitor progress relative to set goals, and discuss strategies to overcome PA barriers. Linking participants to local PA communities to overcome social isolation will be a program priority. The comparison program will consist of 2 consultations (Weeks 1 and 12) and use fewer behavioral support strategies (education, self-monitoring, and action planning only) than Active Choices. Outcome measures will be administered at baseline, end-intervention (12 weeks), and follow-up (24 weeks) to assess changes in moderate intensity self-managed PA, psychological well-being, and social connectedness. We will also measure health service utilization and costs as well as PA choices across the intervention period. End-intervention interviews will capture participant experiences. Results Due to the impacts of the COVID-19 pandemic on human research activities in Australia, participant recruitment will commence when it is safe and feasible to do so. Conclusions Findings will provide valuable pilot data to support up-scaling of the program and larger effectiveness trials with regional and rural as well as city-based Australian Defence Force veterans and their dependents. Trial Registration Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000559910; https://www.anzctr.org.au/ACTRN12620000559910.aspx International Registered Report Identifier (IRRID) PRR1-10.2196/21911
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Affiliation(s)
- Nicholas D Gilson
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Australia
| | - Zoe E Papinczak
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Australia
| | - Gregore Iven Mielke
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Australia
| | - Catherine Haslam
- School of Psychology, The University of Queensland, Brisbane, Australia
| | - Jonas Fooken
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Australia
| | - Jim McKenna
- Active Lifestyles Research Centre, Leeds Beckett University, Leeds, United Kingdom
| | - Wendy J Brown
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Australia
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13
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Faruqui SHA, Alaeddini A, Chang MC, Shirinkam S, Jaramillo C, NajafiRad P, Wang J, Pugh MJ. Summarizing Complex Graphical Models of Multiple Chronic Conditions Using the Second Eigenvalue of Graph Laplacian: Algorithm Development and Validation. JMIR Med Inform 2020; 8:e16372. [PMID: 32554376 PMCID: PMC7330739 DOI: 10.2196/16372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/06/2020] [Accepted: 03/22/2020] [Indexed: 01/16/2023] Open
Abstract
Background It is important but challenging to understand the interactions of multiple chronic conditions (MCC) and how they develop over time in patients and populations. Clinical data on MCC can now be represented using graphical models to study their interaction and identify the path toward the development of MCC. However, the current graphical models representing MCC are often complex and difficult to analyze. Therefore, it is necessary to develop improved methods for generating these models. Objective This study aimed to summarize the complex graphical models of MCC interactions to improve comprehension and aid analysis. Methods We examined the emergence of 5 chronic medical conditions (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], depression [Depr], substance abuse [SuAb], and back pain [BaPa]) over 5 years among 257,633 veteran patients. We developed 3 algorithms that utilize the second eigenvalue of the graph Laplacian to summarize the complex graphical models of MCC by removing less significant edges. The first algorithm learns a sparse probabilistic graphical model of MCC interactions directly from the data. The second algorithm summarizes an existing probabilistic graphical model of MCC interactions when a supporting data set is available. The third algorithm, which is a variation of the second algorithm, summarizes the existing graphical model of MCC interactions with no supporting data. Finally, we examined the coappearance of the 100 most common terms in the literature of MCC to validate the performance of the proposed model. Results The proposed summarization algorithms demonstrate considerable performance in extracting major connections among MCC without reducing the predictive accuracy of the resulting graphical models. For the model learned directly from the data, the area under the curve (AUC) performance for predicting TBI, PTSD, BaPa, SuAb, and Depr, respectively, during the next 4 years is as follows—year 2: 79.91%, 84.04%, 78.83%, 82.50%, and 81.47%; year 3: 76.23%, 80.61%, 73.51%, 79.84%, and 77.13%; year 4: 72.38%, 78.22%, 72.96%, 77.92%, and 72.65%; and year 5: 69.51%, 76.15%, 73.04%, 76.72%, and 69.99%, respectively. This demonstrates an overall 12.07% increase in the cumulative sum of AUC in comparison with the classic multilevel temporal Bayesian network. Conclusions Using graph summarization can improve the interpretability and the predictive power of the complex graphical models of MCC.
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Affiliation(s)
- Syed Hasib Akhter Faruqui
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Adel Alaeddini
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Mike C Chang
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Sara Shirinkam
- Department of Mathematics and Statistics, University of the Incarnate Word, San Antonio, TX, United States
| | - Carlos Jaramillo
- South Texas Veterans Health Care System, San Antonio, TX, United States
| | - Peyman NajafiRad
- Department of Information Systems and Cyber Security, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Jing Wang
- School of Nursing, UT Health San Antonio, San Antonio, TX, United States
| | - Mary Jo Pugh
- VA Salt Lake City Health Care System, Salt Lake City, UT, United States
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14
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Cuthbert K, Hardin S, Zelkowitz R, Mitchell K. Eating Disorders and Overweight/Obesity in Veterans: Prevalence, Risk Factors, and Treatment Considerations. Curr Obes Rep 2020; 9:98-108. [PMID: 32361915 DOI: 10.1007/s13679-020-00374-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Eating disorders (EDs) and overweight/obesity (OW/OB) have a significant impact on veterans. This review highlights current research on EDs and OW/OB in this population. RECENT FINDINGS Prevalence estimates for both EDs and OW/OB among veterans remain consistent with and possibly higher than those in the general population. Both diagnoses share multiple risk factors, including trauma history, and mental health comorbidities. Although weight loss treatments have been fairly well studied among veteran samples, there are no published investigations on psychotherapies for EDs in this population. The Veterans Healthcare Administration is working to train providers in ED treatments. VHA treatments for OW/OB show some benefits and areas for improvement. Areas for future research include structured assessments for EDs and disordered eating behaviors in veterans to clarify prevalence estimates. There is a need for interventions that consider common mechanisms for ED and OW/OB, and there is a need for more research on the associations between different types of trauma and ED/OW/OB in veterans.
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Affiliation(s)
- Kristy Cuthbert
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
- National Center for PTSD at the VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Sabrina Hardin
- National Center for PTSD at the VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Rachel Zelkowitz
- National Center for PTSD at the VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Karen Mitchell
- National Center for PTSD at the VA Boston Healthcare System, Boston, MA, 02130, USA.
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.
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15
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Schmidt EM, Magruder K, Kilbourne AM, Stock EM, Cypel Y, El Burai Félix S, Serpi T, Kimerling R, Cohen B, Spiro A, Furey J, Huang GD, Frayne SM. Four Decades after War: Incident Diabetes among Women Vietnam-Era Veterans in the HealthViEWS Study. Womens Health Issues 2019; 29:471-479. [PMID: 31519465 DOI: 10.1016/j.whi.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 07/26/2019] [Accepted: 08/05/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We analyzed long-term differences in incident diabetes associated with military service in a warzone among women who served during the Vietnam War era. METHODS For HealthViEWS, the largest later-life study of women Vietnam War-era U.S. veterans, a population-based retrospective cohort who served during 1965-1973 completed a health interview in 2011-2012. This cohort included women deployed to Vietnam, near Vietnam, or who served primarily in the United States. We hypothesized a warzone exposure gradient: Vietnam (highest exposure), near Vietnam, and the United States (lowest exposure). We used an extended Cox regression to test for differences in incident diabetes by location of wartime service. RESULTS Of 4,503 women in the analysis, 17.7% developed diabetes. Adjusting for demographics and military service characteristics, hazard of incident diabetes was significantly lower initially in the Vietnam group compared with the U.S. group (hazard ratio, 0.33; 95% confidence interval, 0.15-0.69). However, lower diabetes hazard in the Vietnam group was not constant over time; rather, hazard accumulated faster over time in the Vietnam group compared with the U.S. group (hazard ratio, 1.38; 95% confidence interval, 1.11-1.72). No significant difference in diabetes hazard was found between the near Vietnam and U.S. groups. Older age during military service, minority race/ethnicity, and lower military rank were associated with a higher diabetes hazard. CONCLUSIONS Women deployed to a warzone might have protective health factors that lower risk for diabetes early in their military career, but delivery systems for long-term health should consider that a lower risk for chronic diseases like diabetes can wane quickly in the decades that follow warzone service.
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Affiliation(s)
- Eric M Schmidt
- Veterans Affairs Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California; Program Evaluation Resource Center, Office of Mental Health and Suicide Prevention, Veterans Affairs Central Office, Menlo Park, California.
| | - Kathryn Magruder
- Department of Psychiatry, Medical University of South Carolina, Charleston, South Carolina
| | - Amy M Kilbourne
- Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Eileen M Stock
- Perry Point/Baltimore Coordinating Center, Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland
| | - Yasmin Cypel
- Epidemiology Program Post-Deployment Health Services, Office of Patient Care Services, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Suad El Burai Félix
- Perry Point/Baltimore Coordinating Center, Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland
| | - Tracey Serpi
- Perry Point/Baltimore Coordinating Center, Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland
| | - Rachel Kimerling
- Veterans Affairs Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California; National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California
| | - Beth Cohen
- General Internal Medicine, San Francisco VA Medical Center, San Francisco, California; School of Medicine, University of California, San Francisco, California
| | - Avron Spiro
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Health Care System, Boston, Massachusetts; Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts; Department of Psychiatry, School of Medicine, Boston University, Boston, Massachusetts
| | | | - Grant D Huang
- Cooperative Studies Program Central Office, VA Office of Research and Development, Washington, District of Columbia
| | - Susan M Frayne
- Veterans Affairs Health Services Research and Development Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California; Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California
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16
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Morgan PA, Smith VA, Berkowitz TSZ, Edelman D, Van Houtven CH, Woolson SL, Hendrix CC, Everett CM, White BS, Jackson GL. Impact Of Physicians, Nurse Practitioners, And Physician Assistants On Utilization And Costs For Complex Patients. Health Aff (Millwood) 2019; 38:1028-1036. [DOI: 10.1377/hlthaff.2019.00014] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Perri A. Morgan
- Perri A. Morgan is a professor in the Department of Family Medicine and Community Health, Physician Assistant Program, and Department of Population Health Sciences, Duke University School of Medicine, in Durham, North Carolina
| | - Valerie A. Smith
- Valerie A. Smith is an assistant professor in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs (VA) Health Care System, and the Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine
| | - Theodore S. Z. Berkowitz
- Theodore S. Z. Berkowitz is a statistician in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - David Edelman
- David Edelman is a professor in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and the Division of General Internal Medicine, Duke University School of Medicine
| | - Courtney H. Van Houtven
- Courtney H. Van Houtven is a research scientist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and the Department of Population Health Sciences, Duke University School of Medicine
| | - Sandra L. Woolson
- Sandra L. Woolson is a statistician in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Cristina C. Hendrix
- Cristina C. Hendrix is an associate professor in the Geriatric Research, Education, and Clinical Center, Durham VA Health Care System and Duke University School of Nursing
| | - Christine M. Everett
- Christine M. Everett is an associate professor in the Department of Family Medicine and Community Health, Physician Assistant Program, and Department of Population Health Sciences, Duke University School of Medicine
| | - Brandolyn S. White
- Brandolyn S. White is a research health science specialist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - George L. Jackson
- George L. Jackson is an associate professor in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and the Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine
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Jackson GL, Smith VA, Edelman D, Woolson SL, Hendrix CC, Everett CM, Berkowitz TS, White BS, Morgan PA. Intermediate Diabetes Outcomes in Patients Managed by Physicians, Nurse Practitioners, or Physician Assistants: A Cohort Study. Ann Intern Med 2018; 169:825-835. [PMID: 30458506 DOI: 10.7326/m17-1987] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary care provided by nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a solution to expected workforce shortages. OBJECTIVE To examine potential differences in intermediate diabetes outcomes among patients of physician, NP, and PA primary care providers (PCPs). DESIGN Cohort study using data from the U.S. Department of Veterans Affairs (VA) electronic health record. SETTING 568 VA primary care facilities. PATIENTS 368 481 adult patients with diabetes treated pharmaceutically. MEASUREMENTS The relationship between the profession of the PCP (the provider the patient visited most often in 2012) and both continuous and dichotomous control of hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) was examined on the basis of the mean of measurements in 2013. Inverse probability of PCP type was used to balance cohort characteristics. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes, respectively. RESULTS The PCPs were physicians (n = 3487), NPs (n = 1445), and PAs (n = 443) for 74.9%, 18.2%, and 6.9% of patients, respectively. The difference in HbA1c values compared with physicians was -0.05% (95% CI, -0.07% to -0.02%) for NPs and 0.01% (CI, -0.02% to 0.04%) for PAs. For SBP, the difference was -0.08 mm Hg (CI, -0.34 to 0.18 mm Hg) for NPs and 0.02 mm Hg (CI, -0.42 to 0.38 mm Hg) for PAs. For LDL-C, the difference was 0.01 mmol/L (CI, 0.00 to 0.03 mmol/L) (0.57 mg/dL [CI, 0.03 to 1.11 mg/dL]) for NPs and 0.03 mmol/L (CI, 0.01 to 0.05 mmol/L) (1.08 mg/dL [CI, 0.25 to 1.91 mg/dL]) for PAs. None of these differences were clinically significant. LIMITATION Most VA patients are men who receive treatment in a staff-model health care system. CONCLUSION No clinically significant variation was found among the 3 PCP types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs. PRIMARY FUNDING SOURCE VA Health Services Research and Development.
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Affiliation(s)
- George L Jackson
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | - Valerie A Smith
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | - David Edelman
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | - Sandra L Woolson
- Durham Veterans Affairs Health Care System, Durham, North Carolina (S.L.W., T.S.B., B.S.W.)
| | - Cristina C Hendrix
- Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.)
| | | | - Theodore S Berkowitz
- Durham Veterans Affairs Health Care System, Durham, North Carolina (S.L.W., T.S.B., B.S.W.)
| | - Brandolyn S White
- Durham Veterans Affairs Health Care System, Durham, North Carolina (S.L.W., T.S.B., B.S.W.)
| | - Perri A Morgan
- Duke University, Durham, North Carolina (C.M.E., P.A.M.)
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18
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Oddone EZ, Gierisch JM, Sanders LL, Fagerlin A, Sparks J, McCant F, May C, Olsen MK, Damschroder LJ. A Coaching by Telephone Intervention on Engaging Patients to Address Modifiable Cardiovascular Risk Factors: a Randomized Controlled Trial. J Gen Intern Med 2018; 33:1487-1494. [PMID: 29736750 PMCID: PMC6108991 DOI: 10.1007/s11606-018-4398-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 11/17/2017] [Accepted: 03/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND A large proportion of deaths and chronic illnesses can be attributed to three modifiable risk factors: tobacco use, overweight/obesity, and physical inactivity. OBJECTIVE To test whether telephone-based health coaching after completion of a comprehensive health risk assessment (HRA) increases patient activation and enrollment in a prevention program compared to HRA completion alone. DESIGN Two-arm randomized trial at three sites. SETTING Primary care clinics at Veterans Affairs facilities. PARTICIPANTS Four hundred seventeen veterans with at least one modifiable risk factor (BMI ≥ 30, < 150 min of at least moderate physically activity per week, or current smoker). INTERVENTION Participants completed an online HRA. Intervention participants received two telephone-delivered health coaching calls at 1 and 4 weeks to collaboratively set goals to enroll in, and attend structured prevention programs designed to reduce modifiable risk factors. MEASUREMENTS Primary outcome was enrollment in a structured prevention program by 6 months. Secondary outcomes were Patient Activation Measure (PAM) and Framingham Risk Score (FRS). RESULTS Most participants were male (85%), white (50%), with a mean age of 56. Participants were eligible, because their BMI was ≥ 30 (80%), they were physically inactive (50%), and/or they were current smokers (39%). When compared to HLA only at 6 months, health coaching intervention participants reported higher rates of enrollment in a prevention program, 51 vs 29% (OR = 2.5; 95% CI: 1.7, 3.9; p < 0.0001), higher rates of program participation, 40 vs 23% (OR = 2.3; 95% CI: 1.5, 3.6; p = 0.0004), and greater improvement in PAM scores, mean difference 2.5 (95% CI: 0.2, 4.7; p = 0.03), but no change in FRS scores, mean difference 0.7 (95% CI - 0.7, 2.2; p = 0.33). CONCLUSIONS Brief telephone health coaching after completing an online HRA increased patient activation and increased enrollment in structured prevention programs to improve health behaviors. CLINICALTRIALS. GOV IDENTIFIER NCT01828567.
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Affiliation(s)
- Eugene Z Oddone
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA.
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Jennifer M Gierisch
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Linda L Sanders
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Angela Fagerlin
- VA Salt Lake City Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, UT, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Jordan Sparks
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Felicia McCant
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - Carrie May
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - Maren K Olsen
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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19
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Wooten NR, Brittingham JA, Pitner RO, Tavakoli AS, Jeffery DD, Haddock KS. Purchased Behavioral Health Care Received by Military Health System Beneficiaries in Civilian Medical Facilities, 2000-2014. Mil Med 2018; 183:e278-e290. [PMID: 29420772 PMCID: PMC6027075 DOI: 10.1093/milmed/usx101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/25/2017] [Accepted: 11/15/2017] [Indexed: 11/15/2022] Open
Abstract
Introduction Behavioral health conditions are a significant concern for the U.S. military and the Military Health System (MHS) because of decreased military readiness and increased health care utilization. Although MHS beneficiaries receive direct care in military treatment facilities, a disproportionate majority of behavioral health treatment is purchased care received in civilian facilities. Yet, limited evidence exists about purchased behavioral health care received by MHS beneficiaries. This longitudinal study (1) estimated the prevalence of purchased behavioral health care and (2) identified patient and visit characteristics predicting receipt of purchased behavioral health care in acute care facilities from 2000 to 2014. Materials and Methods Medical claims with Major Diagnostic Code 19 (mental disorders/diseases) or 20 (alcohol/drug disorders) as primary diagnoses and TRICARE as the primary/secondary payer were analyzed for MHS beneficiaries (n = 17,943) receiving behavioral health care in civilian acute care facilities from January 1, 2000, to December 31, 2014. The primary dependent variable, receipt of purchased behavioral health care, was modeled for select mental health and substance use disorders from 2000 to 2014 using generalized estimating equations. Patient characteristics included time, age, sex, and race/ethnicity. Visit types included inpatient hospitalization and emergency department (ED). Time was measured in days and visits were assumed to be correlated over time. Behavioral health care was described by both frequency of patients and visit type. The University of South Carolina Institutional Review Board approved this study. Results From 2000 to 2014, purchased care visits increased significantly for post-traumatic stress disorder, adjustment, anxiety, mood, bipolar, tobacco use, opioid/combination opioid dependence, nondependent cocaine abuse, psychosocial problems, and suicidal ideation among MHS beneficiaries. The majority of care was received for mental health disorders (78.8%) and care was most often received in EDs (56%). Most commonly treated diagnoses included mood, tobacco use, and alcohol use disorders. ED visits were associated with being treated for anxiety (excluding post-traumatic stress disorder; Adjusted odds ratio [AOR]: 9.14 [95% confidence interval (CI): 8.26, 10.12]), alcohol use disorders (AOR = 1.67 [95% CI: 1.53, 1.83]), tobacco use (AOR = 1.16 [95% CI: 1.06, 1.26]), nondependent cocaine abuse (AOR = 5.47 [95% CI: 3.28, 9.12]), nondependent mixed/unspecified drug abuse (AOR = 7.30 [95% CI: 5.11, 10.44]), and psychosis (AOR = 1.38 [95% CI: 1.20, 1.58]). Compared with adults age 60 yr and older, adolescents (ages 12-17 yr), and adults under age 60 yr were more likely to be treated for suicidal ideation, adjustment, mood, bipolar, post-traumatic stress disorder, nondependent cocaine, and mixed/unspecified drug abuse. Adults under age 60 yr also had increased odds of being treated for tobacco use disorders, alcohol use disorders, and opioid/combination opioid dependence compared with adults age 60 yr and older. Conclusions Over the past 15 yr, purchased behavioral health care received by MHS beneficiaries in acute care facilities increased significantly. MHS beneficiaries received the majority of purchased behavioral health care for mental health disorders and were treated most often in the ED. Receiving behavioral health care in civilian EDs raises questions about access to outpatient behavioral health care and patient-centered care coordination between civilian and military facilities. Given the influx of new Veterans Health Administration users from the MHS, findings have implications for military, veteran, and civilian facilities providing behavioral health care to military and veteran populations.
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Affiliation(s)
- Nikki R Wooten
- College of Social Work, University of South Carolina, Hamilton College, Columbia, SC
| | - Jordan A Brittingham
- Arnold School of Public Health, University of South Carolina, 921 Assembly St., Columbia, SC
| | - Ronald O Pitner
- College of Social Work, University of South Carolina, Hamilton College, Columbia, SC
| | - Abbas S Tavakoli
- College of Nursing, University of South Carolina, 1601 Greene St., Columbia, SC
| | - Diana D Jeffery
- Clinical Support Division, Health Operations Directorate, Defense Health Agency, U.S. Department of Defense, 7700 Arlington Blvd, Suite 5101, Falls Church, VA
| | - K Sue Haddock
- Research Service, WJB Dorn Veterans Administration Medical Center, 6439 Garners Ferry Road, Columbia, SC
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20
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Richmond RR, Henebry AD. A Maisonneuve Fracture in an Active Duty Sailor: A Case Report. Mil Med 2018; 183:e278-e280. [PMID: 29415223 DOI: 10.1093/milmed/usx080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/04/2017] [Indexed: 11/13/2022] Open
Abstract
Maisonneuve fractures are relatively well known in the sports medicine, and orthopedic communities, however, can be commonly missed among primary care providers. The following case outlines an active duty 35-yr-old female patient who presented with acute pain on the left ankle and lower leg after she misjudged a step. The injury is a combination of high fibular and medial malleolar fractures with a disruption of the tibiofibular syndesmosis ligaments. This is a result of extreme external rotation and pronation of a fixed foot. The proper diagnosis is reliant on ankle and tibiofibular films, to include orthogonal views. This case serves as a reminder to always examine joints above and below the injury site, obtain orthogonal views of a fracture, as well as the unstable nature of syndesmosis injuries. This fracture is commonly a sports-related injury; thus, it is particularly important for military providers to be aware of Maisonneuve fractures and the common pitfalls in diagnosis and treatment.
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Affiliation(s)
- Ryan R Richmond
- Naval Health Branch Clinic Naval Air Technical Training Command, Naval Hospital Pensacola, 6000 West Highway 98, Pensacola, FL 32512
| | - Andrew D Henebry
- Department of Orthopedics, Naval Hospital Pensacola, 6000 West Highway 98, Pensacola, FL 32512
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21
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Teeters JB, Lancaster CL, Brown DG, Back SE. Substance use disorders in military veterans: prevalence and treatment challenges. Subst Abuse Rehabil 2017; 8:69-77. [PMID: 28919834 PMCID: PMC5587184 DOI: 10.2147/sar.s116720] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Substance use disorders (SUDs) are a significant problem among our nation's military veterans. In the following overview, we provide information on the prevalence of SUDs among military veterans, clinical characteristics of SUDs, options for screening and evidence-based treatment, as well as relevant treatment challenges. Among psychotherapeutic approaches, behavioral interventions for the management of SUDs typically involve short-term, cognitive-behavioral therapy interventions. These interventions focus on the identification and modification of maladaptive thoughts and behaviors associated with increased craving, use, or relapse to substances. Additionally, client-centered motivational interviewing approaches focus on increasing motivation to engage in treatment and reduce substance use. A variety of pharmacotherapies have received some support in the management of SUDs, primarily to help with the reduction of craving or withdrawal symptoms. Currently approved medications as well as treatment challenges are discussed.
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Affiliation(s)
- Jenni B Teeters
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
- Ralph H Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA
| | - Cynthia L Lancaster
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
- Ralph H Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA
| | - Delisa G Brown
- Department of Human Development and Psychoeducation, Howard University, Washington, DC, USA
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
- Ralph H Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA
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22
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Nigg CR, Jake-Schoffman DE, Janke EA. Motivating future directions of behavioral medicine. J Behav Med 2016; 40:1-5. [PMID: 28028656 DOI: 10.1007/s10865-016-9817-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 12/09/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Claudio R Nigg
- Office of Public Health Studies, University of Hawaii, 1960 East-West Road, Honolulu, HI, 96822, USA.
| | - Danielle E Jake-Schoffman
- Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - E Amy Janke
- Department of Behavioral and Social Sciences, University of the Sciences, Philadelphia, PA, USA
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