Understanding veterans' experiences with lung cancer and psychological distress: A multimethod approach

Psychological distress while coping with cancer is a highly prevalent and yet underrecognized and burdensome adverse effect of cancer diagnosis and treatment. Left unaddressed, psychological distress can further exacerbate poor mental health, negatively influence health management behaviors, and lead to a worsening quality of life. This multimethod study primarily focused on understanding veterans' psychological distress and personal experiences living with lung cancer (an underrepresented patient population). In a sample of 60 veterans diagnosed with either nonsmall cell lung cancer (NSCLC) or small cell lung cancer (SCLC), we found that distress is common across clinical psychology measures of depression (37% [using the Patient Health Questionnaire, PHQ-9 measure]), anxiety (35% [using the Generalized Anxiety Disorder, GAD-7 measure]), and cancer-related posttraumatic stress (13% [using the Posttraumatic Stress Symptom Checklist measure]). A total of 23% of the sample endorsed distress scores on two or more mental health screeners. Using a broader cancer-specific distress measure (National Comprehensive Cancer Network), 67% of our sample scored above the clinical cutoff (i.e., ≥ 3), and in the follow-up symptom checklist of the National Comprehensive Cancer Network measure, a majority endorsed feeling sadness (75%), worry (73%), and depression (60%). Qualitative analysis with a subset of 25 veterans highlighted that psychological distress is common, variable in nature, and quite bothersome. Future research should (a) identify veterans at risk for distress while living with lung cancer and (b) test supportive mental health interventions to target psychological distress among this vulnerable veteran population. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Research-practice partnerships: Adapting a care coordination intervention for rural Veterans over 3 years at multiple sites

PURPOSE

Rural Veterans are more likely than urban Veterans to qualify for community care (Veterans Health Administration [VHA]-paid care delivered outside of VHA) due to wait times ≥30 days and longer travel times for VHA care. For rural Veterans receiving both VHA and community care, suboptimal care coordination between VHA and community providers can result in poor follow-up and care fragmentation. We developed Telehealth-based Coordination of Non-VHA Care (TECNO Care) to address this problem.

METHODS

We iteratively developed and adapted TECNO Care with partners from the VHA Office of Rural Health and site-based Home Telehealth Care in the Community programs. Using templated electronic health record notes, Home Telehealth nurses contacted Veterans monthly to facilitate communication with VHA/community providers, coordinate referrals, reconcile medications, and follow up on acute episodes. We evaluated TECNO Care using a patient-level, pre-post effectiveness assessment and rapid qualitative analysis with individual interviews of Veterans and VHA collaborators. Our primary effectiveness outcome was a validated care coordination quality measure. We calculated mean change scores for each care continuity domain.

FINDINGS

Between March 2019 and October 2021, 83 Veterans received TECNO Care. Veterans were predominately White (86.4%) and male (88.6%) with mean age 71.4 years (SD 10.4). Quantitative data demonstrated improvements in perceived care coordination following TECNO Care in 7 categories. Qualitative interviews indicated that Veterans and Home Telehealth nurses perceived TECNO Care as beneficial and addressing an area of high need.

CONCLUSIONS

TECNO Care appeared to improve the coordination of VHA and community care and was valued by Veterans.

Racial Disparities in Lung Cancer Screening Among Veterans, 2013 to 2021

Importance

Racial disparities in lung cancer screening (LCS) are often ascribed to barriers such as cost, insurance status, access to care, and transportation. Because these barriers are minimized within the Veterans Affairs system, there is a question of whether similar racial disparities exist within a Veterans Affairs health care system in North Carolina.

Objectives

To examine whether racial disparities in completing LCS after referral exist at the Durham Veterans Affairs Health Care System (DVAHCS) and, if so, what factors are associated with screening completion.

Design, Setting, and Participants

This cross-sectional study assessed veterans referred to LCS between July 1, 2013, and August 31, 2021, at the DVAHCS. All included veterans self-identified as White or Black and met the US Preventive Services Task Force eligibility criteria as of January 1, 2021. Participants who died within 15 months of consultation or who were screened before consultation were excluded.

Exposures

Self-reported race.

Main Outcomes and Measures

Screening completion was defined as completing computed tomography for LCS. The associations among screening completion, race, and demographic and socioeconomic risk factors were assessed using logistic regression models.

Results

A total of 4562 veterans (mean [SD] age, 65.4 [5.7] years; 4296 [94.2%] male; 1766 [38.7%] Black and 2796 [61.3%] White) were referred for LCS. Of all veterans referred, 1692 (37.1%) ultimately completed screening; 2707 (59.3%) never connected with the LCS program after referral and an informational mailer or telephone call, indicating a critical point in the LCS process. Screening rates were substantially lower among Black compared with White veterans (538 [30.5%] vs 1154 [41.3%]), with Black veterans having 0.66 times lower odds (95% CI, 0.54-0.80) of screening completion after adjusting for demographic and socioeconomic factors.

Conclusions and Relevance

This cross-sectional study found that after referral for initial LCS via a centralized program, Black veterans had 34% lower odds of LCS screening completion compared with White veterans, a disparity that persisted even after accounting for numerous demographic and socioeconomic factors. A critical point in the screening process was when veterans must connect with the screening program after referral. These findings may be used to design, implement, and evaluate interventions to improve LCS rates among Black veterans.

The Association of an Upper Extremity Functional Survey and Glaucoma Medication Administration Success

Purpose/Aim: To determine if an upper extremity functional survey may identify which patients will have eye drop administration difficulty. Materials and Methods: Participants with glaucoma treated at a Veterans Affairs Eye Clinic who did not self-report 100% medication adherence were enrolled in a cross-sectional study. Participants were scored on their observed ability to place a drop into the eye (accuracy) and express no more than one drop from the bottle (efficiency). Successful execution of both of these conditions was defined as good drop technique. Participants also completed the QuickDASH, a validated upper extremity functional survey, with higher scores indicating worse disability. We hypothesized participants with lower QuickDASH scores would have an increased probability of observed success with drop administration measures. Diagnoses of upper extremity co-morbidities were abstracted from participants' medical records and clustered into diagnostic groups of either neurologic or musculoskeletal etiologies. Results: When observed, 80 of 94 participants displayed successful accuracy, 58 of 94 participants displayed successful efficiency, and 50 of 94 participants displayed good drop technique. Accuracy with eye drop performance was not related to QuickDASH scores (odds ratio (OR) [probability of successful administration per 10-point decrease in QuickDASH score]: 1.14, 95% CI: 0.89-1.45, p = .29). Success with drop administration efficiency was strongly associated with QuickDASH score (OR: 1.27, 95% CI: 1.04-1.54, p = .02), as was good drop technique (OR: 1.28, 95% CI: 1.05-1.56, p = .01), with lower (better) QuickDASH scores associated with better drop technique. There were no associations between upper extremity neurologic or musculoskeletal co-morbidities and observed good drop technique. The presence of either a neurologic or musculoskeletal upper extremity co-morbidity in a participant's medical record was associated with a higher QuickDASH score. Conclusions: The QuickDASH survey may identify patients with eye drop administration difficulties so this population receives focused drop technique education and management strategies. Abbreviations: CPRS: Computerized Patient Records System; MSK: musculoskeletal; UE: upper extremity; VA: Veterans Affairs.

Clinical factors associated with persistently poor diabetes control in the Veterans Health Administration: A nationwide cohort study

OBJECTIVE

Patients with persistent poorly-controlled diabetes mellitus (PPDM) despite engagement in clinic-based care are at particularly high risk for diabetes complications and costs. Understanding this population's demographics, comorbidities and care utilization could guide strategies to address PPDM. We characterized factors associated with PPDM in a large sample of Veterans with type 2 diabetes.

METHODS

We identified a cohort of Veterans with medically treated type 2 diabetes, who received Veterans Health Administration primary care during fiscal years 2012 and 2013. PPDM was defined by hemoglobin A1c levels uniformly >8.5% during fiscal year (FY) 2012, despite engagement with care during this period. We used FY 2012 demographic, comorbidity and medication data to describe PPDM in relation to better-controlled diabetes patients and created multivariable models to examine associations between clinical factors and PPDM. We also constructed multivariable models to explore the association between PPDM and FY 2013 care utilization.

RESULTS

In our cohort of diabetes patients (n = 435,820), 12% met criteria for PPDM. Patients with PPDM were younger than better-controlled patients, less often married, and more often Black/African-American and Hispanic or Latino/Latina. Of included comorbidities, only retinopathy (OR 1.68, 95% confidence interval (CI): 1.63,1.73) and nephropathy (OR 1.26, 95% CI: 1.19,1.34) demonstrated clinically significant associations with PPDM. Complex insulin regimens such as premixed (OR 10.80, 95% CI: 10.11,11.54) and prandial-containing regimens (OR 18.74, 95% CI: 17.73,19.81) were strongly associated with PPDM. Patients with PPDM had higher care utilization, particularly endocrinology care (RR 3.56, 95% CI: 3.47,3.66); although only 26.4% of patients saw endocrinology overall.

CONCLUSION

PPDM is strongly associated with complex diabetes regimens, although heterogeneity in care utilization exists. While there is evidence of underutilization, inadequacy of available care may also contribute to PPDM. Our findings should inform tailored approaches to meet the needs of PPDM, who are among the highest-risk, highest-cost patients with diabetes.

Intermediate Diabetes Outcomes in Patients Managed by Physicians, Nurse Practitioners, or Physician Assistants: A Cohort Study

BACKGROUND

Primary care provided by nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a solution to expected workforce shortages.

OBJECTIVE

To examine potential differences in intermediate diabetes outcomes among patients of physician, NP, and PA primary care providers (PCPs).

DESIGN

Cohort study using data from the U.S. Department of Veterans Affairs (VA) electronic health record.

SETTING

568 VA primary care facilities.

PATIENTS

368 481 adult patients with diabetes treated pharmaceutically.

MEASUREMENTS

The relationship between the profession of the PCP (the provider the patient visited most often in 2012) and both continuous and dichotomous control of hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) was examined on the basis of the mean of measurements in 2013. Inverse probability of PCP type was used to balance cohort characteristics. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes, respectively.

RESULTS

The PCPs were physicians (n = 3487), NPs (n = 1445), and PAs (n = 443) for 74.9%, 18.2%, and 6.9% of patients, respectively. The difference in HbA1c values compared with physicians was -0.05% (95% CI, -0.07% to -0.02%) for NPs and 0.01% (CI, -0.02% to 0.04%) for PAs. For SBP, the difference was -0.08 mm Hg (CI, -0.34 to 0.18 mm Hg) for NPs and 0.02 mm Hg (CI, -0.42 to 0.38 mm Hg) for PAs. For LDL-C, the difference was 0.01 mmol/L (CI, 0.00 to 0.03 mmol/L) (0.57 mg/dL [CI, 0.03 to 1.11 mg/dL]) for NPs and 0.03 mmol/L (CI, 0.01 to 0.05 mmol/L) (1.08 mg/dL [CI, 0.25 to 1.91 mg/dL]) for PAs. None of these differences were clinically significant.

LIMITATION

Most VA patients are men who receive treatment in a staff-model health care system.

CONCLUSION

No clinically significant variation was found among the 3 PCP types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs.

PRIMARY FUNDING SOURCE

VA Health Services Research and Development.

Baseline Antihypertensive Drug Count and Patient Response to Hypertension Medication Management

Telemedicine-based medication management improves hypertension control, but has been evaluated primarily in patients with low antihypertensive drug counts. Its impact on patients taking three or more antihypertensive agents is not well-established. To address this evidence gap, the authors conducted an exploratory analysis of an 18-month, 591-patient trial of telemedicine-based hypertension medication management. Using general linear models, the effect of medication management on blood pressure for patients taking two or fewer antihypertensive agents at study baseline vs those taking three or more was compared. While patients taking two or fewer antihypertensive agents had a significant reduction in systolic blood pressure with medication management, those taking three or more had no such response. The between-subgroup effect difference was statistically significant at 6 months (-6.4 mm Hg [95% confidence interval, -12.2 to -0.6]) and near significant at 18 months (-6.0 mm Hg [95% confidence interval, -12.2 to 0.2]). These findings suggest that baseline antihypertensive drug count may impact how patients respond to hypertension medication management and emphasize the need to study management strategies specifically in patients taking three or more antihypertensive medications.

Longitudinal development of cortical and subcortical gray matter from birth to 2 years

Very little is known about cortical development in the first years of life, a time of rapid cognitive development and risk for neurodevelopmental disorders. We studied regional cortical and subcortical gray matter volume growth in a group of 72 children who underwent magnetic resonance scanning after birth and at ages 1 and 2 years using a novel longitudinal registration/parcellation approach. Overall, cortical gray matter volumes increased substantially (106%) in the first year of life and less so in the second year (18%). We found marked regional differences in developmental rates, with primary motor and sensory cortices growing slower in the first year of life with association cortices growing more rapidly. In the second year of life, primary sensory regions continued to grow more slowly, while frontal and parietal regions developed relatively more quickly. The hippocampus grew less than other subcortical structures such as the amygdala and thalamus in the first year of life. It is likely that these patterns of regional gray matter growth reflect maturation and development of underlying function, as they are consistent with cognitive and functional development in the first years of life.

Relative risk of glucose elevation during antipsychotic exposure in a Veterans Administration population

Concern is mounting that atypical antipsychotics cause disturbance in glucose regulation ranging from reversible hyperglycemia to diabetic ketoacidosis and death. It is difficult, however, to know what the level of risk of hyperglycemia might be for an individual patient on a particular medication of this class. We conducted a retrospective nonrandomized cohort analysis of glucose measurements in 18,764 patients receiving outpatient prescriptions for olanzapine, risperidone, or typical antipsychotics from 1 October 1998 to 30 June 2003 at six Veterans Affairs Medical Centers in the southeast United States. In patients without a random plasma glucose measurement > or =160 mg/dl before medication exposure (n=1394), treatment with index medications was associated with an incidence of new diabetes-level hyperglycemia of 78.7 cases per 1,000 individuals exposed per year. Olanzapine exposure was associated with a greater rate of developing at least one glucose measurement > or =200 mg/dl than risperidone (odds ratio=2.14, P=0.003). Olanzapine exposure was also associated with a greater rate of development of at least one fasting glucose measurement > or =126 mg/dl than risperidone. Typical antipsychotics were associated with risk intermediate between the two atypicals. These data indicate that patients with no previously observed glucose elevations develop diabetes-level hyperglycemia during antipsychotic treatment, particularly in patients receiving olanzapine.

Feasibility and acceptability of CD-ROM-based cognitive-behavioural treatment for binge-eating disorder

We compared preliminary feasibility and acceptability of CD-ROM-delivered CBT for overweight individuals with binge-eating disorder (BED) to 10 weekly group CBT sessions (Group) and to a waiting list control (WL). Attrition was numerically greater in the Group than the CD-ROM condition; although only Group differed significantly from WL in dropout rates. Those in the CD-ROM condition reported continued use of their CD-ROM after treatment. Also, the majority of WL participants elected to receive CD-ROM over Group treatment at the end of the waiting period. Preliminarily, no significant differences emerged across the active treatment groups on most outcome measures. However, there was a significantly greater decline in binge days in the two active groups relative to WL. CD-ROM appears to be an acceptable and at least initially preferred method of CBT delivery for overweight individuals with BED.

Evaluating binge eating disorder in children: development of the children's binge eating disorder scale (C-BEDS)

OBJECTIVE

Binge eating disorder (BED) may manifest itself differently in children than adults. Recently researchers have proposed provisional criteria for measuring BED in children. The purpose of this study was to develop a brief, simple, structured, interviewer-administered scale (C-BEDS) to measure BED in children according to the provisional criteria and to compare diagnostic results with SCID diagnoses.

METHOD

A total of 55 children between the ages of 5 and 13 were interviewed with both the SCID and the C-BEDS.

RESULTS

There was a significant association between the two measures (p = .001). Both measures adequately identified children with binge eating behaviors.

CONCLUSION

Both the provisional criteria and the C-BEDS may be developmentally appropriate for use with children, although the C-BEDS may be a better screening instrument as it quickly identified children with subsyndromal BED. If used by physicians and other health providers, this brief measure may assist with identifying early onset binge eating behaviors and avoiding the associated consequences, including adult BED, obesity, and other comorbidities.

Results of the American College of Surgeons Oncology Group Z0050 trial: the utility of positron emission tomography in staging potentially operable non-small cell lung cancer

OBJECTIVES

The American College of Surgeons Oncology Group undertook a trial to ascertain whether positron emission tomography with 18F-fluorodeoxyglucose could detect lesions that would preclude pulmonary resection in a group of patients with documented or suspected non-small cell lung cancer found to be surgical candidates by routine staging procedures.

METHODS

A total of 303 eligible patients registered from 22 institutions underwent positron emission tomography after routine staging (computed tomography of chest and upper abdomen, bone scintigraphy, and brain imaging) had deemed their tumors resectable. Positive findings required confirmatory procedures.

RESULTS

Positron emission tomography was significantly better than computed tomography for the detection of N1 and N2/N3 disease (42% vs 13%, P =.0177, and 58% vs 32%, P =.0041, respectively). The negative predictive value of positron emission tomography for mediastinal node disease was 87%. Unsuspected metastatic disease or second primary malignancy was identified in 18 of 287 patients (6.3%). Distant metastatic disease indicated in 19 of 287 patients (6.6%) was subsequently shown to be benign. By correctly identifying advanced disease (stages IIIA, IIIB, and IV) or benign lesions, positron emission tomography potentially avoided unnecessary thoracotomy in 1 of 5 patients.

CONCLUSIONS

In patients with suspected or proven non-small cell lung cancer considered resectable by standard staging procedures, positron emission tomography can prevent nontherapeutic thoracotomy in a significant number of cases. Use of positron emission tomography for mediastinal staging should not be relied on as a sole staging modality, and positive findings should be confirmed by mediastinoscopy. Metastatic disease, especially a single site, identified by positron emission tomography requires further confirmatory evaluation.