Hepatocellular Carcinoma Surveillance in a Cohort of Chronic Hepatitis C Virus-Infected Patients with Cirrhosis

BACKGROUND

Six-monthly hepatocellular carcinoma (HCC) screening in cirrhotic patients has been recommended since 2011. HCC prognosis is associated with diagnosis at an early stage. We examined the prevalence and correlates of 6-monthly HCC surveillance in a cohort of HCV-infected cirrhotic patients.

METHODS

Data were obtained from the medical records of patients receiving care from four hospitals between January 2011 and December 2016. Frequencies and logistic regression were conducted.

RESULTS

Of 2,933 HCV-infected cirrhotic patients, most were ≥ 60 years old (68.5%), male (62.2%), White (65.8%), and had compensated cirrhosis (74.2%). The median follow-up period was 3.5 years. Among these patients, 10.9% were consistently screened 6 monthly and 21.4% were never screened. Patients with a longer history of cirrhosis (AOR = 0.86, 95% CI = 0.80-0.93) were less likely to be screened 6 monthly while decompensated cirrhotic patients (AOR = 1.39, 95% CI = 1.06-1.81) and cirrhotic patients between 18 and 44 years (AOR = 2.01, 95% CI = 1.07-3.74) were more likely to be screened 6 monthly compared to compensated cirrhotic patients and patients 60 years and older respectively. There were no significant differences by race, gender, or insurance type.

CONCLUSION

The prevalence of consistent HCC surveillance remains low despite formalized recommendations. One in five patients was never surveilled. Patients with a longer history of cirrhosis were less likely to be surveilled consistently despite their greater HCC risk. Improving providers' knowledge about current HCC surveillance guidelines, educating patients about the benefits of consistent HCC surveillance, and systemic interventions like clinical reminders and standing HCC surveillance protocols can improve guideline-concordant surveillance in clinical practice.

Impact of sustained virologic response on risk of type 2 diabetes among hepatitis C patients in the United States

Data regarding the impact of hepatitis C (HCV) therapy on incidence of type 2 diabetes mellitus are limited. We used the data from the longitudinal Chronic Hepatitis Cohort Study-drawn from four large US health systems-to investigate how response to HCV treatment impacts the risk of subsequent diabetes. Among HCV patients without a history of type 2 diabetes mellitus or hepatitis B, we investigated the incidence of type 2 diabetes from 12 weeks post-HCV treatment through December 2015. Cox proportional hazards models were used to test the effect of treatment status (sustained virologic response [SVR] or treatment failure) and baseline risk factors on the development of diabetes, considering any possible risk factor-by-SVR interactions, and death as a competing risk. Among 5127 patients with an average follow-up of 3.7 years, diabetes incidence was significantly lower among patients who achieved SVR (231/3748; 6.2%) than among patients with treatment failure (299/1379; 21.7%; adjusted hazard ratio [aHR] = 0.79; 95% CI: 0.65-0.96). Risk of diabetes was higher among African American and Asian American patients than White patients (aHR = 1.82 and 1.75, respectively; P < .05), and among Hispanic patients than non-Hispanics (aHR = 1.86). Patients with BMI ≥ 30 and 25-30 (demonstrated higher risk of diabetes aHR = 3.62 and 1.72, respectively; P < .05) than those with BMI < 25; patients with cirrhosis at baseline had higher risk than those without cirrhosis (aHR = 1.47). Among a large US cohort of patients treated for HCV, patients who achieved SVR demonstrated a substantially lower risk for the development of type 2 diabetes mellitus than patients with treatment failure.

Distribution of disease phase, treatment prescription and severe liver disease among 1598 patients with chronic hepatitis B in the Chronic Hepatitis Cohort Study, 2006-2013

BACKGROUND

Limited information exists regarding the distribution of disease phases, treatment prescription and severe liver disease among patients with chronic hepatitis B (CHB) in US general healthcare settings.

AIM

To determine the distribution of disease phases, treatment prescription and severe liver disease among patients with CHB in general US healthcare settings.

METHODS

We analysed demographic and clinical data collected during 2006-2013 from patients with confirmed CHB in the Chronic Hepatitis Cohort Study, an observational cohort study involving patients from healthcare organisations in Michigan, Pennsylvania, Oregon and Hawaii. CHB phases were classified according to American Association for the Study of Liver Disease guidelines.

RESULTS

Of 1598 CHB patients with ≥12 months of follow-up (median 6.3 years), 457 (29%) were immune active during follow-up [11% hepatitis B e antigen (HBeAg)-positive, 16% HBeAg-negative, and 2% HBeAg status unknown], 10 (0.6%) were immune tolerant, 112 (7%) were inactive through the duration of follow-up and 886 (55%) were phase indeterminate. Patients with cirrhosis were identified within each group (among 21% of immune active, 3% of inactive and 9% of indeterminate phase patients) except among those with immune-tolerant CHB. Prescription of treatment was 59% among immune active patients and 84% among patients with cirrhosis and hepatitis B virus (HBV) DNA >2000 IU/mL.

CONCLUSIONS

Approximately, one-third of the cohort had active disease during follow-up; 60% of eligible patients were prescribed treatment. Our findings underscore the importance of ascertainment of fibrosis status in addition to regular assessment of ALT and HBV DNA levels.

Higher all-cause hospitalization among patients with chronic hepatitis C: the Chronic Hepatitis Cohort Study (CHeCS), 2006-2013

In the United States, hospitalization among patients with chronic hepatitis C virus (HCV) infection is high. The healthcare burden associated with hospitalization is not clearly known. We analysed data from the Chronic Hepatitis Cohort Study, an observational cohort of patients receiving care at four integrated healthcare systems, collected from 2006 to 2013 to determine all-cause hospitalization rates of patients with chronic HCV infection and the other health system patients. To compare the hospitalization rates, we selected two health system patients for each chronic HCV patient using their propensity score (PS). Propensity score matching was conducted by site, gender, race, age and household income to minimize differences attributable to these characteristics. We also compared primary reason for hospitalization between chronic HCV patients and the other health system patients. Overall, 10 131 patients with chronic HCV infection and 20 262 health system patients were selected from the 1 867 802 health system patients and were matched by PS. All-cause hospitalization rates were 27.4 (27.0-27.8) and 7.4 (7.2-7.5) per 100 persons-year (PY) for chronic HCV patients and for the other health system patients, respectively. Compared to health system patients, hospitalization rates were significantly higher by site, gender, age group, race and household income among chronic HCV patients (P < 0.001). Compared to health system patients, chronic HCV patients were more likely to be hospitalized from liver-related conditions (RR = 24.8, P < 0.001). Hence, patients with chronic HCV infection had approximately 3.7-fold higher all-cause hospitalization rate than other health system patients. These findings highlight the incremental costs and healthcare burden of patients with chronic HCV infection associated with hospitalization.

APRI and FIB-4 are good predictors of the stage of liver fibrosis in chronic hepatitis B: the Chronic Hepatitis Cohort Study (CHeCS)

We aim to determine the predictive ability of APRI, FIB-4 and AST/ALT ratio for staging of liver fibrosis and to differentiate significant fibrosis (F2-F4) from none to minimal fibrosis (F0-F1) in chronic hepatitis B (CHB). Liver biopsy results were mapped to an F0-4 equivalent fibrosis stage. Mean APRI and FIB-4 scores were significantly higher for each successive fibrosis level from F1 to F4 (P < 0.05). Based on optimized cut-offs, the AUROCs in distinguishing F2-F4 from F0 to F1 were 0.81 (0.76-0.87) for APRI, 0.81 (0.75-0.86) for FIB-4 and 0.56 (0.49-0.64) for AST/ALT ratio. APRI and FIB-4 distinguished F2-F4 from F0 to F1 with good sensitivity and specificity and can be useful for treatment decisions and monitoring progression of fibrosis.

The validity of serum markers for fibrosis staging in chronic hepatitis B and C

Assessment of liver fibrosis is critical for successful individualized disease management in persons with chronic hepatitis B (CHB) or chronic hepatitis C (CHC). We expanded and validated serum marker indices to provide accurate, reproducible and easily applied methods of fibrosis assessment. Liver biopsy results from over 284 CHB and 2304 CHC patients in the Chronic Hepatitis Cohort Study ('CHeCS') were mapped to a F0-F4 equivalent scale. APRI and FIB-4 scores within a 6-month window of biopsy were mapped to the same scale. A novel algorithm was applied to derive and validate optimal cut-offs for differentiating fibrosis levels. For the prediction of advanced fibrosis and cirrhosis, the FIB-4 score outperformed the other serum marker indices in the CHC cohort and was similar to APRI in the CHB cohort. The area under the receiver operating characteristic curves (AUROC) for FIB-4 in differentiating F3-F4 from F0-F2 was 0.86 (95% CI: 0.80-0.92) for CHB and 0.83 (95% CI: 0.81-0.85) for CHC. The suggested cut-offs based on FIB-4 model produced high positive predictive values [CHB: 90.0% for F0-F2, 100.0% for cirrhosis (F4); CHC: 89.7% for F0-F2; 82.9% for cirrhosis (F4)]. In this large observational cohort, FIB-4 predicted the upper and lower end of liver fibrosis stage (cirrhosis and F0-F2, respectively) with a high degree of accuracy in both CHB and CHC patients.

A clinical demonstration model for assessing the effectiveness of therapeutic interventions: an expanded clinical trials methodology

Both the evaluation of current treatment interventions and the innovation of new ones are vital to maintaining a viable clinical profession. In the field of psychology, however, often there are serious challenges facing these worthy endeavors. This article reviews several problems and limitations with evaluation of innovative psychotherapy treatments in clinical practice and suggests a strategy to overcome these. This approach, which we term the "Systematic Clinical Demonstration Methodology," (SCDM) combines the skills of clinicians with the rigors of clinical trials methods and permits concurrent clinical innovation and scientific evaluation. Here we suggest that the SCDM approach allows innovative practitioners to assist in the development and evaluation of promising clinical interventions by working closely with clinical trials researchers. This allows innovative clinicians to demonstrate new treatment approaches, while clinical researchers evaluate the effectiveness and safety of these interventions using clinical trials methods that incorporate qualitative data. We suggest that this approach can result in the development and evaluation of new treatment innovations more quickly and cost effectively than traditionally has been the case. In addition, some limitations commonly associated with clinical trials, such as not treating patients typically found in clinical practice, failing to treat patients with multiple disorders, or treating patients from different cultural or sociodemographic groups, can be more effectively addressed. Our experiences with using this method to evaluate different psychotherapy treatments for posttraumatic stress disorder are presented as an example of this new approach.

HIV infection and risk behaviors in two cross-sectional surveys of heterosexuals in alcoholism treatment

OBJECTIVE

To measure the prevalence of human immunodeficiency virus (HIV) infection and high-risk behaviors among heterosexuals in alcoholism treatment, comparing two cross-sectional surveys completed 2 to 3 years apart.

METHOD

Two groups of entrants to alcoholism treatment clinics were recruited, between October 1990 and December 1991 (n = 860; 639 men) and between January 1993 and March 1994 (n = 752; 520 men). Participants underwent a structured interview including an assessment of demographics. substance abuse characteristics and sexual behaviors, as well as serotesting for HIV antibodies. Associations were examined between HIV serostatus and several factors, including demographic variables, substance use and high-risk sexual behaviors.

RESULTS

The overall HIV seroprevalence in the first and second samples was 5% (95% CI: 3-6%) and 5% (95% CI: 3-7%). When the two samples were compared, there were no significant differences in prevalence of HIV infection by categories of gender, race, income and most other demographic characteristics within either sample: history of injection drug use (IDU) was significantly related to HIV serostatus in both samples. Unsafe sexual practices were common in both samples. When samples were combined, those 30 years of age or older were more likely to be HIV infected, and men and women with no reported history of IDU still had an HIV prevalence of 3% and 2%, respectively. More than half of the respondents had two or more partners in the previous 6 months and reported a history of a sexually transmitted disease.

CONCLUSIONS

There was no change in the substantial prevalence of HIV infection and high-risk behavior among heterosexual clients entering alcoholism treatment programs over the 3.5-year study period. The HIV prevalence among non-IDU clients remained several times higher than published estimates from similar community-based heterosexual samples. These data reinforce the concept that heterosexual noninjection drug users are at high risk for HIV and may benefit from intervention programs.

Beyond survey data: a claims-based analysis of drug use and spending by the elderly

Previous estimates of Medicare beneficiaries total and out-of-pocket spending on outpatient prescription drugs have largely been based on data from the 1995 Medicare Current Beneficiary Survey and have focused on how expenditures vary among beneficiaries with different demographic characteristics. This paper reports the results of an analysis of prescription claims from 1998 for more than 375,000 elderly persons whose prescription benefit was managed by Merck-Medco Managed Care. In addition to examining how total and out-of-pocket drug spending in a well-insured population varies by age and sex, we report how total and condition-specific drug spending varies for elderly persons with ten common chronic diseases. Our results illustrate the highly skewed nature of prescription drug spending, even among those with drug coverage, and underscore the particularly high cost burden that pharmaceuticals place on elderly people with chronic diseases.

Nontraditional services provided by nonprofit and for-profit hospitals: implications for community health

In part because of reimbursement changes in the 1980s, hospitals became involved in health promotion and disease prevention activities often to attract patients. Today, these services may have an effect on the burden of disease and on illness prevention in some communities. Given the changes anticipated in healthcare delivery, assessing the scope of these services and integrating them with other private-public efforts is of utmost importance. Here we use a 1993 survey of all 4,977 private medical and surgical hospitals in the United States to determine the scope of disease prevention, health enhancement, and palliative services provided by facility type, geographic location, and institutional ownership. We found that church-operated and other nonprofit hospitals appear to provide a spectrum of palliative and preventive health services both for their patients and those in the local community. Given their apparent scope, these services could have an effect on the burden of disease and on illness prevention in many communities. With major changes anticipated in future healthcare delivery and the recent failures reported for many community health intervention programs, healthcare administrators need to focus on ways to integrate their services with other private and public health efforts. If this could be achieved, then private hospitals could be more successful in serving their local communities and in enhancing the public's health in the new century. This article outlines several basic steps to assist administrators in achieving these goals.

Treatment and outcome of myocardial infarction in hospitals with and without invasive capability. Investigators in the National Registry of Myocardial Infarction

OBJECTIVES

We sought to determine the extent to which the capability of a hospital to perform invasive cardiovascular procedures influences treatment and outcome of patients admitted with acute myocardial infarction (AMI).

BACKGROUND

Patients with AMI are usually transported to the closest hospital. However, relatively few hospitals have the capability for immediate coronary arteriography, percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG), should these interventions be needed.

METHODS

The 1,506 hospitals participating in the National Registry of Myocardial Infarction 2 were classified according to their highest level of invasive capability: 1) none (noninvasive, 28.1%); 2) coronary arteriography (cath-capable, 25.2%); 3) coronary angioplasty (PTCA-capable, 7.4%); and 4) bypass surgery (CABG-capable, 39.2%). Treatment and in-hospital outcomes were assessed for 305,812 patients admitted from June 1994 through October 1996. Follow-up through 90 days was ascertained in a subset of 30,402 patients enrolled simultaneously in both the National Registry of Myocardial Infarction (NRMI) 2 and the Cooperative Cardiovascular Project (CCP).

RESULTS

The proportion of patients receiving initial reperfusion intervention was only slightly higher at the more invasive hospitals (noninvasive 32.5%, cath-capable 31.2%, PTCA-capable 32.9% and CABG-capable 35.9%, p < 0.001 by chi-square statistic). Among thrombolytic recipients, median door-to-drug time interval differed little among hospital types and ranged from 42 to 45 minutes. At cath-capable, PTCA-capable and CABG-capable hospitals, coronary arteriography was performed in 32.9%, 37.4% and 64.9%, respectively, and PTCA in 0.0%, 5.1% and 31.4%, both p < 0.001 by chi-square statistic. The proportion of patients transferred out to other facilities was 51.0%, 42.2%, 39.9% and 4.4% (p < 0.0001) among noninvasive, cath-capable, PTCA-capable and CABG-capable hospitals, respectively. Among patients in the combined NRMI and CCP data set, mortality at 90 days postinfarction was similar among patients initially admitted to each of the four hospital types.

CONCLUSIONS

Although patients with AMI admitted to hospitals without invasive cardiac facilities have a high likelihood of subsequent transfer to other facilities, their likelihood of receiving a reperfusion intervention at the first hospital, their door to thrombolytic drug intervals and their 90-day survival rates are similar to those of patients initially admitted to more invasively equipped hospitals. These data suggest that a policy of initial treatment of myocardial infarction at the closest medical facility is appropriate medical practice.

Electrocardiogram abnormalities among men with stress-related psychiatric disorders: implications for coronary heart disease and clinical research

Research suggests psychological distress could result in arterial endothelial injury and coronary heart disease (CHD). Studies also show Posttraumatic Stress Disorder (PTSD) victims have higher circulating catecholamines and other sympathoadrenal-neuroendocrine bioactive agents implicated in arterial damage. Here we analyzed resting 12-lead electrocardiographic (ECG) results among a national sample of 4,462 nonhospitalized male veterans (mean age = 38) about 20 years after military service by current posttraumatic stress (n = 54), general anxiety (n = 186), and depression (n = 157) disorders. ECGs were interpreted by board-certified cardiologists and summarized using the Minnesota Code Manual of Electrocardiographic Findings. Psychiatric disorders were diagnosed based on the Diagnostic Interview Schedule, Version III. Controlling for age, place of service, illicit drug use, medication use, race, body mass index, alcohol use, cigarette smoking, and education, PTSD (odds ratio [OR] = 2.23, 95% confidence interval [CI] = 1.17-4.26, p < 0.05), anxiety (OR = 1.51, 95% CI = 1.03-2.22, p < 0.05), and depression (OR = 1.71, 95% CI = 1.13-2.58, p < 0.01) were associated with having a positive ECG finding. Specific results indicate PTSD was associated with atrioventricular (AV) conduction defects (OR = 2.81, 95% CI = 1.03-7.66, p < 0.05) and infarctions (OR = 4.44, 95% CI = 1.20-16.43, p < 0.05), while depression was associated with arrhythmias (OR = 1.98, 95% CI = 1.22-3.23, p < 0.01). The PTSD associations for AV conduction defects and infarctions held, even after controlling for current anxiety and depression. These findings suggest psychological distress may result in CHD, because we controlled for obvious biases and confounders, the men studied had current PTSD due to combat exposures 20 years ago, combat exposure was associated with anxiety and depression among these men, and the men were disease free a military induction. These findings suggest the need for clinical surveillance among combat veterans, better psychobiologic models of CHD pathogenesis, and additional research.

Higher abnormal leukocyte and lymphocyte counts 20 years after exposure to severe stress: research and clinical implications

OBJECTIVES

Research suggests that individuals with posttraumatic stress disorder (PTSD) are more likely to develop medical conditions and other stress-related psychiatric disorders. Given these findings and others suggesting that PTSD victims may have altered neuroendocrine and immune systems, the hypothesis that Vietnam veterans with PTSD have abnormally high leukocyte and lymphocyte counts was tested.

METHODS

The leukocyte and lymphocyte status of male Vietnam "theater" veterans with current partial posttraumatic stress (N = 286), anxiety (N = 274), and depression disorders (N = 192) were compared with those of Vietnam veterans without these disorders 20 years after military service (N = 2190), controlling for intelligence, race, age, income, education, type of enlistment, Vietnam volunteer status, region of birth, cigarette smoking, illicit drug use, body mass index, and alcohol consumption. Abnormal values were defined using standard laboratory reference ranges. Adjusted mean differences also were compared.

RESULTS

Based on the results of two-tailed tests, PTSD-positive veterans are more likely to have adjusted leukocyte (OR = 1.83, p = .04) and T-cell (OR = 1.82, p = .045) counts above the normal range and higher mean adjusted leukocyte (p = .042), lymphocyte (p = .01), T-cell (p = .008), and CD4 cell (p = .027) counts. Those with anxiety disorders have adjusted lymphocyte (OR = 1.68, p = .048) and T-cell (OR = 2.06, p = .011) counts above range. They also have test results indicating reactive delayed cutaneous hypersensitivity (OR = 1.77, p = .006), which suggests the presence of highly sensitized T-cell lymphocytes. Finally, depressed veterans are less likely to have B-cell counts above the reference range (OR = 0.55, p = .006). Results of one-tailed tests further suggest that PTSD-positive men also have abnormally high CD4 and CD8 T-cell lymphocyte counts as well (p < .05).

CONCLUSIONS

Our findings suggest that chronic, primarily combat-related PTSD is associated with clinically elevated leukocyte and total T-cell counts. Those with current anxiety also have some of these abnormalities in addition to highly sensitized T-cell lymphocytes. Additional research is needed to specify the mechanisms involved here and to investigate the health risks associated with these findings.

The public's perception of quality hospitals II: Implications for patient surveys

Because there is growing consensus that monitoring quality care should be based, at least in part, on patients' perceptions (Davies and Ware 1988), this article expands earlier findings on how the public perceives the quality of hospitals and hospital care (Boscarino 1988b). In this study, the public's overall quality ratings of 155 short-term medical and surgical hospitals are analyzed by the type, size, staff ratio, mortality rate, case mix, and location. The hospitals in the study represented a national cross-section of institutions, with the results based on 20,000 adults surveyed in 40 U.S. market areas. Initial analysis shows that the public rates nonrural, larger, tertiary care, teaching, higher-patient census, better-staffed, and lower-mortality facilities higher in overall quality. Hospitals that are located in the Midwest or West, have higher average employee salaries, and that are more costly are also perceived to be of a higher quality. A multiple regression analysis reveals that combined these variables account for 50 percent of the public's quality perception, with the most important being tertiary care level, patient-census level, average employee salary, and teaching status (all positively related to higher quality). Using these variables in a discriminant function analysis, hospitals with high-perceived quality can be correctly identified 80 percent of the time. It is suggested that these findings have major significance for monitoring the quality of care, based on patients' perceptions. A practical model for doing this, one that minimizes patient biases and incorporates medical outcomes, is described in detail.

Survival after coronary artery bypass graft surgery and community socioeconomic status: clinical and research implications

OBJECTIVES

Epidemiologic studies have linked adverse health outcomes to lower socioeconomic status (SES). To our knowledge, none have associated post-operative coronary artery bypass graft (CABG) surgery survival to this risk factor. To assess this, we compared post-operative survival among 771 CABG patients from different SES communities in a Southeastern state 36 months after surgery (mean follow-up = 30 months). All patients were admitted to the same tertiary care medical center for surgery in 1994 (mean age = 62; females = 214; African Americans = 13; person years of follow-up = 2,153; 36-month mortality = 8.8%).

METHODS

Data were extracted from the medical records of all CABG patients admitted in 1994 using the Society of Thoracic Surgeons' data-collection protocol. The study hypothesis was that patients from "disadvantaged" communities would have lower survival rates after surgery, controlling for the severity of the patient's medical condition. In this study, 181 patients were from an Appalachian county and 437 were from a medically under-served county. Post-discharge mortality was ascertained from state mortality files. Forward and backwards step-wise Cox proportional hazard regression models were used to select the most significant risk factors for mortality from 8 county-level community indicators and 32 clinical risk factor variables potentially associated with post-operative survival.

RESULTS

Controlling for traditional risk factors for post-operative CABG survival, patients from counties with the lowest housing values have a significant increased risk of death 36 months after CABG surgery (hazard ratio [HR] = 2.46, 95% CI = 1.26-4.78, P = 0.008). Being an African American also appeared to be a significant and independent risk factor for death 36 months after surgery, as well (HR = 4.55, 95% CI = 1.37-15.11, P = 0.013).

CONCLUSION

This study suggests that residence in a poor community and possibly African American status are significant and independent risk factors for mortality 36 months after CABG surgery, although the latter may have included too few cases (n = 13) to assess this effectively. Additional research is needed to determine why these associations exist and to develop specific interventions. In the mean time, closer surveillance is recommended for CABG patients admitted from lower SES communities and possibly for African American patients.

Commentary: inaccurate data on the quality of care may do more harm than good--an alternative approach is required

Recently the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced that it would integrate the use of clinical outcomes and other performance measures into the accreditation process through its new "ORYX" program. This JCAHO initiative represents a significant new development that will include more than 100 different performance measurement systems, most of which are available through commercial firms and outside organizations. However, we see some potential problems with this new initiative. This is because some indicators recommended by JCAHO may be questionable due to the fact they are based on flawed methodologies that could result in biased and confounded data. To illustrate some of the potential adverse effects that could result from using such data to compare health care providers and facilities, we discuss some common problems associated with several widely available performance measurement systems. We then suggest an alternative approach that could potentially avoid many of these problems in the future.

Diseases among men 20 years after exposure to severe stress: implications for clinical research and medical care

OBJECTIVE

Epidemiologic studies have linked exposure to severe environmental stress, such as natural disasters and combat operations, to the onset of specific psychiatric disorders. Some research also suggests that these exposures may be associated with the onset of chronic diseases as well. However, these chronic disease outcome studies often have been obscured by bias and confounding.

METHOD

The medical histories of 1399 male Vietnam veterans approximately 20 years after combat exposure (mean years = 17) were analyzed by lifetime posttraumatic stress disorder (PTSD) status (lifetime PTSD = 332 cases). These men were included in a national, random in-person study of United States Army veterans of the Vietnam War (study completion rate = 65%).

RESULTS

After controlling for preservice, in-service, and postservice factors (including intelligence, race, region of birth, enlistment status, volunteer status, Army marital status, Army medical profile, hypochondriasis, age, smoking history, substance abuse, education, and income), associations were found for reported circulatory [odds ratio (OR) = 1.62, p = .007], digestive (OR = 1.47, p = .036), musculoskeletal (OR = 1.78, p = .008), endocrine-nutritional-metabolic (OR = 1.58, p = .10), nervous system (OR = 2.47, p < .001), respiratory (OR = 1.54, p = .042), and nonsexually transmitted infectious diseases (OR = 2.14, p < .004) after military service.

CONCLUSION

Although this study has some limitations, it suggests that there is a direct link between severe stress exposures and a broad spectrum of human diseases. In the future, medical researchers and clinicians should focus more on the medical consequences of exposure to severe environmental stress and seek to better integrate psychobiologic models of disease pathogenesis.

Posttraumatic stress disorder, exposure to combat, and lower plasma cortisol among Vietnam veterans: findings and clinical implications

Several clinical studies suggest that individuals with posttraumatic stress disorder (PTSD) experience neuroendocrine system alterations, resulting in significantly lower plasma cortisol. To test this hypothesis, morning serum cortisol was compared among a national sample of Vietnam "theater" veterans (n = 2,490) and a sample of Vietnam "era" veterans (n = 1,972) without service in Vietnam. Analysis of covariance was used to compare cortisol concentrations after adjusting for 9 covariates (education, income, race, age, smoking status, alcohol use, illicit drug use, medication use, and body mass index). Adjusted cortisol was lower among theater veterans with current PTSD but not era or theater veterans with lifetime PTSD. Among theater veterans, cortisol was inversely related to combat exposure, with veterans exposed to heavy combat having the lowest concentrations. Analysis of plasma cortisol, together with other clinical data, may be instrumental in the future diagnosis and treatment of stress disorders.

Changes in HIV-related behaviors among heterosexual alcoholics following addiction treatment

In order to measure changes in HIV-related behaviors among heterosexual alcoholics following treatment, we conducted a prospective cohort study of 700 self-identified alcoholics recruited from five public alcohol treatment centers, all of which included HIV risk-reduction counseling. Respondents underwent an HIV antibody test and interviewer-administered questionnaire at entry to alcohol treatment and after a mean of 13 months later. Compared to baseline, at follow-up there was an overall 26% reduction in having sex with an injection-drug-using partner (23% versus 32%, P < .001) and a 58% reduction in the use of injection drugs (15% versus 37%, P < .001), along with smaller improvements in other behaviors. Respondents also showed a 77% improvement in consistent condom use with multiple sexual partners (35% versus 20%, P < .01) and a 23% improvement in partner screening (71% versus 57%, P < .001). Respondents who remained abstinent showed substantially greater improvement than those who continued to drink.

Patients' perception of quality hospital care and hospital occupancy: are there biases associated with assessing quality care based on patients' perceptions?

There currently is interest in evaluating medical outcomes based on patient perceptions. However, in the US there may be biases associated with these perceptions because of past marketing activities and other factors, such as facility location. The research question examined is whether perceived overall quality could predict hospital occupancy. To assess this, the quality ratings of 155 local hospitals by over 20,000 household heads surveyed in 20 US states were analyzed using an ecological research design. Facility image and hospital occupancy were assessed after controlling for community, facility and quality care differences between facilities. Results indicated that hospitals in more urbanized areas (p = 0.003), with lower costs (p = 0.0001), that were non-teaching (p = 0.033) and those with more employees per bed (p < 0.0001) had higher occupancies, but that perceived quality did not predict admissions after facility differences were controlled (p = 0.302). However, further analysis suggested both positive and negative biases may exist: controlling for community, facility, and quality care differences, facilities with "high" ratings appeared to have consistently higher occupancies, those with "low" ratings consistently lower occupancies, and facilities with "average" ratings appeared to be unaffected. Based on this finding, an interaction effect was tested and confirmed for community rating x facility size (p = 0.015), suggesting that smaller hospitals with low ratings had lower than expected occupancies. Although this study has limitations, it was suggested that researchers should use quality indicators based on patients' perceptions with caution and be open to additional scientific research, until these measures are better understood.

Predictors of HIV-related risk behaviors among heterosexuals in alcoholism treatment

OBJECTIVE

To determine which measures of alcohol and drug use are associated with HIV-related sexual risk and protective behaviors.

METHOD

Entrants (N = 743, 72% male) to alcoholism treatment clinics underwent a structured interview including an assessment of demographics, substance abuse characteristics and sexual behaviors. Associations were examined between alcohol- and drug-related behaviors, and demographic variables, with the prevalence of high-risk sexual behaviors.

RESULTS

Those more likely to use alcohol or drugs when having sex, and those who expect to have high-risk sex when they drink alcohol, were more likely to engage in high-risk sexual behavior. Measures of severity of alcohol or drug problems alone were not consistently related to high-risk or protective behaviors. Several other concurrently used measures (such as the Addition Severity Index and alcohol expectancies) showed more consistent association with high-risk behaviors. There was no apparent reduction in the likelihood of practicing risk-reducing behaviors among those more severely addicted and those who combined alcohol and/or drugs with sex.

CONCLUSIONS

This study suggests that sexual risk and protective behaviors are not consistently associated with severity of addiction problems. Some measures of alcohol and drug use (i.e., the ASI Drug Composite Score and the Enhanced Risk subscale of the alcohol expectancy measure) were more consistently related to the specific risk behaviors measured than were others (e.g., the ASI Alcohol Composite Score), while most measures showed little or no association with protective behaviors.

AIDS knowledge, teaching comfort, and support for AIDS education among school teachers: a statewide survey

With development of an effective HIV vaccine still elusive (Blower & McLean 1994; McLean & Blower 1993), the control of HIV infection may depend on our ability to successfully educate diverse groups of adolescents in different communities about homosexuality and other sensitive subject matter. A statewide survey of California teachers (n = 835) indicated that teachers generally were knowledgeable about AIDS, felt comfortable presenting AIDS prevention information to students, and supported AIDS education in schools. Nevertheless, teachers' level of AIDS knowledge, comfort, and support varied by grade and other background characteristics. Elementary teachers were less knowledgeable (p < .001), felt less comfortable teaching (p < .001), and were less supportive of school-based AIDS education (p < .01). Teachers in urban schools (p < .05) and nonwhite teachers (p < .01) also had lower AIDS knowledge relative to other teachers. However, in comparison to surveys conducted in other states, California teachers appeared more knowledgeable of and progressive about AIDS education in the schools. As new school-based HIV and AIDS policies and prevention programs are formulated in the 1990s, teacher input will be critical to effective program development and implementation. To achieve success, it is important that differences in teachers' knowledge, comfort, and support be taken into consideration during both the development and implementation phases of these programs.

Posttraumatic stress disorder, exposure to combat, and lower plasma cortisol among Vietnam veterans: findings and clinical implications

Several clinical studies suggest that individuals with posttraumatic stress disorder (PTSD) experience neuroendocrine system alterations, resulting in significantly lower plasma cortisol. To test this hypothesis, morning serum cortisol was compared among a national sample of Vietnam "theater" veterans (n = 2,490) and a sample of Vietnam "era" veterans (n = 1,972) without service in Vietnam. Analysis of covariance was used to compare cortisol concentrations after adjusting for 9 covariates (education, income, race, age, smoking status, alcohol use, illicit drug use, medication use, and body mass index). Adjusted cortisol was lower among theater veterans with current PTSD but not era or theater veterans with lifetime PTSD. Among theater veterans, cortisol was inversely related to combat exposure, with veterans exposed to heavy combat having the lowest concentrations. Analysis of plasma cortisol, together with other clinical data, may be instrumental in the future diagnosis and treatment of stress disorders.

Alcohol-related risk factors associated with HIV infection among patients entering alcoholism treatment: implications for prevention

OBJECTIVE

Reports suggest that alcoholics may be at risk for HIV infection. In this article we examine several alcohol-related risk factors for HIV infection among patients entering alcoholism treatment in an AIDS epicenter. Our objective was to identify key factors for HIV prevention and screening among populations receiving treatment for alcohol abuse or alcohol dependence.

METHOD

Clients (N = 921) entering five alcoholism treatment centers in the San Francisco Bay area underwent an interview and blind serotesting for HIV antibodies (76% were male, 16% men who had sex with men, 50% black, 10% Latinos and 6.5% were HIV seropositive). Logistic regression was used to predict HIV serostatus from five possible alcohol-associated risk factors, controlling for demographics and traditional HIV risk factors. These were alcohol impairment, attitudes about socializing in bars, increased sexual risk expectancies when drinking, enhanced sexual expectancies when drinking and decreased nervousness when drinking. Male and female heterosexuals and men with a history of homosexuality were analyzed separately.

RESULTS

Among male and female heterosexuals, HIV infection was positively associated with higher alcohol impairment (OR = 2.69, p = .031) and negatively associated with higher sexual risk expectancies when drinking (OR = 0.24, p = .075). Among men who had sex with men, HIV infection was positively associated with higher bar socializing orientations (OR = 10.06, p = .004). Infection was also negatively associated with higher alcohol impairment (OR = 0.34, p = .052) and higher sexual risk expectancies when drinking (OR = 0.26, p = .024) for these men.

CONCLUSIONS

Since these associations were independent of demographics and traditional HIV risk factors, our research suggests it may be important to also focus HIV screening and prevention on alcohol-related risk factors in AIDS epicenters. For heterosexual alcoholics, the focus should be on those with higher alcohol dependence. For male alcoholics who had sex with men, the focus should be on those who primarily socialize in bars. Further research is needed to determine why higher sexual risk perceptions when drinking were associated with lower rates of HIV infection for both groups, since this discovery may have important prevention implications. The negative association between infection and alcohol impairment among homosexual men also warrants further investigation.

Post-traumatic stress and associated disorders among Vietnam veterans: the significance of combat exposure and social support

The hypothesis is tested that individuals exposed to traumatic stress who currently have lower social support have higher rates of post-traumatic stress and associated disorders. To test this, the current prevalence of five psychiatric disorders, including post-traumatic stress, generalized anxiety, depression, alcohol abuse, and drug abuse, were studied among a random sample of veterans who served in Vietnam (N = 2,490) and a random sample of "era" veterans who did not (N = 1,972). Logistic regression was used to analyze each disorder, controlling for past combat exposure, current social status, childhood delinquency, military adjustment, and current social support. Combat exposure was the best predictor of post-traumatic stress and was also associated with anxiety and depression, but not alcohol or drug abuse. Substance abuse was associated with childhood delinquency, and the best predictor of drug abuse was illicit Army drug use. Lower social support was associated with all disorders, except drug abuse. Although the causal nexus is not clear in this case, this study suggests that future research and clinical interventions should not overlook the significance of social support among victims of traumatic stress.

Support for hospital-based HIV testing and counseling: a national survey of hospital marketing executives

Today, hospitals are involved extensively in social marketing and promotional activities. Recently, investigators from the Centers for Disease Control and Prevention (CDC) estimated that routine testing of hospital patients for human immunodeficiency virus (HIV) could identify more than 100,000 patients with previously unrecognized HIV infections. Several issues are assessed in this paper. These include hospital support for voluntary HIV testing and AIDS education and the impact that treating AIDS patients has on the hospital's image. Also tested is the hypothesis that certain hospitals, such as for-profit institutions and those outside the AIDS epicenters, would be less supportive of hospital-based AIDS intervention strategies. To assess these issues, a national random sample of 193 executives in charge of hospital marketing and public relations were surveyed between December 1992 and January 1993. The survey was part of an ongoing annual survey of hospitals and included questions about AIDS, health education, marketing, patient satisfaction, and hospital planning. Altogether, 12.4 percent of executives indicated their hospital had a reputation for treating AIDS patients. Among hospitals without an AIDS reputation, 34.1 percent believed developing one would be harmful to the hospital's image, in contrast to none in hospitals that had such a reputation (chi 2 = 11.676, df = 1, P = .0006). Although 16.6 percent did not know if large-scale HIV testing should be implemented, a near majority (47.7 percent) expressed some support. In addition, 15 percent reported that HIV-positive physicians on the hospital's medical staff should not be allowed to practice medicine, but 32.1 percent indicated that they should. Also, 33.1 percent thought the hospital should be more involved in AIDS education. Finally, certain hospital characteristics,such as location and for-profit status, were not associated with support for hospital-based AIDS interventions. Contrary to what was hypothesized,however, hospitals in AIDS epicenters were less supportive of the CDC recommendations for some reason (X2 = 7.735, df = 1, P = .005).Support for AIDS education and voluntary testing is significant among hospital marketing and public relations executives. Over the past decade, community marketing and public relations have become an integral part of the hospital's business activities.However, financial pressures now are forcing hospitals to restrict these efforts. Findings reported in this paper suggest that future health care reform may assist public health aims by redirecting these endeavors towards the fight against AIDS and other preventable diseases, not eliminating them. Additional research is needed to determine why executives in AIDS epicenters are less supportive of large-scale hospital HIV testing and counseling in comparison with those outside these areas.

Consumers link size, quality in rating U.S. hospitals: study

The competitive environment in the health care industry nationwide is forcing hospitals to constantly reexamine their place in their immediate market. How do potential patients view them? How do perceptions change with the size and location of the institution? Do consumers link quality with such factors as census mix? In the following article, the author discusses the results of a survey that examines those trends.

Speaking up for nurses. Concerted political action garners some relief for personnel shortage

To better understand public opinion and encourage trustee and community support concerning the nursing shortage in central New Jersey, a major medical center surveyed 400 household heads in a two-county area with a population of approximately 1 million. The findings suggested that an effective political action plan requiring trustee, hospital, and community involvement could be developed. The survey revealed that 75 percent of the respondents knew about the area nursing shortage, 82 percent believed the shortage was genuine, 67 percent believed it was serious, 86 percent believed it would adversely affect the quality of healthcare, and the majority was willing to take some political action to relieve the shortage. The New Jersey Hospital Association ran a campaign to explain the impact of the nursing shortage and other problems hospitals were facing. This effort suggested hospitals encourage their trustees, employees, and medical staffs to write the governor and key state officials. Hospital administrators, association representatives, and nursing groups lobbied state legislators and attended Hospital Rate Setting Commission hearings. As a result, hospitals received a temporary increase in their reimbursement rates in 1988 specifically intended to raise nursing salaries. In addition, the New Jersey Department of Health promised to reevaluate the cost components on which the state's diagnosis-related group system is based.

The public's rating of hospitals

Increasingly, hospital administrators have been concerned about the public's perception of the facility. Nationwide, they have engaged marketing firms to study how consumers rate their local facilities in comparison to others. This type of information has been important to develop effective marketing and advertising programs (Steiber and Boscarino 1985). In this study, hospital ratings were analyzed for 65 short-term (nongovernment), medical and surgical hospitals across the United States. These hospitals represented different regions of the country (east, west, north, south, and central), as well as urban, suburban, and rural areas. Over 14,000 consumers were surveyed in these local market surveys. The public's ratings of these local hospitals were analyzed in terms of hospital size (number of beds), inpatient census, the "urbanicity" level of the local area, the level of care provided (primary, secondary, or tertiary), geographic region, and the 1984 Health Care Financing Administration death rate reported for Medicare patients. A multivariate analysis of the data indicates that hospital ratings are significantly related to the level of care provided and to the hospital's census level. Both of these are positively related to the public's attitude toward that facility (the higher the rating, the more specialized the care provided and the higher the census at that facility). Other variables are also positively related to ratings for example, bed size), but this is because of the relationship of these variables to either census or care level.

Hospital wellness centers: strategic implementation, marketing, and management

Fitness and wellness programs can be a strategic extension of a hospital's services, assist in attracting totally new patients to a facility, and help improve a hospital's image.

Hospital planners as political activists

Faced with increasing financial pressures under the state's all-payer prospective pricing system, the New Jersey Hospital Assn. launched a broad-based political action campaign last year to bring relief to its beleaguered hospital members. The New Jersey experience makes a compelling case for hospitals or hospitals group elsewhere to formulate political action plans.

Measuring negative publicity

Measuring the impact of negative news coverage on a hospital's image is an important first step in repairing the damage. That was the task at hand for a group of East Coast hospitals following a series of unfavorable newspaper stories. This article shows how public opinion research helped the hospitals to gauge the extent to which the negative press coverage affected their reputations and to identify targeted corrective action.

Surveying the public's attitudes on AIDS

In a survey of southern New Jersey residents, the author found that the general public, in particular those who were less educated and older, showed considerable fear and concern about AIDS. The author contends that as hospitals in the surveyed area begin to experience their projected increase in AIDS patients, they will have to deal constructively with these attitudes.

Successfully marketing women's health care services: a realistic approach to segment marketing

Women's health care has become increasingly competitive and now requires a focus on the tactics of implementation as well as the market positioning of the services. Global positioning will no longer work for women's health services; therefore, marketers must carefully identify their market targets. If possible, the product should be tested, for product testing will offer valuable experience for the organization and protect it from the hazards of overextension, a sure route to failure.

Collecting and using strategic market data

To evaluate their markets, health care executives need accurate data. There are several techniques available for collecting this information. In this article, the author examines three methods for gathering data on the employer market: focus groups, mail and telephone surveys. The author outlines the mechanics of collection and the potential uses of the resulting information.

The fitness market: strategic alternative for hospitals?

In an era of declining inpatient admissions, the development of wellness and fitness programs is proving a successful diversification strategy for increasing revenue while providing community service. This article examines critical assessments that must be made to ensure success for these new programs.