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Setia K, Otoya D, Boyd S, Fong K, Amendola MF, Lavingia KS. Socioeconomic Status Based on Area Deprivation Index Does Not Affect Postoperative Outcomes in Patients Undergoing Endovascular Aortic Aneurysm Repair in the VA Healthcare System. Ann Vasc Surg 2024:S0890-5096(24)00475-8. [PMID: 39067846 DOI: 10.1016/j.avsg.2024.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 05/09/2024] [Accepted: 06/02/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Living conditions and socioeconomic status are known to impact individual health and access to medical care. Prior research has validated the Area Deprivation Index (ADI) tool as a measure of socioeconomic disadvantage for a given locality. Living in a neighborhood with a higher ADI score has been associated with increased rates of hospital readmission due to complications following surgery. We set forth to identify the possible associations between a patient's ADI score and post-operative endovascular aneurysm repair (EVAR) outcomes in the Veterans Health Care Administration (VHA). METHODS We retrospectively analyzed the outcomes of patients who underwent EVAR from January 2010 to December 2021 at a Level 1A VHA Hospital. Patient demographics and intra-operative variables were obtained. ADI score was calculated based on home addresses and resulted in a local score on a scale of 1-10 and a national percentile on a scale of 1-100. We then further stratified these patients into local and national quintile groups. Local ADI 1 included scores of 1-2, and local ADI 5 included scores of 9-10. National ADI 1 comprised scores 1-20, and national ADI 5 scored 81-100. The other scores were equally divided into ADI 2, 3, and 4. Higher ADI scores were associated with lower socioeconomic status. We identified clinical outcomes, including wound infection, respiratory failure, urinary tract infection, acute kidney injury, limb stenosis, readmission, length of stay, and subsequent re-intervention rates. RESULTS 241 patients underwent EVAR over the time period examined. 57.3% (n=138) of patients were in quintiles 4 and 5 for local ADI; when national ADI percentiles organized these same patients, 47.3% (n=114) were in quintiles 4 and 5. Patient demographics did not vary between the local and national groups. We saw no statistically significant difference in intra-operative variables, postoperative complications, readmission, loss to follow-up, or 1-year mortality rates across ADI quintiles at the local or national level. Binary Logistic Regression showed no statistical significance for local and national ADI quintiles for hospital readmission and overall postoperative complications. CONCLUSION We found that there was no statistical significance between hospital readmission rates or worse surgical outcomes across local and national ADI quintiles. This suggests that the VHA resources and multidisciplinary support may improve care across neighborhoods. This comprehensive care provided at VHA may mitigate post-operative complications in patients undergoing EVARs. Further research is warranted to investigate the role of area deprivation in healthcare and EVAR outcomes in a veteran population.
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Affiliation(s)
- Karishma Setia
- Virginia Commonwealth University School of Medicine, Richmond Virginia
| | - Diana Otoya
- Virginia Commonwealth University Healthcare System, Richmond Virginia
| | - Sally Boyd
- Virginia Commonwealth University Healthcare System, Richmond Virginia
| | - Kathryn Fong
- Virginia Commonwealth University School of Medicine, Richmond Virginia; Central Virginia VA Healthcare System, Richmond Virginia
| | - Michael F Amendola
- Virginia Commonwealth University School of Medicine, Richmond Virginia; Central Virginia VA Healthcare System, Richmond Virginia
| | - Kedar S Lavingia
- Virginia Commonwealth University School of Medicine, Richmond Virginia; Central Virginia VA Healthcare System, Richmond Virginia
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Wong MS, Tseng CH, Moy E, Jones KT, Kothari AJ, Washington DL. Relationship between health system quality and racial and ethnic equity in diabetes care. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae073. [PMID: 38989064 PMCID: PMC11235325 DOI: 10.1093/haschl/qxae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/02/2024] [Accepted: 05/16/2024] [Indexed: 07/12/2024]
Abstract
Failing to consider disparities in quality measures, such as by race and ethnicity, may obscure inequities in care, which could exist in facilities with overall high-quality ratings. We examined the relationship between overall quality and racial and ethnic disparities in diabetes care quality by health care facility-level performance on a diabetes-related quality measure within a national dataset of veterans using Veterans Health Administration (VA) ambulatory care between March 1, 2020 and Feburary 28, 2021, and were eligible for diabetes quality assessment. We found racial and ethnic disparities in diabetes care quality existed in top-performing VA medical centers (VAMCs) among American Indian or Alaska Native (AIAN) (predicted probability = 30%), Black (predicted probability = 29%), and Hispanic VA-users (predicted probability = 30%) vs White VA-users (predicted probability = 26%). While disparities among Black and Hispanic VA-users were similar relative to White VA-users across VAMCs at all performance levels, disparities were exacerbated for AIAN and Native Hawaiian or Other Pacific Islander VA-users in bottom-performing VAMCs. Equity remains an issue even in facilities providing overall high-quality care. Integrating equity as a component of quality measures can incentivize greater focus on equity in quality improvement.
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Affiliation(s)
- Michelle S Wong
- HSR Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, United States
| | - Ernest Moy
- US Department of Veterans Affairs, Office of Health Equity, Washington, DC 20420, United States
| | - Kenneth T Jones
- US Department of Veterans Affairs, Office of Health Equity, Washington, DC 20420, United States
| | - Amit J Kothari
- Office of the Chief of Staff, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
| | - Donna L Washington
- HSR Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, United States
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, United States
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Washington L, Bronson J, Timko C, Han B, Blue-Howells J, Finlay AK. Health Conditions and Treatment Utilization Among Older Male Veterans Incarcerated in Prisons. J Gen Intern Med 2024; 39:1369-1377. [PMID: 38228986 PMCID: PMC11169130 DOI: 10.1007/s11606-023-08587-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND More than 50,000 older male veterans incarcerated in prisons are expected to return to their communities and utilize the Veterans Health Administration (VHA) and community healthcare systems. To support the continuity of healthcare and overall successful community reentry of older incarcerated veterans, an understanding of their health profiles and treatment utilization while in correctional care is needed. OBJECTIVE To assess the health status of older male veterans incarcerated in state prisons and explore demographic, military, and VHA-related factors associated with medical conditions, disabilities, behavioral conditions, and medical and behavioral treatment utilization. DESIGN/PARTICIPANTS Cross-sectional observational study of 880 male veterans aged 50 + incarcerated in state prisons using data from the 2016 Bureau of Justice Statistics Survey of Prison Inmates. MAIN MEASURES Veteran status, self-report health status, and treatment utilization since prison admission. Prevalence rates for conditions and treatment utilization were calculated. Logistic regression models were used to examine the association of characteristics with conditions and treatment utilization. KEY RESULTS Among the 880 older male veterans in state prisons, the majority reported having a current medical condition (79.3%) or disability (61.6%), almost half had history of a mental health condition (44.5%), and more than a quarter (29%) had a substance use disorder. Compared to White veterans, Black veterans were less likely to report a disability or mental health condition. Few demographic, military, and VA-related characteristics were associated with medical or behavioral conditions or treatment utilization. CONCLUSION Our results suggest that the VHA and community healthcare systems need to be prepared to address medical and disability conditions among the majority of older male veterans who will be leaving prison and returning to their communities. Integrated medical and behavioral healthcare delivery models may be especially important for these veterans as many did not receive behavioral health treatment while in prison.
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Affiliation(s)
- Lance Washington
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Rd (152-MPD), Menlo Park, CA, 94025, USA.
| | | | - Christine Timko
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Rd (152-MPD), Menlo Park, CA, 94025, USA
| | - Benjamin Han
- Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, University of California San Diego, San Diego, USA
- Veterans Affairs San Diego Healthcare System, San Diego, USA
| | - Jessica Blue-Howells
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Rd (152-MPD), Menlo Park, CA, 94025, USA
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Rd (152-MPD), Menlo Park, CA, 94025, USA
- National Center On Homelessness Among Veterans, Veterans Health Administration, Menlo Park, CA, USA
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Weeda ER, Ward R, Gebregziabher M, Axon RN, Taber DJ. Impact of Race and Ethnicity on Severe Hypoglycemia Associated with Sulfonylurea Use for Type 2 Diabetes among Veterans. J Racial Ethn Health Disparities 2024; 11:1427-1433. [PMID: 37129787 PMCID: PMC10620099 DOI: 10.1007/s40615-023-01619-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/03/2023]
Abstract
Sulfonylureas are associated with hypoglycemia. Whether a racial/ethnic disparity in this safety outcome exists is unknown. We sought to assess the impact of race/ethnicity on severe hypoglycemia associated with sulfonylurea use for type 2 diabetes (T2D). Using Veterans Affairs and Medicare data, Veterans initially receiving metformin monotherapy for T2D between 2004 and 2006 were identified. Sulfonylurea use (either alone or via the addition of a prescription for a sulfonylurea to metformin) was captured and compared to remaining on metformin alone during the follow-up period (2007-2016). Hazard ratios (HR) and 95% confidence intervals (CI) from longitudinal competing risk Cox models were used to measure the association between sulfonylurea use and severe hypoglycemia defined as hospitalization for hypoglycemia. A total of 113,668 Veterans with T2D were included. A higher risk of severe hypoglycemia was associated with the receipt of sulfonylurea prescriptions versus remaining on metformin alone across all groups. The effect was largest among Hispanic Veterans (HR: 7.59, 95%CI:4.32-13.33), followed by Veterans in the other race/ethnicity cohort (HR: 4.57, 95%CI:2.50-8.36) and Non-Hispanic Black Veterans (HR: 3.67, 95%CI:2.78-4.85). The effect was smallest among Non-Hispanic White Veterans (HR: 3.11, 95%CI:2.77-3.48). In conclusion, a higher risk of severe hypoglycemia associated with sulfonylurea prescriptions was observed across all analyses. The relationship was most pronounced for Hispanic Veterans, who had nearly 8 times the risk of severe hypoglycemia with sulfonylureas versus remaining on metformin alone.
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Affiliation(s)
- Erin R Weeda
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
- College of Pharmacy, Medical University of South Carolina, 280 Calhoun Street, Charleston, SC, 29425, USA.
| | - Ralph Ward
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- Department of Public Health Science, Medical University of South Carolina, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- Department of Public Health Science, Medical University of South Carolina, Charleston, SC, USA
| | - R Neal Axon
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - David J Taber
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Chu GM, Almklov E, Wang C, McLean CL, Pittman JOE, Lang AJ. Relationships among race, ethnicity, and gender and whole health among U.S. veterans. Psychol Serv 2024; 21:294-304. [PMID: 37824243 PMCID: PMC11009376 DOI: 10.1037/ser0000807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Racial, ethnic, and gender health care disparities in the United States are well-documented and stretch across the lifespan. Even in large integrated health care systems such as Veteran Health Administration, which are designed to provide equality in care, social and economic disparities persist, and limit patients' achievement of health goals across multiple domains. We explore Veterans' Whole Health priorities among Veteran demographic groups. Participants who were enrolling in Veteran Health Administration provided demographics and Whole Health priorities using eScreening, a web-based self-assessment tool. Veterans had similar health care goals regardless of demographic characteristics but differences were noted in current health appraisals. Non-White and women Veterans reported worse health-relevant functioning. Black Veterans were more likely to endorse a low rating for their personal development/relationships. Multiracial Veterans were more likely to endorse a low rating of their surroundings. Asian Veterans were less likely to provide a high rating of their surroundings. Women Veterans reported lower appraisals for body and personal development but higher appraisals of professional care. Results indicated that demographic factors such as race and gender, and to a lesser extent ethnicity, were associated with health disparities. The Whole Health model provides a holistic framework for addressing these disparities. These findings may inform more culturally sensitive care and enhance Veteran Health Administration equal access initiatives. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
| | - Erin Almklov
- VA San Diego Healthcare System
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System
| | | | - Caitlin L. McLean
- VA San Diego Healthcare System
- Department of Psychiatry, University of California, San Diego
| | - James O. E. Pittman
- VA San Diego Healthcare System
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System
- Department of Psychiatry, University of California, San Diego
| | - Ariel J. Lang
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System
- Department of Psychiatry, University of California, San Diego
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego
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Howard JT, Stewart IJ, Walker LE, Amuan M, Rayha K, Janak JC, Pugh MJ. Comparison of Racial and Ethnic Mortality Disparities among Post-9/11 Veterans with and without Traumatic Brain Injury to the Total U.S. Adult Population. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02004-1. [PMID: 38622427 DOI: 10.1007/s40615-024-02004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/27/2024] [Accepted: 04/07/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION The extent of racial/ethnic disparities and whether they are attenuated in the Veteran population compared to the total US population is not well understood. We aimed to assess racial/ethnic mortality disparities from all-cause, cardiovascular (CVD) and cancer among post-9/11 military Veterans with and without exposure to TBI, compared to the total US population. METHODS This cohort study included 2,502,101 US military Veterans (18,932,083 person-years) who served after 09/11/2001 with 3 or more years of care in the Military Health System (MHS); or had 3 or more years of care in the MHS and 2 or more years of care in the Veterans Health Administration. Mortality follow-up occurred from 01/01/2002 to 12/31/2020. Mortality rate ratios (MRR) from negative binomial regression models were reported for racial/ethnic groups compared to White non-Hispanic Veterans for all-cause, CVD and cancer mortality. Veteran MRR were compared to the total US population. RESULTS Mortality rates for Black Non-Hispanic Veterans were higher for all-cause (MRR = 1.21;95%CI: 1.13-1.29; p < 0.001), CVD (MRR = 1.78;95%CI: 1.62-1.96; p < 0.001) and cancer (MRR = 1.17;95%CI: 1.10-1.25; p < 0.001) than in White Non-Hispanic Veterans. Among Veterans with TBI, only Black Non-Hispanics had higher mortality than White Non-Hispanics and only for CVD (MRR = 1.32;95%CI: 1.12-1.54; p < 0.001), while CVD mortality was higher among Veterans without TBI (MRR = 1.77;95%CI: 1.63-1.93;p < 0.001). MRR for Black Non-Hispanics in the total US population, were consistently higher than those in the Veteran population for all-cause (MRR = 1.52;95%CI: 1.46-1.58; p < 0.001), CVD (MRR = 2.03;95%CI: 1.95-2.13; p < 0.001) and cancer (MRR = 1.26;95%CI: 1.22-1.30; p < 0.001). CONCLUSION This Veteran cohort experienced less racial/ethnic disparity in mortality than the total US population, especially among Veterans with TBI.
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Affiliation(s)
- Jeffrey T Howard
- Department of Public Health, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249, USA.
| | - Ian J Stewart
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
- Military Cardiovascular Outcomes Research Program, Bethesda, MD, USA
| | - Lauren E Walker
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Megan Amuan
- University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, Utah, USA
- United States Department of Veterans Affairs, 550 Foothill Dr, Salt Lake City, Utah, USA
| | - Kara Rayha
- Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, USA
| | | | - Mary Jo Pugh
- University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, Utah, USA
- United States Department of Veterans Affairs, 550 Foothill Dr, Salt Lake City, Utah, USA
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Aron J, Baldomero AK, Rau A, Fiecas MB, Wendt CH, Berman JD. Individual Risk Factors of PM 2.5 Associated With Wintertime Mortality in Urban Patients With COPD. Chest 2024; 165:825-835. [PMID: 37858719 PMCID: PMC11026168 DOI: 10.1016/j.chest.2023.10.016] [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: 07/05/2023] [Revised: 09/19/2023] [Accepted: 10/11/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Air pollution contributes to premature mortality, but potential impacts differ in populations with existing disease, particularly for individuals with multiple risk factors. Although COPD increases vulnerability to air pollution, individuals with COPD and other individual risk factors are at the intersection of multiple risks and may be especially susceptible to the effect of acute outdoor air pollution. RESEARCH QUESTION What is the association between wintertime air pollution and mortality in patients with COPD and the modifying role of individual risk factors? STUDY DESIGN AND METHODS This study evaluated 19,243 deceased veterans with prior COPD diagnosis who had resided in 25 US metropolitan regions (2016-2019). Electronic health records included patient demographic characteristics; smoking status; and comorbidities such as asthma, coronary artery disease (CAD), obesity, and diabetes. Using geocoded addresses, individuals were assigned wintertime fine particulate matter (particulate matter smaller than 2.5 μg in diameter [PM2.5]) and nitrogen dioxide air pollution exposures. Associations between acute air pollution and mortality were estimated by using a time-stratified case-crossover design with a conditional logistic model, and individual risk differences were assessed according to stratified analysis. RESULTS A 1.05 (95% CI, 1.02-1.09) mortality risk was estimated for each 10 μg/m3 increase in daily wintertime PM2.5). Older patients and Black individuals displayed elevated risk. Obesity was a substantial air pollution-related mortality risk factor (OR, 1.11; 95% CI, 1.01-1.23), and the estimated risk for individuals with obesity plus CAD or obesity plus diabetes was 16% higher. INTERPRETATION Wintertime PM2.5 exposure was associated with elevated mortality risk in people with COPD, but individuals with multiple comorbidities, notably obesity, had high vulnerability. Our study suggests that obesity, CAD, and diabetes are understudied modifiers of air pollution-related risks for people with existing COPD.
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Affiliation(s)
- Jordan Aron
- Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN.
| | - Arianne K Baldomero
- Pulmonary, Allergy, Critical Care and Sleep Medicine, Medical School, University of Minnesota, Minneapolis, MN; Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN; Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN
| | - Austin Rau
- Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Mark B Fiecas
- Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Christine H Wendt
- Pulmonary, Allergy, Critical Care and Sleep Medicine, Medical School, University of Minnesota, Minneapolis, MN; Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN
| | - Jesse D Berman
- Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, MN
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Roman Souza G, Nooruddin Z, Lee S, Boyle L, Lucero KT, Ananth S, Franklin K, Mader M, Toro Velez E, Naqvi A, Kaur S. The Impact of Time From Diagnosis to Initiation of Chemotherapy on Survival of Patients With Newly Diagnosed Diffuse Large B-Cell Lymphoma in the Veterans Health Administration. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e67-e77. [PMID: 38151390 DOI: 10.1016/j.clml.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/18/2023] [Accepted: 11/19/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Our retrospective study evaluates the impact of time from diagnosis to treatment (TDT) on outcomes of patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) treated within the Veterans Health Administration (VHA). METHODS VHA patients diagnosed with DLBCL between 2011 and 2019 were included, while those with primary central nervous system lymphoma were excluded. The median overall survival and progression-free survival were estimated with the Kaplan-Meier method. Univariate, bivariate, and multivariable analyses were performed using the Cox proportional hazards model. The odds ratio for refractory outcomes was calculated using logistic regression. RESULTS A total of 2448 patients were included. The median time from diagnosis to treatment of the cohort was 19 days. When comparing median progression-free survival, median overall survival, and the 2-year overall survival between the group that started treatment within 1 week and each of the other groups individually, there was a significant difference favoring improved survival in all groups with a TDT longer than 1 week (P < .0001). These patients also had a lower odds ratio for refractory outcomes. On multivariable analysis, TDT remained an independent prognostic factor. CONCLUSION Our study shows that a TDT equal to or less than 1 week is associated with adverse clinical factors, worse outcomes, and response in DLBCL, even after adjusting for multiple known poor prognostic factors. This was the first time that response to first-line therapy was correlated to time to treatment. Our findings support ongoing efforts to improve currently standardized prognostic tools and the incorporation of TDT into clinical trials to avoid selection bias.
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Affiliation(s)
| | - Zohra Nooruddin
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Sophia Lee
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Lauren Boyle
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Kana Tai Lucero
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | | | | | - Michael Mader
- South Texas Veterans Health Care System, San Antonio, TX
| | | | - Amna Naqvi
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Supreet Kaur
- University of Texas Health Science Center San Antonio, San Antonio, TX
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Shannon EM, Steers WN, Washington DL. Investigation of the role of perceived access to primary care in mediating and moderating racial and ethnic disparities in chronic disease control in the veterans health administration. Health Serv Res 2024; 59:e14260. [PMID: 37974469 PMCID: PMC10771907 DOI: 10.1111/1475-6773.14260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE To examine the role of patient-perceived access to primary care in mediating and moderating racial and ethnic disparities in hypertension control and diabetes control among Veterans Health Administration (VA) users. DATA SOURCE AND STUDY SETTING We performed a secondary analysis of national VA user administrative data for fiscal years 2016-2019. STUDY DESIGN Our primary exposure was race or ethnicity and primary outcomes were binary indicators of hypertension control (<140/90 mmHg) and diabetes control (HgbA1c < 9%) among patients with known disease. We used the inverse odds-weighting method to test for mediation and logistic regression with race and ethnicity-by-perceived access interaction product terms to test moderation. All models were adjusted for age, sex, socioeconomic status, rurality, education, self-rated physical and mental health, and comorbidities. DATA COLLECTION/EXTRACTION METHODS We included VA users with hypertension and diabetes control data from the External Peer Review Program who had contemporaneously completed the Survey of Healthcare Experience of Patients-Patient-Centered Medical Home. Hypertension (34,233 patients) and diabetes (23,039 patients) samples were analyzed separately. PRINCIPAL FINDINGS After adjustment, Black patients had significantly lower rates of hypertension control than White patients (75.5% vs. 78.8%, p < 0.01); both Black (81.8%) and Hispanic (80.4%) patients had significantly lower rates of diabetes control than White patients (85.9%, p < 0.01 for both differences). Perceived access was lower among Black, Multi-Race and Native Hawaiian and Other Pacific Islanders compared to White patients in both samples. There was no evidence that perceived access mediated or moderated associations between Black race, Hispanic ethnicity, and hypertension or diabetes control. CONCLUSIONS We observed disparities in hypertension and diabetes control among minoritized patients. There was no evidence that patients' perception of access to primary care mediated or moderated these disparities. Reducing racial and ethnic disparities within VA in hypertension and diabetes control may require interventions beyond those focused on improving patient access.
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Affiliation(s)
- Evan Michael Shannon
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Division of General Internal Medicine and Health Services ResearchUCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Division of General Internal Medicine and Health Services ResearchUCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
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Marôco JL, Manafi MM, Hayman LL. Race and Ethnicity Disparities in Cardiovascular and Cancer Mortality: the Role of Socioeconomic Status-a Systematic Review and Meta-analysis. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01872-3. [PMID: 38038904 DOI: 10.1007/s40615-023-01872-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/24/2023] [Accepted: 11/12/2023] [Indexed: 12/02/2023]
Abstract
To clarify the role of socioeconomic status (SES) in cardiovascular and cancer mortality disparities observed between Black, Hispanic, and Asian compared to White adults, we conducted a meta-analysis of the longitudinal research in the USA. A PubMed, Ovid Medline, Web of Science, and EBSCO search was performed from January 1995 to May 2023. Two authors independently screened the studies and conducted risk assessments, with conflicts resolved via consensus. Studies were required to analyze mortality data using Cox proportional hazard regression. Random-effects models were used to pool hazard ratios (HR) and reporting followed PRISMA guidelines. Twenty-two studies with cardiovascular mortality (White and Black (n = 22), Hispanic (n = 7), and Asian (n = 3) adults) and twenty-three with cancer mortality endpoints (White and Black (n = 23), Hispanic (n = 11), and Asian (n = 10) adults) were included. The meta-analytic sample for cardiovascular mortality endpoints was 6,199,049 adults (White = 4,891,735; Black = 935,002; Hispanic = 295,623; Asian = 76,689), while for cancer-specific mortality endpoints was 7,745,180 adults (White = 5,988,392; Black= 1,070,447; Hispanic= 484,848; Asian = 201,493). Median follow-up was 10 and 11 years in cohorts with cardiovascular and cancer mortality endpoints, respectively. Adjustments for SES attenuated the higher risk for cardiovascular (HR, 1.46; 95% CI, 1.30-1.64) and cancer mortality (HR, 1.35; 95% CI, 1.32-1.38) of Black compared to White adults by 25% (HR, 1.21; 95% CI, 1.15-1.28) and 19% (HR, 1.16; 95% CI, 1.13-1.18), respectively. However, the Hispanic cardiovascular (HR, 0.79; 95% CI, 0.73-0.85) and Asian cancer mortality (HR, 0.81; 95% CI, 0.76-0.86) advantage were independent of SES. These findings emphasize the need to develop strategies focused on SES to reduce cardiovascular and cancer mortality in Black adults.
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Affiliation(s)
- João L Marôco
- Integrative Human Physiology Laboratory, Manning College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA.
- Department of Exercise and Health Sciences, Manning College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA.
| | - Mahdiyeh M Manafi
- Department of Exercise and Health Sciences, Manning College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Laura L Hayman
- Department of Nursing, Manning College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
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Shannon EM, Haderlein TP, Neil Steers W, Wong MS, Washington DL. Comparison of Racial and Ethnic Disparities in COVID-19 Mortality Between Veterans Health Administration and US Populations. J Gen Intern Med 2023; 38:3657-3659. [PMID: 37740169 PMCID: PMC10713933 DOI: 10.1007/s11606-023-08430-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Evan M Shannon
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA, USA.
| | - Taona P Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA, USA
| | - W Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Michelle S Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
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List JM, Palevsky P, Tamang S, Crowley S, Au D, Yarbrough WC, Navathe AS, Kreisler C, Parikh RB, Wang-Rodriguez J, Klutts JS, Conlin P, Pogach L, Meerwijk E, Moy E. Eliminating Algorithmic Racial Bias in Clinical Decision Support Algorithms: Use Cases from the Veterans Health Administration. Health Equity 2023; 7:809-816. [PMID: 38076213 PMCID: PMC10698768 DOI: 10.1089/heq.2023.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 01/29/2024] Open
Abstract
The Veterans Health Administration uses equity- and evidence-based principles to examine, correct, and eliminate use of potentially biased clinical equations and predictive models. We discuss the processes, successes, challenges, and next steps in four examples. We detail elimination of the race modifier for estimated kidney function and discuss steps to achieve more equitable pulmonary function testing measurement. We detail the use of equity lenses in two predictive clinical modeling tools: Stratification Tool for Opioid Risk Mitigation (STORM) and Care Assessment Need (CAN) predictive models. We conclude with consideration of ways to advance racial health equity in clinical decision support algorithms.
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Affiliation(s)
- Justin M. List
- VA Office of Health Equity, Washington, District of Columbia, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Paul Palevsky
- Kidney Medicine Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Suzanne Tamang
- Department of Veterans Affairs, Palo Alto, California, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Susan Crowley
- Nephrology Section, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - David Au
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - William C. Yarbrough
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
- VA North Texas Health Care System, Dallas, Texas, USA
| | - Amol S. Navathe
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Craig Kreisler
- Analytics and Performance Integration (API), Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Ravi B. Parikh
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jessica Wang-Rodriguez
- VA National Pathology and Laboratory Medicine Service, Washington, District of Columbia, USA
- Department of Pathology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - J. Stacey Klutts
- National VHA Diagnostics Office, Washington, District of Columbia, USA
- Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Paul Conlin
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Leonard Pogach
- Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey, USA
| | | | - Ernest Moy
- VA Office of Health Equity, Washington, District of Columbia, USA
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Vassy JL, Brunette CA, Lebo MS, MacIsaac K, Yi T, Danowski ME, Alexander NVJ, Cardellino MP, Christensen KD, Gala M, Green RC, Harris E, Jones NE, Kerman BJ, Kraft P, Kulkarni P, Lewis ACF, Lubitz SA, Natarajan P, Antwi AA. The GenoVA study: Equitable implementation of a pragmatic randomized trial of polygenic-risk scoring in primary care. Am J Hum Genet 2023; 110:1841-1852. [PMID: 37922883 PMCID: PMC10645559 DOI: 10.1016/j.ajhg.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023] Open
Abstract
Polygenic risk scores (PRSs) hold promise for disease risk assessment and prevention. The Genomic Medicine at Veterans Affairs (GenoVA) Study is addressing three main challenges to the clinical implementation of PRSs in preventive care: defining and determining their clinical utility, implementing them in time-constrained primary care settings, and countering their potential to exacerbate healthcare disparities. The study processes used to test patients, report their PRS results to them and their primary care providers (PCPs), and promote the use of those results in clinical decision-making are modeled on common practices in primary care. The following diseases were chosen for their prevalence and familiarity to PCPs: coronary artery disease; type 2 diabetes; atrial fibrillation; and breast, colorectal, and prostate cancers. A randomized clinical trial (RCT) design and primary outcome of time-to-new-diagnosis of a target disease bring methodological rigor to the question of the clinical utility of PRS implementation. The study's pragmatic RCT design enhances its relevance to how PRS might reasonably be implemented in primary care. Steps the study has taken to promote health equity include the thoughtful handling of genetic ancestry in PRS construction and reporting and enhanced recruitment strategies to address underrepresentation in research participation. To date, enhanced recruitment efforts have been both necessary and successful: participants of underrepresented race and ethnicity groups have been less likely to enroll in the study than expected but ultimately achieved proportional representation through targeted efforts. The GenoVA Study experience to date offers insights for evaluating the clinical utility of equitable PRS implementation in adult primary care.
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Affiliation(s)
- Jason L Vassy
- VA Boston Healthcare System, Boston, MA, USA; Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA; Ariadne Labs, Boston, MA, USA.
| | - Charles A Brunette
- VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Matthew S Lebo
- Harvard Medical School, Boston, MA, USA; Laboratory for Molecular Medicine, Mass General Brigham, Boston, MA, USA; Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Thomas Yi
- VA Boston Healthcare System, Boston, MA, USA
| | | | - Nicholas V J Alexander
- VA Boston Healthcare System, Boston, MA, USA; Bucharest University Emergency Hospital, Bucharest, Romania; Bucharest University of Economic Studies, Bucharest, Romania
| | | | - Kurt D Christensen
- Harvard Medical School, Boston, MA, USA; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Manish Gala
- Harvard Medical School, Boston, MA, USA; Division of Gastroenterology and Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Robert C Green
- Harvard Medical School, Boston, MA, USA; Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA; Ariadne Labs, Boston, MA, USA; Department of Medicine (Genetics), Mass General Brigham, Boston, MA, USA
| | | | - Natalie E Jones
- VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Benjamin J Kerman
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Peter Kraft
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | | | - Anna C F Lewis
- Department of Medicine (Genetics), Mass General Brigham, Boston, MA, USA; Edmond and Lily Safra Center for Ethics, Harvard University, Boston, MA, USA
| | - Steven A Lubitz
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA; Novartis Institutes for BioMedical Research, Novartis, Basel, Basel-Stadt, Switzerland
| | - Pradeep Natarajan
- Harvard Medical School, Boston, MA, USA; Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA; Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
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14
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Rasmussen KM, Patil V, Li C, Yong C, Appukkutan S, Grossman JP, Jhaveri J, Halwani AS. Survival Outcomes by Race and Ethnicity in Veterans With Nonmetastatic Castration-Resistant Prostate Cancer. JAMA Netw Open 2023; 6:e2337272. [PMID: 37819658 PMCID: PMC10568364 DOI: 10.1001/jamanetworkopen.2023.37272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/28/2023] [Indexed: 10/13/2023] Open
Abstract
Importance Racial and ethnic disparities in prostate cancer are poorly understood. A given disparity-related factor may affect outcomes differently at each point along the highly variable trajectory of the disease. Objective To examine clinical outcomes by race and ethnicity in patients with nonmetastatic castration-resistant prostate cancer (nmCRPC) within the US Veterans Health Administration. Design, Setting, and Participants A retrospective, observational cohort study using electronic health care records (January 1, 2006, to December 31, 2021) in a nationwide equal-access health care system was conducted. Mean (SD) follow-up time was 4.3 (3.3) years. Patients included in the analysis were diagnosed with prostate cancer from January 1, 2006, to December 30, 2020, that progressed to nmCRPC defined by (1) increasing prostate-specific antigen levels, (2) ongoing androgen deprivation, and (3) no evidence of metastatic disease. Patients with metastatic disease or death within the landmark period (3 months after the first nmCRPC evidence) were excluded. Main Outcomes and Measures The primary outcome was time from the landmark period to death or metastasis; the secondary outcome was overall survival. A multivariate Cox proportional hazards model, Kaplan-Meier estimates, and adjusted survival curves were used to evaluate outcome differences by race and ethnicity. Results Of 12 992 patients in the cohort, 826 patients identified as Hispanic (6%), 3671 as non-Hispanic Black (28%; henceforth Black), 7323 as non-Hispanic White (56%; henceforth White), and 1172 of other race and ethnicity (9%; henceforth other, including American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, unknown by patient, and patient declined to answer). Median time elapsed from nmCRPC to metastasis or death was 5.96 (95% CI, 5.58-6.34) years for Black patients, 5.62 (95% CI, 5.11-6.67) years for Hispanic patients, 4.11 (95% CI, 3.96-4.25) years for White patients, and 3.59 (95% CI, 3.23-3.97) years for other patients. Median unadjusted overall survival was 6.26 (95% CI, 6.03-6.46) years among all patients, 8.36 (95% CI, 8.0-8.8) years for Black patients, 8.56 (95% CI, 7.3-9.7) years for Hispanic patients, 5.48 (95% CI, 5.2-5.7) years for White patients, and 4.48 (95% CI, 4.1-5.0) years for other patients. Conclusions and Relevance The findings of this cohort study of patients with nmCRPC suggest that differences in outcomes by race and ethnicity exist; in addition, Black and Hispanic men may have considerably improved outcomes when treated in an equal-access setting.
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Affiliation(s)
- Kelli M. Rasmussen
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
| | - Vikas Patil
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
| | - Chunyang Li
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
| | - Christina Yong
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
| | | | | | | | - Ahmad S. Halwani
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
- Huntsman Cancer Institute, Salt Lake City, Utah
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15
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Peltzman T, Forehand JA, Freytes IM, Shiner B. Rural and Urban Hispanic Patients of the Veterans Health Administration. J Racial Ethn Health Disparities 2023; 10:2273-2283. [PMID: 36100811 DOI: 10.1007/s40615-022-01406-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 01/05/2023]
Abstract
Hispanic Veterans are the largest growing racial and ethnic minority group in the Veterans Health Administration (VA) system. Though recent research has found increasing suicide rates in this population and a growing rural-urban disparity, literature on core population characteristics remains sparse. We used extensive patient demographic and clinical data from VA's electronic medical record repository to examine geographic and longitudinal variation in Hispanic VA patients from 2001 to 2018. As the first such detailed characterization of this population, this study was largely descriptive in nature, and included heatmaps of Hispanic patient residence across rural and urban US counties, along with descriptive measures of patient characteristics by rurality, and first year of VA use. We found that Hispanic patients (n = 722,893) represented 5.2% of new VA users between 2001 and 2018, a proportion which grew nearly 90% from 4.0% (2001-2006) to 7.5% (2013-2018). Hispanic patients were largely White, male, under age 50, and had minimal illness or disability. The highest prevalence of Hispanic patients was in the Southwest US/Mexico border region, while the Midwest experienced the largest growth of Hispanic patients. Rural Hispanic patients were more likely to be older, male, and to live in areas characterized by small foreign-born populations and high socioeconomic deprivation. Compared with Hispanic patients entering the VA system in 2001-2006, patients in 2013-2018 were younger, more likely to be female, and to live in urban areas. These findings illustrate the wide range of demographic, clinical, and geographic experiences in the growing VA Hispanic population and demonstrate that culturally competent care for Hispanic Veterans must reflect their intra-ethnic diversity.
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Affiliation(s)
- Talya Peltzman
- Mental Health and Behavioral Science Service, Veterans Affairs Medical Center, White River Junction, VT, USA.
| | - Jenna A Forehand
- Mental Health and Behavioral Science Service, Veterans Affairs Medical Center, White River Junction, VT, USA
| | - Ivette M Freytes
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Brian Shiner
- Mental Health and Behavioral Science Service, Veterans Affairs Medical Center, White River Junction, VT, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- National Center for Posttraumatic Stress Disorder, Veterans Affairs Medical Center, White River Junction, VT, USA
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16
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Abella MKIL, Lee AY, Kitamura RK, Ahn HJ, Woo RK. Disparities and Risk Factors for Surgical Complication in American Indians and Native Hawaiians. J Surg Res 2023; 288:99-107. [PMID: 36963299 DOI: 10.1016/j.jss.2023.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/25/2023] [Accepted: 02/18/2023] [Indexed: 03/26/2023]
Abstract
INTRODUCTION American Indian and Alaskan Natives (AIAN) and Native Hawaiian and Pacific Islanders (NHPI) research is limited, particularly in postoperative surgical outcomes. This study analyzes disparities in AIAN and NHPI surgical complications across all surgical types and identifies factors that contribute to postoperative complications. METHODS This retrospective cohort study examined all surgeries from 2011 to 2020 in the National Surgical Quality Improvement Program, queried by race. Multivariable models analyzed the association of race and ethnicity and 30-day postoperative complication. Next, multivariable models were used to identify preoperative variables associated with postoperative complications, specifically in AIAN and NHPI patients. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated. RESULTS AIAN patients were associated with higher odds of postoperative complication (AOR: 1.008 [CI: 1.005-1.011], P < 0.001) compared to non-Hispanic white patients. The comorbidities that were of higher incidence in AIAN patients, which also adversely contributed to postoperative complication, included dependent functional status, diabetes, congestive heart failure (CHF), open wounds, preoperative weight loss, bleeding disorders, preoperative transfusion, sepsis, hypoalbuminemia, along with an active smoking status and ASA ≥3. In NHPI patients, dependent functional status, CHF, renal failure, preoperative transfusion, open wounds, and sepsis were of higher incidence and significantly contributed to postoperative complication. CONCLUSIONS Surgical outcome disparities exist particularly in AIAN patients. Identification of modifiable patient risk factors may benefit perioperative care for AIAN and NHPI patients, which are historically understudied racial groups.
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Affiliation(s)
| | - Anson Y Lee
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Riley K Kitamura
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Queen's Medical Center, Honolulu, Hawaii
| | - Hyeong Jun Ahn
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Russell K Woo
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Kapi'olani Medical Center for Women and Children, Hawai'i Pacific Health, Honolulu, Hawaii
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17
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Bowersox NW, Browne J, Grau PP, Merrill SL, Haderlein TP, Llorente MD, Washington DL. COVID-19 mortality among veterans with serious mental illness in the veterans health administration. J Psychiatr Res 2023; 163:222-229. [PMID: 37230006 PMCID: PMC10171776 DOI: 10.1016/j.jpsychires.2023.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/31/2023] [Accepted: 05/01/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Persons with serious mental illness (SMI: schizophrenia-spectrum disorders, bipolar disorder) experience increased risk of mortality after contracting COVID-19 based on the results of several international evaluations. However, information about COVID-19 mortality risk among patients with SMI in the Veterans Health Administration (VHA) has been limited, precluding identification of protective factors. The current evaluation was conducted to assess COVID-19 mortality risk among VHA patients with SMI and to evaluate potential protective factors in mitigating mortality risk following a positive COVID-19 diagnosis. METHODS National VHA administrative data was used to identify all patients (N = 52,916) who received a positive COVID-19 test result between March 1, 2020, and September 30, 2020. Mortality risk was assessed by SMI status via bivariate comparisons and multivariate regression analyses. RESULTS In unadjusted analyses, VHA patients with SMI overall and patients with bipolar disorder in particular did not experience increased mortality risk in the 30 days following a positive COVID test, although patients with schizophrenia had increased risk. Within adjusted analyses, patients with schizophrenia remained at increased mortality risk (OR = 1.38), but at reduced levels relative to previous evaluations in other healthcare settings. CONCLUSIONS Within VHA, patients with schizophrenia, but not those with bipolar disorder, experience increased mortality risk in the 30 days following a positive COVID-19 test. Large integrated healthcare settings such as VHA may offer services which may protect against COVID-19 mortality for vulnerable groups such as persons with SMI. Additional work is needed to identify practices which may reduce the risk of COVID-19 mortality among persons with SMI.
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Affiliation(s)
- Nicholas W Bowersox
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Julia Browne
- Research Service, VA Providence Healthcare System, Providence, RI, USA; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter P Grau
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephanie L Merrill
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA
| | - Taona P Haderlein
- Veterans Health Administration Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA; Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Maria D Llorente
- Patient Care Services, Department of Veterans Affairs, Washington DC, USA; Department of Psychiatry, Georgetown University School of Medicine, Washington DC, USA
| | - Donna L Washington
- Veterans Health Administration Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA; Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, Los Angeles, CA, USA
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18
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Wang C, Malaktaris A, McLean CL, Kelsven S, Chu GM, Ross KS, Endsley M, Minassian A, Liu L, Hong S, Lang AJ. Mitigating the health effects of systemic racism: Evaluation of the Race-Based Stress and Trauma Empowerment intervention. Contemp Clin Trials 2023; 127:107118. [PMID: 36796623 PMCID: PMC10389054 DOI: 10.1016/j.cct.2023.107118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Disparities in physical and mental health among Black, Indigenous, and People of Color (BIPOC) are well-documented and mirrored in the Veteran population. Chronic stress due to racism and discrimination is one possible mechanism driving these negative health outcomes. The Race-Based Stress and Trauma Empowerment (RBSTE) group is a novel, manualized, health promotion intervention designed to address the direct and indirect impacts of racism among Veterans of Color. This paper describes the protocol of the first pilot randomized controlled trial (RCT) of RBSTE. This study will examine the feasibility, acceptability, and appropriateness of RBSTE compared to an active control (an adaptation of Present-Centered Therapy; PCT) in a Veterans Affairs (VA) healthcare setting. A secondary aim is to identify and optimize strategies for holistic evaluation. METHODS Veterans of Color (N = 48) endorsing perceived discrimination and stress will be randomized to RBSTE or PCT; both groups will be delivered in 8 weekly, 90-min virtual group sessions. Outcomes will include measures of psychological distress, discrimination and ethnoracial identity, holistic wellness, and allostatic load. Measures will be administered at baseline and post-intervention. CONCLUSION This study will inform future interventions targeting identity-based stressors and represents an important step in advancing equity for BIPOC in medicine and research. CLINICAL TRIAL REGISTRATION NUMBER NCT05422638.
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Affiliation(s)
- Clarice Wang
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Anne Malaktaris
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Caitlin L McLean
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA.
| | - Skylar Kelsven
- University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Gage M Chu
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Keisha S Ross
- VA St. Louis Health Care System, 915 N. Grand Blvd, St. Louis, MO 63106, USA.
| | - Maurice Endsley
- VA Northern California Health Care System, 10535 Hospital Way, Mather, CA 95655, USA.
| | - Arpi Minassian
- University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA.
| | - Lin Liu
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA.
| | - Suzi Hong
- University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA.
| | - Ariel J Lang
- University of California San Diego, Department of Psychiatry, 9500 Gilman Dr., La Jolla, CA 92093, USA; VA San Diego Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr., San Diego, CA 92161, USA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA.
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19
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Feyman Y, Avila CJ, Auty S, Mulugeta M, Strombotne K, Legler A, Griffith K. Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic. Health Serv Res 2022; 58:642-653. [PMID: 36478574 PMCID: PMC9878051 DOI: 10.1111/1475-6773.14112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity. DATA SOURCES Administrative data from the Veterans Health Administration's Corporate Data Warehouse. STUDY DESIGN We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects. DATA COLLECTION We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity. PRINCIPAL FINDINGS Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population. CONCLUSIONS Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.
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Affiliation(s)
- Yevgeniy Feyman
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Cecille Joan Avila
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Samantha Auty
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Martha Mulugeta
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Kiersten Strombotne
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Aaron Legler
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Kevin Griffith
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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20
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Friedman S, Shaw JG, Hamilton AB, Vinekar K, Washington DL, Mattocks K, Yano EM, Phibbs CS, Johnson AM, Saechao F, Berg E, Frayne SM. Gynecologist Supply Deserts Across the VA and in the Community. J Gen Intern Med 2022; 37:690-697. [PMID: 36042097 PMCID: PMC9481821 DOI: 10.1007/s11606-022-07591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 04/01/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care. OBJECTIVE Compare gynecologist supply in veterans' county of residence versus at their VA site. DESIGN We identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called "local") of veterans' VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were "inadequate-supply" counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences. PARTICIPANTS All women veteran FY2017 VA primary care users nationally. MAIN MEASURES Availability of a VA gynecologist within 50 miles of a veteran's VA homesite; county-level "inadequate-supply" of gynecologists. KEY RESULTS Among 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women's clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist. CONCLUSIONS Most veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA's critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity.
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Affiliation(s)
- Sarah Friedman
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.
- School of Public Health, University of Nevada Reno, Reno, NV, USA.
| | - Jonathan G Shaw
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kavita Vinekar
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ciaran S Phibbs
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
- VA Health Economics Resource Center, Menlo Park, CA, USA
| | | | - Fay Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Eric Berg
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
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21
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Muirhead L, Echt KV, Alexis AM, Mirk A. Social Determinants of Health: Considerations for Care of Older Veterans. Nurs Clin North Am 2022; 57:329-345. [PMID: 35985723 DOI: 10.1016/j.cnur.2022.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Social determinants of health (SDOH), the environments and circumstances in which people are born, grow, live, work and age, are potent drivers of health, health disparities, and health outcomes over the lifespan. Military service affords unique experiences, exposures, and social and health vulnerabilities which impact the life course and may alter health equity and health outcomes for older veterans. Identifying and addressing SDOH, inclusive of the military experience, allows person-centered, more equitable care to this vulnerable population. Nurses and other health professionals should be familiar with how to identify and address health-related social needs and implement interdiciplinary, team-based approaches to connect patients with resources and benefits specifically available to veterans.
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Affiliation(s)
- Lisa Muirhead
- Emory University, Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA.
| | - Katharina V Echt
- Veterans Affairs Birmingham/ Atlanta Geriatric Research, Education and Clinical Center (GRECC), Atlanta VA Health Care System, 3101 Clairmont Road Northeast, Brookhaven, GA 30329-1044, USA; Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrea M Alexis
- Atlanta VA Health Care System, Nursing Education, 1M-116A, 1670 Clairmont Road, Decatur, GA 30033, USA
| | - Anna Mirk
- Veterans Affairs Birmingham/ Atlanta Geriatric Research, Education and Clinical Center (GRECC), Atlanta VA Health Care System, 3101 Clairmont Road Northeast, Brookhaven, GA 30329-1044, USA; Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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22
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Peltzman T, Rice K, Jones KT, Washington DL, Shiner B. Optimizing Data on Race and Ethnicity for Veterans Affairs Patients. Mil Med 2022; 187:e955-e962. [PMID: 35323934 DOI: 10.1093/milmed/usac066] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Maintaining accurate race and ethnicity data among patients of the Veterans Affairs (VA) healthcare system has historically been a challenge. This work expands on previous efforts to optimize race and ethnicity values by combining multiple VA data sources and exploring race- and ethnicity-specific collation algorithms. MATERIALS AND METHODS We linked VA patient data from 2000 to 2018 with race and ethnicity data from four administrative and electronic health record sources: VA Medical SAS files (MedSAS), Corporate Data Warehouse (CDW), VA Centers for Medicare extracts (CMS), and VA Defense Identity Repository Data (VADIR). To assess the accuracy of each data source, we compared race and ethnicity values to self-reported data from the Survey of Health Experiences of Patients (SHEP). We used Cohen's Kappa to assess overall (holistic) source agreement and positive predictive values (PPV) to determine the accuracy of sources for each race and ethnicity separately. RESULTS Holistic agreement with SHEP data was excellent (K > 0.80 for all sources), while race- and ethnicity-specific agreement varied. All sources were best at identifying White and Black users (average PPV = 0.94, 0.93, respectively). When applied to the full VA user population, both holistic and race-specific algorithms substantially reduced unknown values, as compared to single-source methods. CONCLUSIONS Combining multiple sources to generate race and ethnicity values improves data accuracy among VA patients. Based on the overall agreement with self-reported data, we recommend using non-missing values from sources in the following order to fill in race values-SHEP, CMS, CDW, MedSAS, and VADIR-and in the following order to fill in ethnicity values-SHEP, CDW, MedSAS, VADIR, and CMS.
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Affiliation(s)
- Talya Peltzman
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
| | - Korie Rice
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
| | | | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles Geffen School of Medicine, Los Angeles, CA 90024, USA
| | - Brian Shiner
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
- Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA
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23
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Rentas C, Baker S, Goss L, Richman J, Knight SJ, Key C, Morris M. Patients undergoing colorectal surgery at a Veterans Affairs Hospital do not experience racial disparity in length of stay either before or after implementing an enhanced recovery pathway. BMC Surg 2022; 22:201. [PMID: 35598012 PMCID: PMC9124421 DOI: 10.1186/s12893-022-01647-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Enhanced Recovery Pathways (ERP) have been shown to reduce racial disparities following surgery. The objective of this study is to determine whether ERP implementation mitigates racial disparities at a Veterans Affairs Hospital. Methods A retrospective cohort study was conducted using data obtained from the Veterans Affairs Surgical Quality Improvement Program. All patients undergoing elective colorectal surgery following ERP implementation were included. Current procedural terminology (CPT) codes were used to identify patients who underwent similar procedures prior to ERP implementation. Results Our study included 417 patients (314 pre-ERP vs. 103 ERP), 97.1% of which were male, with an average age of 62.32 (interquartile range (IQR): 25–90). ERP patients overall had a significantly shorter post-operative length of stay (pLOS) vs. pre-ERP patients (median 4 days (IQR: 3–6.5) vs. 6 days (IQR: 4–9) days (p < 0.001)). Within the pre-ERP group, median pLOS for both races was 6 days (IQR: 4–6; p < 0.976) and both groups experienced a decrease in median pLOS (4 vs. 6 days; p < 0.009 and p < 0.001) following ERP implementation. Conclusions Racial disparities did not exist in patients undergoing elective surgery at a single VA Medical Center. Implementation of an ERP significantly reduced pLOS for black and white patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-022-01647-3.
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Affiliation(s)
- C Rentas
- Department of Surgery, University of Alabama at Birmingham School of Medicine, 1808 7th Avenue South #503, Birmingham, AL, 35233, USA.
| | - S Baker
- Department of Surgery, University of Alabama at Birmingham School of Medicine, 1808 7th Avenue South #503, Birmingham, AL, 35233, USA.,Birmingham VA Medical Center, 700 19th Street South, Birmingham, AL, 35233, USA
| | - L Goss
- Birmingham VA Medical Center, 700 19th Street South, Birmingham, AL, 35233, USA
| | - J Richman
- Department of Surgery, University of Alabama at Birmingham School of Medicine, 1808 7th Avenue South #503, Birmingham, AL, 35233, USA.,Birmingham VA Medical Center, 700 19th Street South, Birmingham, AL, 35233, USA
| | - S J Knight
- VA Salt Lake City Health Care System, University of Utah, 500 Foothill Dr, Salt Lake City, UT, 84148, USA
| | - C Key
- Department of Surgery, University of Alabama at Birmingham School of Medicine, 1808 7th Avenue South #503, Birmingham, AL, 35233, USA.,Birmingham VA Medical Center, 700 19th Street South, Birmingham, AL, 35233, USA
| | - M Morris
- Department of Surgery, University of Alabama at Birmingham School of Medicine, 1808 7th Avenue South #503, Birmingham, AL, 35233, USA.,Birmingham VA Medical Center, 700 19th Street South, Birmingham, AL, 35233, USA
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24
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Del Valle JP, Fillmore NR, Molina G, Fairweather M, Wang J, Clancy TE, Ashley SW, Urman RD, Whang EE, Gold JS. Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration. Ann Surg Oncol 2022; 29:3194-3202. [PMID: 35006509 DOI: 10.1245/s10434-021-11250-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/06/2021] [Indexed: 12/17/2023]
Abstract
BACKGROUND Disparities based on socioeconomic factors such as race, ethnicity, marital status, and insurance status are associated with pancreatic cancer resection, but these disparities are usually not observed for survival after resection. It is unknown if there are disparities when patients undergo their treatment in a non-fee-for-service, equal-access healthcare system such as the Veterans Health Administration (VHA). METHODS Patients having T1-T3 M0 pancreatic adenocarcinoma diagnosed between 2006 and 2017 were identified from the VHA Corporate Data Warehouse. Socioeconomic, demographic, and tumor variables associated with resection and survival were assessed. RESULTS In total, 2580 patients with early-stage pancreatic cancer were identified. The resection rate was 36.5%. Surgical resection was independently associated with younger age [odds ratio (OR) 0.94, p < 0.001], White race (OR 1.35, p = 0.028), married status (OR 1.85, p = 0.001), and employment status (retired vs. unemployed, OR 1.41, p = 0.008). There were no independent associations with Hispanic ethnicity, geographic region, or Social Deprivation Index. Resection was associated with significantly improved survival (median 21 vs. 8 months, p = 0.001). Among resected patients, survival was independently associated with younger age (HR 1.019, p = 0.002), geographic region (South vs. Pacific West, HR 0.721, p = 0.005), and employment (employed vs. unemployed, HR 0.752, p = 0.029). Race, Hispanic ethnicity, marital status, and Social Deprivation Index were not independently associated with survival after resection. CONCLUSIONS Race, marital status, and employment status are independently associated with resection of pancreatic cancer in the VHA, whereas geographic region and employment status are independently associated with survival after resection. Further studies are warranted to determine the basis for these inequities.
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Affiliation(s)
- Jonathan Pastrana Del Valle
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nathanael R Fillmore
- Harvard Medical School, Boston, MA, USA
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA, USA
| | - George Molina
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mark Fairweather
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jiping Wang
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas E Clancy
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Stanley W Ashley
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard D Urman
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward E Whang
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason S Gold
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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25
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Moy E. Veterans Health Administration Is Working Urgently to Reduce High Rates of Suicide Among American Indian and Alaska Native Veteran. Med Care 2022; 60:273-274. [PMID: 35081087 DOI: 10.1097/mlr.0000000000001690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ernest Moy
- Office of Health Equity (12POP1), Veterans Health Administration, Washington, DC
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26
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Sullivan BA, Qin X, Miller C, Hauser ER, Redding TS, Gellad ZF, Madison AN, Musselwhite LW, Efird JT, Sims KJ, Williams CD, Weiss D, Lieberman D, Provenzale D. Screening Colonoscopy Findings Are Associated With Noncolorectal Cancer Mortality. Clin Transl Gastroenterol 2022; 13:e00479. [PMID: 35333777 PMCID: PMC9038496 DOI: 10.14309/ctg.0000000000000479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Controversy exists regarding the impact of various risk factors on noncolorectal cancer (CRC) mortality in healthy screening populations. We examined the impact of known CRC risk factors, including baseline colonoscopy findings, on non-CRC mortality in a screening population. METHODS Cooperative Studies Program (CSP) #380 is comprised of 3,121 veterans aged 50-75 years who underwent screening colonoscopy from 1994 to 97 and were then followed for at least 10 years or until death. Hazard ratios (HRs) for risk factors on non-CRC mortality were estimated by multivariate Cox proportional hazards. RESULTS Current smoking (HR 2.12, 95% confidence interval [CI] 1.78-2.52, compared with nonsmokers) and physical activity (HR 0.89, 95% CI 0.84-0.93) were the modifiable factors most associated with non-CRC mortality in CSP#380. In addition, compared with no neoplasia at baseline colonoscopy, non-CRC mortality was higher in participants with ≥3 small adenomas (HR 1.43, 95% CI 1.06-1.94), advanced adenomas (HR 1.32, 95% CI 0.99-1.75), and CRC (HR 2.95, 95% CI 0.98-8.85). Those with 1-2 small adenomas were not at increased risk for non-CRC mortality (HR 1.15, 95% CI 0.94-1.4). DISCUSSION In a CRC screening population, known modifiable risk factors were significantly associated with 10-year non-CRC mortality. Furthermore, those who died from non-CRC causes within 10 years were more likely to have had high-risk findings at baseline colonoscopy. These results suggest that advanced colonoscopy findings may be a risk marker of poor health outcomes. Integrated efforts are needed to motivate healthy lifestyle changes during CRC screening, particularly in those with high-risk colonoscopy findings and unaddressed risk factors.
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Affiliation(s)
- Brian A. Sullivan
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
- Duke University, Durham, North Carolina, USA
| | - Xuejun Qin
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
- Duke University, Durham, North Carolina, USA
| | - Cameron Miller
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
- Duke University, Durham, North Carolina, USA
| | - Elizabeth R. Hauser
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
- Duke University, Durham, North Carolina, USA
| | - Thomas S. Redding
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
| | - Ziad F. Gellad
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
- Duke University, Durham, North Carolina, USA
| | - Ashton N. Madison
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
| | - Laura W. Musselwhite
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Solid Tumor Oncology, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Jimmy T. Efird
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
| | - Kellie J. Sims
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
| | - Christina D. Williams
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
- Duke University, Durham, North Carolina, USA
| | - David Weiss
- Perry Point VA Medical Center, Perry Point, Maryland, USA
| | - David Lieberman
- VA Portland Health Care System, Portland, Oregon, USA
- Oregon Health & Science University, Portland, Oregon, USA
| | - Dawn Provenzale
- Cooperative Studies Program Epidemiology Center-Durham, Durham VA Health Care System, Durham, North Carolina, USA
- Duke University, Durham, North Carolina, USA
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27
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Lukowsky LR, Der-Martirosian C, Dobalian A. Disparities in Excess, All-Cause Mortality among Black, Hispanic, and White Veterans at the U.S. Department of Veterans Affairs during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042368. [PMID: 35206555 PMCID: PMC8874890 DOI: 10.3390/ijerph19042368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/28/2022]
Abstract
Background: From 2019 to 2020, all-cause mortality in the U.S. increased, with most of the rise attributed to COVID-19. No studies have examined the racial disparities in all-cause mortality among U.S. veterans receiving medical care (VA users) at the U.S. Department of Veterans Affairs (VA) during the pandemic. Methods: In the present paper, we conduct a longitudinal study examining the differences in mortality among White, Black, and Hispanic veterans, aged 45 years and older, during the first, full year of the pandemic (March 2020–February 2021). We calculated the Standardized Mortality Rates (SMRs) per 100,000 VA users for each racial and ethnic group by age and gender. Results: The highest percentage increase between the number of deaths occurred between pre- and post-pandemic years (March 2020–February 2021 vs. March 2019–February 2020). For Hispanics, the all-cause mortality increased by 34%, while for Blacks, it increased by 32%. At the same time, we observed that an 18% increase in all-cause mortality occurred among Whites. Conclusion: Blacks and Hispanics were disproportionately affected by the COVID-19 pandemic, leading both directly and indirectly to higher all-cause mortality among these groups compared to Whites. Disparities in the all-cause mortality rates varied over time and across groups. Additional research is needed to examine which factors may account for the observed changes over time. Understanding those factors will permit the development of strategies to mitigate these disparities.
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Affiliation(s)
- Lilia R. Lukowsky
- Veterans Emergency Management Evaluation Center (VEMEC), US Department of Veterans Affairs, Los Angeles, CA 91343, USA; (C.D.-M.); (A.D.)
- Correspondence:
| | - Claudia Der-Martirosian
- Veterans Emergency Management Evaluation Center (VEMEC), US Department of Veterans Affairs, Los Angeles, CA 91343, USA; (C.D.-M.); (A.D.)
| | - Aram Dobalian
- Veterans Emergency Management Evaluation Center (VEMEC), US Department of Veterans Affairs, Los Angeles, CA 91343, USA; (C.D.-M.); (A.D.)
- Division of Health Services Management and Policy in the College of Public Health, The Ohio State University, Columbus, OH 43210, USA
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Finch T, Jonas MC, Rubenstein K, Watson E, Basra S, Martinez J, Horberg M. Life Expectancy Trends Among Integrated Health Care System Enrollees, 2014-2017. Perm J 2021; 25:20.286. [PMID: 35348069 PMCID: PMC8784056 DOI: 10.7812/tpp/20.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Centers for Disease Control and Prevention (CDC) has reported downward trends in life expectancy and racial/ethnic differences between 2014 and 2017. OBJECTIVE To determine the life expectancy of the Kaiser Permanente Mid-Atlantic States (KPMAS) insured population as compared to the CDC National Vital Statistics data from 2014 to 2017. We also aimed to highlight the utilization of membership data to inform population statistical estimates such as life expectancy. We examine whether national trends in life expectancy are reflected in an insured population with relatively uniform access to care. METHODS This retrospective, data only study examined life expectancy between 2014 and 2017. Data from electronic medical records and the National Death Index were combined to construct complete life tables by race and sex for the KPMAS population, which was compared to the CDC National Vital Statistics data. RESULTS From 2014 to 2017, the overall KPMAS population life expectancy at birth varied between 84.6 and 85.2 years compared to the CDC reported national average of 78.6-78.9 years (p < 0.001). While the CDC dataset reported a 3.5- to 3.7-year life expectancy gap between non-Hispanic White and non-Hispanic Black populations, in the KPMAS population, this gap was significantly smaller (0.0-0.9 years). The gap in life expectancy between males and females was consistent across KPMAS and the CDC data; however, overall KPMAS male and female patient life expectancy was extended in comparison. CONCLUSION Among members who disclosed their race/ethnicity, KPMAS Hispanic, non-Hispanic Black, and non-Hispanic White members had significantly higher life expectancies than the CDC dataset in all years reported.
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Affiliation(s)
- Tori Finch
- Mid-Atlantic Permanente Medical Group, Rockville, MD
| | - M Cabell Jonas
- Mid-Atlantic Permanente Medical Group, Rockville, MD
- Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Kevin Rubenstein
- Mid-Atlantic Permanente Medical Group, Rockville, MD
- Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Eric Watson
- Mid-Atlantic Permanente Medical Group, Rockville, MD
- Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Sundeep Basra
- Mid-Atlantic Permanente Medical Group, Rockville, MD
- Mid-Atlantic Permanente Research Institute, Rockville, MD
| | - Jose Martinez
- Mid-Atlantic Permanente Medical Group, Rockville, MD
| | - Michael Horberg
- Mid-Atlantic Permanente Medical Group, Rockville, MD
- Mid-Atlantic Permanente Research Institute, Rockville, MD
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Wong MS, Yuan AH, Haderlein TP, Jones KT, Washington DL. Variations by race/ethnicity and time in Covid-19 testing among Veterans Health Administration users with COVID-19 symptoms or exposure. Prev Med Rep 2021; 24:101503. [PMID: 34312589 PMCID: PMC8295495 DOI: 10.1016/j.pmedr.2021.101503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/10/2021] [Accepted: 07/18/2021] [Indexed: 12/19/2022] Open
Abstract
Racial/ethnic disparities in coronavirus disease 2019 (COVID-19) hospitalization and mortality have emerged in the United States, but less is known about whether similar differences exist in testing, and how this changed as COVID-19 knowledge and policies evolved. We examined racial/ethnic variations in COVID-19 testing over time among veterans who sought care for COVID-19 symptoms or exposure. In the national population of all Veterans who sought Veterans Health Administration (VHA) care for COVID-19 symptoms or exposure (n = 913,806), we conducted multivariate logistic regressions to explore race/ethnicity-by-time period differences in testing from 3/1/2020-11/25/2020, and calculated predicted probabilities by race/ethnicity and time period. Early in the pandemic (3/1/2020-4/6/2020) when testing was limited and there was less awareness of racial/ethnic disparities, non-Hispanic Black, Hispanic, and other non-White racial/ethnic minority Veterans who sought care from VHA for COVID-19 symptoms or exposure were more likely than non-Hispanic White Veterans to receive a COVID-19 test (p < 0.05). In subsequent time periods (4/7/2020-11/25/2020), testing was similar among all racial/ethnic groups. Among Veterans with COVID-19 symptoms or exposure, non-Hispanic Black and Hispanic patients were just as likely, and in some cases, more likely, to receive a COVID-19 test versus non-Hispanic White patients. The United States faced testing shortages at the start of the third wave of the pandemic; additional shortages are likely to emerge as the pandemic continues to peak and ebb. It is important to ensure that racial/ethnic minorities and others at greater risk for infection continue to have access to COVID-19 testing with each of these peaks.
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Affiliation(s)
- Michelle S. Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
| | - Anita H. Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
| | - Taona P. Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
| | - Kenneth T. Jones
- VHA Office of Health Equity, 810 Vermont Ave, NW, Washington, DC 20420, United States
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, United States
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, 1100 Glendon Ave, Suite 850, Los Angeles, CA 90024, United States
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Voora RS, Kotha NV, Kumar A, Qiao EM, Qian AS, Panuganti BA, Banegas MP, Weissbrod PA, Stewart TF, Rose BS, Orosco RK. Association of race and health care system with disease stage and survival in veterans with larynx cancer. Cancer 2021; 127:2705-2713. [PMID: 33799314 DOI: 10.1002/cncr.33557] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Black patients with laryngeal squamous cell carcinoma (LSCC) historically have inferior outcomes in comparison with White patients. The authors investigated these racial disparities within the Veterans Health Administration (VHA), an equal-access system, and within the Surveillance, Epidemiology, and End Results (SEER) program, which is representative of the US hybrid-payer system. METHODS Patients with invasive (T1 or greater) LSCC were included from SEER (2004-2015) and the VHA (2000-2017). The primary outcomes of overall survival (OS) and larynx cancer-specific survival (LCS) were evaluated in Cox and Fine-Gray models. RESULTS In the SEER cohort (7122 patients: 82.6% White and 17.4% Black), Black patients were more likely to present with advanced disease and had inferior OS (hazard ratio [HR], 1.37; 95% CI, 1.26-1.50; P < .0001) in a multivariable analysis. Black LCS was worse in a univariable analysis (HR, 1.42; 95% CI, 1.27-1.58; P < .0001), but this effect was attenuated by 83% when the authors controlled for the TNM category and was found to be insignificant in a multivariable analysis (HR, 1.05; 95% CI, 0.93-1.18; P = .42). In the VHA cohort (9248 patients: 79.7% White and 20.3% Black), the 2 racial cohorts presented with similar tumor characteristics and similar OS (HR, 0.95; 95% CI, 0.89-1.02; P = .14). Black LCS was similar in univariable (HR, 1.10; 95% CI, 1.00-1.22; P = .05) and multivariable analyses (HR, 1.02; 95% CI, 0.92-1.14; P = .67). CONCLUSIONS Black patients with LSCC had a tumor burden at diagnosis and survival outcomes comparable to those of White patients within the VHA; this was counter to what was observed in the SEER analysis and prior national trends. This study's findings point toward the notable role of health care access in contributing to racial health disparities in the realm of larynx cancer.
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Affiliation(s)
- Rohith S Voora
- School of Medicine, University of California San Diego, San Diego, California
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California
- Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Nikhil V Kotha
- School of Medicine, University of California San Diego, San Diego, California
- Veterans Affairs San Diego Healthcare System, San Diego, California
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California
| | - Abhishek Kumar
- Veterans Affairs San Diego Healthcare System, San Diego, California
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California
| | - Edmund M Qiao
- School of Medicine, University of California San Diego, San Diego, California
- Veterans Affairs San Diego Healthcare System, San Diego, California
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California
| | - Alexander S Qian
- School of Medicine, University of California San Diego, San Diego, California
- Veterans Affairs San Diego Healthcare System, San Diego, California
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California
| | - Bharat A Panuganti
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California
- Moores Cancer Center, La Jolla, California
| | | | - Philip A Weissbrod
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California
- Moores Cancer Center, La Jolla, California
| | - Tyler F Stewart
- Moores Cancer Center, La Jolla, California
- Division of Hematology-Oncology, University of California San Diego, San Diego, California
- Division of Blood and Marrow Transplantation, University of California San Diego, San Diego, California
| | - Brent S Rose
- Veterans Affairs San Diego Healthcare System, San Diego, California
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California
- Moores Cancer Center, La Jolla, California
| | - Ryan K Orosco
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California
- Veterans Affairs San Diego Healthcare System, San Diego, California
- Moores Cancer Center, La Jolla, California
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Rude T, Walter D, Ciprut S, Kelly MD, Wang C, Fagerlin A, Langford AT, Lepor H, Becker DJ, Li H, Loeb S, Ravenell J, Leppert JT, Makarov DV. Interaction between race and prostate cancer treatment benefit in the Veterans Health Administration. Cancer 2021; 127:3985-3990. [PMID: 34184271 DOI: 10.1002/cncr.33643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/09/2021] [Accepted: 04/06/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Studies have demonstrated that Black men may undergo definitive prostate cancer (CaP) treatment less often than men of other races, but it is unclear whether they are avoiding overtreatment of low-risk disease or experiencing a reduction in appropriate care. The authors' aim was to assess the role of race as it relates to treatment benefit in access to CaP treatment in a single-payer population. METHODS The authors used the Veterans Health Administration (VHA) Corporate Data Warehouse to perform a retrospective cohort study of veterans diagnosed with low- or intermediate-risk CaP between 2011 and 2017. RESULTS The authors identified 35,427 men with incident low- or intermediate-risk CaP. When they controlled for covariates, Black men had 1.05 times the odds of receiving treatment in comparison with non-Black men (P < .001), and high-treatment-benefit men had 1.4 times the odds of receiving treatment in comparison with those in the low-treatment-benefit group (P < .001). The interaction of race and treatment benefit was significant, with Black men in the high-treatment-benefit category less likely to receive treatment than non-Black men in the same treatment category (odds ratio, 0.89; P < .001). CONCLUSIONS Although race does appear to influence the receipt of definitive treatment in the VHA, this relationship varies in the context of the patient's treatment benefit, with Black men receiving less definitive treatment in high-benefit situations. The influence of patient race at high treatment benefit levels invites further investigation into the driving forces behind this persistent disparity in this consequential group.
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Affiliation(s)
- Temitope Rude
- Department of Urology, New York University, New York, New York
| | - Dawn Walter
- Department of Urology, New York University, New York, New York.,Department of Population Health, New York University, New York, New York.,Perlmutter Cancer Center, New York University, New York, New York.,VA New York Harbor Healthcare System, New York, New York
| | - Shannon Ciprut
- Department of Urology, New York University, New York, New York.,Department of Population Health, New York University, New York, New York.,Perlmutter Cancer Center, New York University, New York, New York.,VA New York Harbor Healthcare System, New York, New York
| | - Matthew D Kelly
- Department of Urology, New York University, New York, New York.,Department of Population Health, New York University, New York, New York.,Perlmutter Cancer Center, New York University, New York, New York.,VA New York Harbor Healthcare System, New York, New York
| | - Chan Wang
- Department of Population Health, New York University, New York, New York
| | - Angela Fagerlin
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences Center for Innovation, Salt Lake City, Utah.,Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Aisha T Langford
- Department of Population Health, New York University, New York, New York
| | - Herbert Lepor
- Department of Urology, New York University, New York, New York.,Perlmutter Cancer Center, New York University, New York, New York
| | - Daniel J Becker
- Perlmutter Cancer Center, New York University, New York, New York.,VA New York Harbor Healthcare System, New York, New York
| | - Huilin Li
- Perlmutter Cancer Center, New York University, New York, New York
| | - Stacy Loeb
- Department of Urology, New York University, New York, New York.,Department of Population Health, New York University, New York, New York.,Perlmutter Cancer Center, New York University, New York, New York.,VA New York Harbor Healthcare System, New York, New York
| | - Joseph Ravenell
- Department of Population Health, New York University, New York, New York
| | - John T Leppert
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Department of Urology, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, VA Palo Alto Health Care System, Palo Alto, California
| | - Danil V Makarov
- Department of Urology, New York University, New York, New York.,Department of Population Health, New York University, New York, New York.,Perlmutter Cancer Center, New York University, New York, New York.,VA New York Harbor Healthcare System, New York, New York.,Robert F. Wagner Graduate School of Public Service, New York University, New York, New York
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Kelly JD, Bravata DM, Bent S, Wray CM, Leonard SJ, Boscardin WJ, Myers LJ, Keyhani S. Association of Social and Behavioral Risk Factors With Mortality Among US Veterans With COVID-19. JAMA Netw Open 2021; 4:e2113031. [PMID: 34106264 PMCID: PMC8190626 DOI: 10.1001/jamanetworkopen.2021.13031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE The US Department of Veterans Affairs (VA) offers programs that reduce barriers to care for veterans and those with housing instability, poverty, and substance use disorder. In this setting, however, the role that social and behavioral risk factors play in COVID-19 outcomes is unclear. OBJECTIVE To examine whether social and behavioral risk factors were associated with mortality among US veterans with COVID-19 and whether this association might be modified by race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained data from the VA Corporate Data Warehouse to form a cohort of veterans who received a positive COVID-19 test result between March 2 and September 30, 2020, in a VA health care facility. All veterans who met the inclusion criteria were eligible to participate in the study, and participants were followed up for 30 days after the first SARS-CoV-2 or COVID-19 diagnosis. The final follow-up date was October 31, 2020. EXPOSURES Social risk factors included housing problems and financial hardship. Behavioral risk factors included current tobacco use, alcohol use, and substance use. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality in the 30-day period after the SARS-CoV-2 or COVID-19 diagnosis date. Multivariable logistic regression was used to estimate odds ratios, clustering for health care facilities and adjusting for age, sex, race, ethnicity, marital status, clinical factors, and month of COVID-19 diagnosis. RESULTS Among 27 640 veterans with COVID-19 who were included in the analysis, 24 496 were men (88.6%) and the mean (SD) age was 57.2 (16.6) years. A total of 3090 veterans (11.2%) had housing problems, 4450 (16.1%) had financial hardship, 5358 (19.4%) used alcohol, and 3569 (12.9%) reported substance use. Hospitalization occurred in 7663 veterans (27.7%), and 1230 veterans (4.5%) died. Housing problems (adjusted odds ratio [AOR], 0.96; 95% CI, 0.77-1.19; P = .70), financial hardship (AOR, 1.13; 95% CI, 0.97-1.31; P = .11), alcohol use (AOR, 0.82; 95% CI, 0.68-1.01; P = .06), current tobacco use (AOR, 0.85; 95% CI, 0.68-1.06; P = .14), and substance use (AOR, 0.90; 95% CI, 0.71-1.15; P = .41) were not associated with higher mortality. Interaction analyses by race/ethnicity did not find associations between mortality and social and behavioral risk factors. CONCLUSIONS AND RELEVANCE Results of this study showed that, in an integrated health system such as the VA, social and behavioral risk factors were not associated with mortality from COVID-19. Further research is needed to substantiate the potential of an integrated health system to be a model of support services for households with COVID-19 and populations who are at risk for the disease.
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Affiliation(s)
- J. Daniel Kelly
- San Francisco VA Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco
| | - Dawn M. Bravata
- US Department of Veterans Affairs, Health Services and Development, Center for Health Information and Communication, Indianapolis, Indiana
- Department of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Stephen Bent
- San Francisco VA Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Charlie M. Wray
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Samuel J. Leonard
- Department of Medicine, University of California, San Francisco, San Francisco
| | - W. John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Laura J. Myers
- US Department of Veterans Affairs, Health Services and Development, Center for Health Information and Communication, Indianapolis, Indiana
| | - Salomeh Keyhani
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco
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Napolitano MA, Sparks AD, Werba G, Rosenfeld ES, Antevil JL, Trachiotis GD. Video-Assisted Thoracoscopic Surgery Lung Resection in United States Veterans: Trends and Outcomes versus Thoracotomy. Thorac Cardiovasc Surg 2021; 70:346-354. [PMID: 34044463 DOI: 10.1055/s-0041-1728707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Video-assisted thoracoscopic surgery (VATS) offers reduced morbidity compared with open thoracotomy (OT) for pulmonary surgery. The use of VATS over time has increased, but at a modest rate in civilian populations. This study examines temporal trends in VATS use and compares outcomes between VATS and OT in the Veterans Health Administration (VHA). METHODS Patients who underwent pulmonary surgery (wedge or segmental resection, lobectomy, or pneumonectomy) at Veterans Affairs centers from 2008 to 2018 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Project database. The cohort was divided into OT and VATS and propensity score matched, taking into account the type of pulmonary resection, preoperative diagnosis, and comorbidities. Thirty-day postoperative outcomes were compared. The prevalence of VATS use and respective complications over time was also analyzed. RESULTS A total of 16,895 patients were identified, with 5,748 per group after propensity matching. VATS had significantly lower rates of morbidity and a 2-day reduction in hospital stay. Whereas 76% of lung resections were performed open in 2008, nearly 70% of procedures were performed using VATS in 2018. While VATS was associated with an 8% lower rate of major complications compared with thoracotomy in 2008, patients undergoing VATS lung resection in 2018 had a 58% lower rate of complications (p < 0.001). CONCLUSIONS VATS utilization at VHA centers has become the predominant technique used for pulmonary surgeries over time. OT patients had more complications and longer hospital stays compared with VATS. Over the study period, VATS patients had increasingly lower complication rates compared with open surgery.
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Affiliation(s)
- Michael A Napolitano
- Division of Cardiothoracic Surgery and Heart Center, Washington D.C. Veterans Affairs Medical Center, Washington, District of Columbia, United States.,Department of Surgery, George Washington University, Washington, District of Columbia, United States
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, District of Columbia, United States
| | - Gregor Werba
- Department of Surgery, George Washington University, Washington, District of Columbia, United States
| | - Ethan S Rosenfeld
- Division of Cardiothoracic Surgery and Heart Center, Washington D.C. Veterans Affairs Medical Center, Washington, District of Columbia, United States.,Department of Surgery, George Washington University, Washington, District of Columbia, United States
| | - Jared L Antevil
- Division of Cardiothoracic Surgery and Heart Center, Washington D.C. Veterans Affairs Medical Center, Washington, District of Columbia, United States
| | - Gregory D Trachiotis
- Division of Cardiothoracic Surgery and Heart Center, Washington D.C. Veterans Affairs Medical Center, Washington, District of Columbia, United States.,Department of Surgery, George Washington University, Washington, District of Columbia, United States
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Kerkar A, Gummidipundi S, Heidenreich PA, Yong CM. Pre-procedural barriers to accessing novel treatments for aortic stenosis among racial/ethnic minorities in the veterans affairs healthcare system. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 5:100029. [PMID: 38560411 PMCID: PMC10976283 DOI: 10.1016/j.ahjo.2021.100029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/22/2021] [Accepted: 06/12/2021] [Indexed: 04/04/2024]
Abstract
Background Novel structural heart procedures offer life-saving treatment advantages, yet little is known about pre-procedural barriers to care by race/ethnicity. Methods All echocardiograms performed at a Veterans Affairs hospital from 2015 to 2019 were reviewed to identify patients with severe aortic stenosis and their access to transcatheter aortic valve replacement (TAVR) by race/ethnicity. Results From 19,403 echocardiograms, 355 individuals were identified to have severe aortic stenosis (72.6% White, 9.8% Hispanic, 3.9% Black). There was a non-significant trend towards increased TAVR treatment among White compared to non-White patients (OR 2.02, CI 0.96-4.24, p = 0.063), which attenuated after adjustment for age and comorbidities. Reasons for not undergoing replacement included poor procedural candidacy (25.3%), loss of follow-up (17.8%), and patient refusal (16.4%). Conclusions Racial/ethnic inequities were not detected in novel structural heart treatment within the VA. However, a high proportion of eligible patients did not receive procedural treatment due to patient refusal or loss of follow-up, highlighting barriers that require further study.
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Affiliation(s)
- Ashwini Kerkar
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford Cardiovascular Institute, Stanford, CA, USA
| | | | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford Cardiovascular Institute, Stanford, CA, USA
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Celina M. Yong
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford Cardiovascular Institute, Stanford, CA, USA
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA
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Wong MS, Haderlein TP, Yuan AH, Moy E, Jones KT, Washington DL. Time Trends in Racial/Ethnic Differences in COVID-19 Infection and Mortality. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4848. [PMID: 34062806 PMCID: PMC8124342 DOI: 10.3390/ijerph18094848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 11/20/2022]
Abstract
Studies documenting coronavirus disease 2019 (COVID-19) racial/ethnic disparities in the United States were limited to data from the initial few months of the pandemic, did not account for changes over time, and focused primarily on Black and Hispanic minority groups. To fill these gaps, we examined time trends in racial/ethnic disparities in COVID-19 infection and mortality. We used the Veteran Health Administration's (VHA) national database of veteran COVID-19 infections over three time periods: 3/1/2020-5/31/2020 (spring); 6/1/2020-8/31/2020 (summer); and 9/1/2020-11/25/2020 (fall). We calculated COVID-19 infection and mortality predicted probabilities from logistic regression models that included time period-by-race/ethnicity interaction terms, and controlled for age, gender, and prior diagnosis of CDC risk factors. Racial/ethnic groups at higher risk for COVID-19 infection and mortality changed over time. American Indian/Alaskan Natives (AI/AN), Blacks, Hispanics, and Native Hawaiians/Other Pacific Islanders experienced higher COVID-19 infections compared to Whites during the summertime. There were mortality disparities for Blacks in springtime, and AI/ANs, Asians, and Hispanics in summertime. Policy makers should consider the dynamic nature of racial/ethnic disparities as the pandemic evolves, and potential effects of risk mitigation and other (e.g., economic) policies on these disparities. Researchers should consider how trends in disparities change over time in other samples.
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Affiliation(s)
- Michelle S. Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
| | - Taona P. Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
| | - Anita H. Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
| | - Ernest Moy
- VHA Office of Health Equity, 810 Vermont Ave NW, Washington, DC 20420, USA; (E.M.); (K.T.J.)
| | - Kenneth T. Jones
- VHA Office of Health Equity, 810 Vermont Ave NW, Washington, DC 20420, USA; (E.M.); (K.T.J.)
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; (T.P.H.); (A.H.Y.); (D.L.W.)
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles Geffen School of Medicine, 1100 Glendon Ave STE 850, Los Angeles, CA 90024, USA
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Dehom S, Knutsen S, Bahjri K, Shavlik D, Oda K, Ali H, Pompe L, Spencer-Hwang R. Racial Difference in the Association of Long-Term Exposure to Fine Particulate Matter (PM 2.5) and Cardiovascular Disease Mortality among Renal Transplant Recipients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4297. [PMID: 33919563 PMCID: PMC8073484 DOI: 10.3390/ijerph18084297] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022]
Abstract
Ambient air pollutants are known risk factors for cardiovascular disease (CVD) morbidity and mortality with significant racial disparities. However, few studies have explored racial differences among highly susceptible subpopulations, such as renal transplant recipients (RTRs). Despite improvements in quality of life after transplantation, CVD remains the major cause of mortality, especially among Black recipients. This study aimed to evaluate potential racial differences in the association between long-term levels of PM2.5 and the risk of all-cause, total CVD, and coronary heart disease (CHD) mortality among RTRs. This retrospective study consists of 93,857 non-smoking adults who received a renal transplant between 2001 and 2015. Time-dependent Cox regression was used to assess the association between annual concentrations of PM2.5 and mortality risk. In the multivariable-adjusted models, a 10 μg/m3 increase in ambient PM2.5 levels found increased risk of all-cause (HR = 3.45, 95% CI: 3.08-3.78), CVD (HR = 2.38, 95% CI: 1.94-2.92), and CHD mortality (HR = 3.10, 95% CI: 1.96-4.90). Black recipients had higher risks of all-cause (HR = 4.09, 95% CI: 3.43-4.88) and CHD mortality (HR = 6.73, 95% CI: 2.96-15.32). High levels of ambient PM2.5 were associated with all-cause, CVD, and CHD mortality. The association tended to be higher among Black recipients than non-Blacks.
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Affiliation(s)
- Salem Dehom
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
- School of Nursing, Loma Linda University, 11262 Campus Street, Loma Linda, CA 92350, USA
| | - Synnove Knutsen
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
| | - Khaled Bahjri
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
- School of Pharmacy, Loma Linda University, 24745 Stewart Street, Loma Linda, CA 92350, USA
| | - David Shavlik
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
| | - Keiji Oda
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
| | - Hatem Ali
- Redlands Community Hospital, 305 Terracina Blvd, Redlands, CA 92350, USA;
| | - Lance Pompe
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
| | - Rhonda Spencer-Hwang
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
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Advancement of echocardiography for surveillance of iron overload cardiomyopathy: comparison to cardiac magnetic resonance imaging. J Echocardiogr 2021; 19:141-149. [PMID: 33772457 DOI: 10.1007/s12574-021-00524-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/03/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
The prevalence of iron overload cardiomyopathy (IOC) is increasing. Patients with transfusion-dependent anemias or conditions associated with increased iron absorption over time are at a significant risk for the development of iron-overloaded states such as IOC. Current guidelines regarding the diagnostic evaluation and follow-up of patients at risk for IOC exist, and are composed of multiple components, including such as echocardiography, genetic testing, magnetic resonance imaging of liver, and cardiac magnetic resonance imaging (CMR). While these are considered reliable for the evaluation of patients at risk for an iron-overloaded state, there is an access challenge associated with initial and serial CMR scanning in this patient population. Furthermore, there are other limiting factors, such as patient characteristics that may preclude the use of CMR as a viable diagnostic imaging modality for these patients. On the other hand, recent evidence in the literature suggests that transthoracic echocardiography, which has had significant technological advances, can equal or even outperform CMR to identify cardiac functional abnormalities such as subclinical left ventricular strain and left atrial functional abnormalities in iron overload conditions. Therefore, there is a potential role of more frequent use of echocardiography for surveillance of the development of IOC. Our purpose with this narrative review is to describe recent advances in echocardiography and propose a potential increased use of echocardiography in the surveillance of the development of IOC.
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Millett GA. New pathogen, same disparities: why COVID-19 and HIV remain prevalent in U.S. communities of colour and implications for ending the HIV epidemic. J Int AIDS Soc 2020; 23:e25639. [PMID: 33222424 PMCID: PMC7645849 DOI: 10.1002/jia2.25639] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/20/2020] [Accepted: 10/22/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The U.S. Ending the HIV Epidemic (EHE) Initiative was launched nationally in February 2019. With a target of ending the HIV epidemic by 2030, EHE initially scales up effective HIV prevention and care in 57 localities that comprise the greatest proportion of annual HIV diagnoses in the United States (US). However, the EHE effort has been eclipsed by another infectious disease 11 months into the Initiative's implementation. SARS-COV-2, a novel coronavirus, has infected more than eight million Americans and at least 223 000 (as of 23 October 2020) have succumbed to the disease. This commentary explores the social conditions that place communities of colour at greater risk for COVID-19 and HIV, and assesses challenges to EHE in a post-COVID-19 universe. DISCUSSION One of the many common threads between HIV and COVID-19 is the disproportionate impact of each disease among communities of colour. A recent report by the National Academy of Sciences surmised that as much as 70% of health outcomes are due to health access, socio-economic factors and environmental conditions. Social determinants of health associated with greater HIV burden in Black and Brown communities have re-emerged in epidemiological studies of disproportionate COVID-19 cases, hospitalizations and deaths in communities of colour. Using data from the scientific literature, this commentary makes direct comparisons between HIV and COVID-19 racial disparities across the social determinants of health. Furthermore, I examine three sets of challenges facing EHE: (1) Challenges that hamper both the EHE and COVID-19 response (i.e. insufficiently addressing the social determinants of health; amplification of disparities as new health technologies are introduced) (2) Challenges posed by COVID-19 (i.e. diverting HIV resources to address COVID-19 and tapering of EHE funding generally); and (3) Challenges unrelated to COVID-19 (i.e. emergence of new and related health disparities; repeal of the Affordable Care Act and long-term viability of EHE). CONCLUSIONS Racism and discrimination place communities of colour at greater risk for COVID-19 as well as HIV. Achieving and sustaining an end to the U.S. HIV epidemic will require structural change to eliminate conditions that give rise to and maintain disparities.
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Deville C, Lee WR. Reconciling outcomes for Black men with prostate cancer within and outside the Veterans Health Administration. Cancer 2020; 127:342-344. [PMID: 33036061 DOI: 10.1002/cncr.33225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 08/30/2020] [Accepted: 09/04/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Bethesda, Maryland
| | - W Robert Lee
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
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Millett GA, Honermann B, Jones A, Lankiewicz E, Sherwood J, Blumenthal S, Sayas A. White Counties Stand Apart: The Primacy of Residential Segregation in COVID-19 and HIV Diagnoses. AIDS Patient Care STDS 2020; 34:417-424. [PMID: 32833494 PMCID: PMC7585613 DOI: 10.1089/apc.2020.0155] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Emerging epidemiological data suggest that white Americans have a lower risk of acquiring COVID-19. Although many studies have pointed to the role of systemic racism in COVID-19 racial/ethnic disparities, few studies have examined the contribution of racial segregation. Residential segregation is associated with differing health outcomes by race/ethnicity for various diseases, including HIV. This commentary documents differing HIV and COVID-19 outcomes and service delivery by race/ethnicity and the crucial role of racial segregation. Using publicly available Census data, we divide US counties into quintiles by percentage of non-Hispanic white residents and examine HIV diagnoses and COVID-19 per 100,000 population. HIV diagnoses decrease as the proportion of white residents increase across US counties. COVID-19 diagnoses follow a similar pattern: Counties with the highest proportion of white residents have the fewest cases of COVID-19 irrespective of geographic region or state political party inclination (i.e., red or blue states). Moreover, comparatively fewer COVID-19 diagnoses have occurred in primarily white counties throughout the duration of the US COVID-19 pandemic. Systemic drivers place racial minorities at greater risk for COVID-19 and HIV. Individual-level characteristics (e.g., underlying health conditions for COVID-19 or risk behavior for HIV) do not fully explain excess disease burden in racial minority communities. Corresponding interventions must use structural- and policy-level solutions to address racial and ethnic health disparities.
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Affiliation(s)
| | - Brian Honermann
- amfAR, Foundation for AIDS Research, Washington, District of Columbia, USA
| | - Austin Jones
- amfAR, Foundation for AIDS Research, Washington, District of Columbia, USA
| | - Elise Lankiewicz
- amfAR, Foundation for AIDS Research, Washington, District of Columbia, USA
| | - Jennifer Sherwood
- amfAR, Foundation for AIDS Research, Washington, District of Columbia, USA
| | - Susan Blumenthal
- amfAR, Foundation for AIDS Research, Washington, District of Columbia, USA
| | - Asal Sayas
- amfAR, Foundation for AIDS Research, Washington, District of Columbia, USA
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Wong MS, Steers WN, Hoggatt KJ, Ziaeian B, Washington DL. Relationship of neighborhood social determinants of health on racial/ethnic mortality disparities in US veterans-Mediation and moderating effects. Health Serv Res 2020; 55 Suppl 2:851-862. [PMID: 32860253 PMCID: PMC7518818 DOI: 10.1111/1475-6773.13547] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation. DATA SOURCES Electronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census. STUDY DESIGN Racial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions. PRINCIPAL FINDINGS Mortality disparities existed for AI/ANs (HR = 1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (P = .047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations. CONCLUSIONS Neighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.
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Affiliation(s)
- Michelle S. Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)VA Greater Los Angeles Healthcare SystemLos AngelesCAUSA
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)VA Greater Los Angeles Healthcare SystemLos AngelesCAUSA
| | - Katherine J. Hoggatt
- San Francisco VA Healthcare SystemSan FranciscoCAUSA
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Boback Ziaeian
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)VA Greater Los Angeles Healthcare SystemLos AngelesCAUSA
- Division of Cardiology, Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP)VA Greater Los Angeles Healthcare SystemLos AngelesCAUSA
- Division of General Internal Medicine and Health Services Research, Department of MedicineDavid Geffen School of Medicine at UCLALos AngelesCAUSA
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Napolitano MA, Sparks AD, Randall JA, Brody FJ, Duncan JE. Elective surgery for diverticular disease in U.S. veterans: A VASQIP study of national trends and outcomes from 2004 to 2018. Am J Surg 2020; 221:1042-1049. [PMID: 32938529 DOI: 10.1016/j.amjsurg.2020.08.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Treatment for diverticular disease has evolved over time. In the United States, there has been a trend towards minimally invasive surgical approaches and fewer postoperative complications, but no study has investigated this subject in the Veterans Health Administration. METHODS This retrospective review identified patients undergoing elective surgery for diverticular disease from 2004 to 2018. Demographics, comorbidities, operative approach, rates of ostomy creation, and 30-day outcomes were compared. The 15-year time period was divided into 3-year increments to assess changes over time. RESULTS 4198 patients were identified. Complication rate decreased significantly over time (28.1%-15.7%, p < 0.001), as did infectious complications (21.5-6.3%, p < 0.001). Median hospital length-of-stay decreased from 7 to 5 days (p < 0.001). Rates of laparoscopic surgery increased over time (17.7%-48.1%, p < 0.001). CONCLUSIONS Increased utilization of laparoscopy in veterans undergoing elective surgery for diverticular disease coincided with fewer complications and a shorter length-of-stay. These trends mirror outcomes reported in non-veterans.
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Affiliation(s)
- Michael A Napolitano
- Department of Surgery, Washington, D.C. Veterans Affairs Medical Center. 50 Irving St.NW, Suite 2B-100, Washington, DC, 20422, USA; Department of Surgery, George Washington University, 2150 Pennsylvania Ave Suite 6B. Washington, DC, 20037, USA.
| | - Andrew D Sparks
- Department of Surgery, George Washington University, 2150 Pennsylvania Ave Suite 6B. Washington, DC, 20037, USA.
| | - J Alex Randall
- Stritch School of Medicine, Loyola University Chicago, 2160 S 1st Ave, Maywood, IL, 60153, USA.
| | - Fred J Brody
- Department of Surgery, Washington, D.C. Veterans Affairs Medical Center. 50 Irving St.NW, Suite 2B-100, Washington, DC, 20422, USA.
| | - James E Duncan
- Department of Surgery, Washington, D.C. Veterans Affairs Medical Center. 50 Irving St.NW, Suite 2B-100, Washington, DC, 20422, USA.
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Chen JA, Glass JE, Bensley KMK, Goldberg SB, Lehavot K, Williams EC. Racial/ethnic and gender differences in receipt of brief intervention among patients with unhealthy alcohol use in the U.S. Veterans Health Administration. J Subst Abuse Treat 2020; 119:108078. [PMID: 32736926 DOI: 10.1016/j.jsat.2020.108078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 06/18/2020] [Accepted: 07/08/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Brief intervention (BI) for unhealthy alcohol use is a top prevention priority for adults in the U.S, but rates of BI receipt vary across patients. We examine BI receipt across race/ethnicity and gender in a national cohort of patients from the Department of Veterans Affairs (VA)-the largest U.S. integrated healthcare system and a leader in implementing preventive care for unhealthy alcohol use. METHODS Among 779,041 VA patients with documented race/ethnicity and gender who screened positive for unhealthy alcohol use (AUDIT-C score ≥ 5) between 10/1/09 and 5/30/13, we fit Poisson regression models to estimate the predicted prevalence of BI (EHR-documented advice to reduce or abstain from drinking) across race/ethnicity and gender. RESULTS Rates of BI were lowest among Black women (67%), Black men (68%), and Asian/Pacific Islander women (68%), and highest among white men (75%), Hispanic men (75%), and Asian/Pacific Islander men (75%). A significant race/ethnicity by gender interaction indicated that the associations between race/ethnicity and gender with BI depended on the other factor. Gender differences were largest among Asian/Pacific Islander patients and were nonsignificant among American Indian/Alaska Native patients. Adjustment for covariates not expected to be on the causal pathway (e.g., age, year of AUDIT-C screen) slightly attenuated but did not change the direction of results. CONCLUSIONS Receipt of BI for unhealthy alcohol use varied by race/ethnicity and gender, and the impact of one factor depended on the other. Black women, Black men, and Asian/Pacific Islander women had the lowest rates of receiving recommended alcohol-related care. We found these disparities in a healthcare system that has implemented universal alcohol screening and incentivized BI for all patients with unhealthy alcohol use, suggesting that reducing disparities in alcohol-related care may require targeted interventions.
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Affiliation(s)
- Jessica A Chen
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560, USA.
| | - Joseph E Glass
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Box 357660, Seattle, WA 98195-7660, USA.
| | - Kara M K Bensley
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St, Suite 450, Emeryville, CA 94608, USA; Department of Public Health, Bastyr University, 14500 Juanita Dr NE, Kenmore, WA 98028, USA.
| | - Simon B Goldberg
- Department of Counseling Psychology, University of Wisconsin - Madison, 335 Education Building, 1000 Bascom Mall, Madison, WI, 53706, USA.
| | - Keren Lehavot
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Box 357660, Seattle, WA 98195-7660, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA 98108, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA; Department of Health Services, University of Washington, 1959 NE Pacific St., Box 357660, Seattle, WA 98195-7660, USA.
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