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Greenberg JW, Koller CR, Lightfoot C, Brinkley GJ, Leinwand G, Wang J, Krane LS. Annual mpMRI surveillance: PI-RADS upgrading and increasing trend correlated with patients who harbor clinically significant disease. Urol Oncol 2024; 42:158.e11-158.e16. [PMID: 38365461 DOI: 10.1016/j.urolonc.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/19/2023] [Accepted: 01/05/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Prostate cancer screening has routinely identified men with very low- or low-risk disease, per the National Comprehensive Cancer Network guidelines. Current literature has demonstrated that the most appropriate management strategy for these patients is active surveillance (AS). The mainstay of AS includes periodic biopsies and biannual prostate-specific antigen tests. However, multiparametric magnetic resonance imaging (mpMRI) is uniquely posed to improve patient surveillance. This study aimed to evaluate the utility of an annual mpMRI in patients on AS, focusing on radiologic upgrading and Prostate Imaging-Reporting and Data System (PI-RADS) trends as indicators of clinically significant disease. METHODS This prospective, single intuition, study enrolled 208 patients on AS who had at least two biopsies and 1 mpMRI with a median follow-up of 5.03 years. The main outcome variable was time to Gleason grade (GG) reclassification. RESULTS After delineating patients on their initial PI-RADS score, men with score 3 and 5 lesions at first MRI had comparable GG reclassification-free survival to their counterparts. Conversely, men with initial PI-RADS 4 lesions showed a lower 5-year GG reclassification-free survival compared to those with PI-RADS score 1-2. The cohort was then subset to 70 patients who obtained ≥2 mpMRIs on protocol. Men experiencing uptrending mpMRI scores had an increased risk of GG reclassification, with a 35.4% difference in 5 year GG reclassification-free survival probability on the Kaplan-Meier curve analysis. CONCLUSION In conclusion, this study demonstrates that for men on AS with stable recapitulated disease, an annual MRI may replace repeat biopsies after confirmatory sampling has been obtained. On the other hand, men who initiate AS with PI-RADS 4 and/or who display uptrending mpMRI scores require periodic biopsies along with repeat imaging. This study highlights the utility of integrating an annual MRI into AS protocols, thus promising a more effective approach to management.
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Affiliation(s)
- Jacob W Greenberg
- Department of Urology, Tulane University School of Medicine, New Orleans, LA
| | | | - Christine Lightfoot
- Department of Urology, Tulane University School of Medicine, New Orleans, LA
| | - Garrett J Brinkley
- Department of Urology, Tulane University School of Medicine, New Orleans, LA
| | - Gabriel Leinwand
- Department of Urology, Southeastern Louisiana Veterans Health Care System, New Orleans, LA
| | - Julie Wang
- Department of Urology, Southeastern Louisiana Veterans Health Care System, New Orleans, LA
| | - L Spencer Krane
- Department of Urology, Southeastern Louisiana Veterans Health Care System, New Orleans, LA.
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Relyea MR, Presseau C, Runels T, Humbert MM, Martino S, Brandt CA, Haskell SG, Portnoy GA. Understanding Veterans' intimate partner violence use and patterns of healthcare utilization. Health Serv Res 2023; 58:1198-1208. [PMID: 37452496 PMCID: PMC10622301 DOI: 10.1111/1475-6773.14201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE To understand the association between Veterans' healthcare utilization and intimate partner violence (IPV) use (i.e., perpetration) in order to (1) identify conditions comorbid with IPV use and (2) inform clinical settings to target for IPV use screening, intervention, and provider training. DATA SOURCES AND STUDY SETTING We examined survey data from a national sample of 834 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) Veterans. STUDY DESIGN We assessed associations between past-year IPV use and medical treatment, health issues, and use of Veterans Health Administration (VA) and non-VA services using chi-square tests and logistic regression. DATA COLLECTION/EXTRACTION METHODS Data were derived from the Department of Defense OEF/OIF/OND Roster. Surveys were sent to all women Veterans and a random sample of men from participating study sites. PRINCIPAL FINDINGS Half (49%) of the Veterans who reported utilizing VA healthcare in the past year indicated using IPV. Q values using a 5% false discovery rate indicated that Veterans who used IPV were more likely than Veterans who did not use IPV to have received treatment for post-traumatic stress disorder (PTSD; 39% vs. 27%), chronic sleep problems (36% vs. 26%), anxiety or depression (44% vs. 36%), severe chronic pain (31% vs. 22%), and stomach or digestive disorders (24% vs. 16%). Veterans who used IPV were also more likely than Veterans who did not use IPV to have received medical treatment in the past year (86% vs. 80%), seen psychiatrists outside VA (39% vs. 20%), and have outpatient healthcare outside VA (49% vs. 41%). IPV use was not related to whether Veterans received care from VA or non-VA providers. CONCLUSIONS Veterans' IPV use was related to greater utilization of services for mental health, chronic pain, and digestive issues. Future research should examine whether these are risk factors or consequences of IPV use.
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Affiliation(s)
- Mark R. Relyea
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Candice Presseau
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Tessa Runels
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | | | - Steve Martino
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Cynthia A. Brandt
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Sally G. Haskell
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Galina A. Portnoy
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
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Lee-Tauler SY, Grammer J, LaCroix JM, Walsh AK, Clark SE, Holloway KJ, Sundararaman R, Carter CKM, Crouterfield CB, Hazlett CGR, Hess CRM, Miyahara CJM, Varsogea CCE, Whalen CC, Ghahramanlou-Holloway M. Pilot Evaluation of the Online 'Chaplains-CARE' Program: Enhancing Skills for United States Military Suicide Intervention Practices and Care. J Relig Health 2023; 62:3856-3873. [PMID: 37612485 DOI: 10.1007/s10943-023-01882-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/25/2023]
Abstract
Chaplains frequently serve as first responders for United States military personnel experiencing suicidal thoughts and behaviors. The Chaplains-CARE Program, a self-paced, e-learning course grounded in suicide-focused cognitive behavioral therapy principles, was tailored for United States military chaplains to enhance their suicide intervention skills. A pilot program evaluation gathered 76 Department of Defense (DoD), Veterans Affairs (VA), and international military chaplain learners' responses. Most learners indicated that the course was helpful, easy to use, relevant, applicable, and that they were likely to recommend it to other chaplains. Based on open-ended responses, one-quarter (25.0%) of learners indicated that all content was useful, and over one-quarter (26.3%) of learners highlighted the usefulness of the self-care module. One-third (30.3%) of learners reported the usefulness of the interactive e-learning features, while others (26.3%) highlighted the usefulness of chaplains' role play demonstrations, which portrayed counseling scenarios with service members. Suggested areas of improvement include specific course adaptation for VA chaplains and further incorporation of experiential learning and spiritual care principles. The pilot findings suggest that Chaplains-CARE Online was perceived as a useful suicide intervention training for chaplains. Future training can be enhanced by providing experiential, simulation-based practice of suicide intervention skills.
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Affiliation(s)
- Su Yeon Lee-Tauler
- Department of Medical and Clinical Psychology, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814-4799, USA
| | - Joseph Grammer
- Department of Medical and Clinical Psychology, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814-4799, USA
| | - Jessica M LaCroix
- Department of Medical and Clinical Psychology, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814-4799, USA
| | - Adam K Walsh
- Defense Suicide Prevention Office, Alexandria, VA, USA
| | | | | | | | | | | | | | | | | | | | | | - Marjan Ghahramanlou-Holloway
- Department of Medical and Clinical Psychology, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814-4799, USA.
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Yu Y, Oliver JB, Kunac A, Sehat AJ, Anjaria DJ. Declining Surgical Resident Operative Autonomy-All Trainees Are Not Created Equal. J Surg Res 2023; 292:330-338. [PMID: 37117092 DOI: 10.1016/j.jss.2023.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 02/07/2023] [Accepted: 02/18/2023] [Indexed: 04/30/2023]
Abstract
INTRODUCTION We have previously shown that resident autonomy has decreased over time overall for all surgery residents. The purpose of this study is to examine changes in operative autonomy in general surgery residency within each postgraduate year (PGY) level. MATERIALS AND METHODS This is a retrospective analysis of the Veterans Association Surgical Quality Improvement Program database from July 1, 2004 to September 30, 2019. All general surgery, vascular surgery, and thoracic surgery procedures were analyzed and categorized by level of resident supervision as attending primary, attending operating with resident, or resident primary without attending scrubbed. Procedure work portion of relative value unit was used to capture procedure complexity. Changes in resident autonomy over time, procedure complexity, and outcomes were compared among PGY levels 1 to 5. RESULTS A total of 385,482 cases were analyzed. At each PGY level from 2014 to 2018, the relative decrease in resident primary cases ranged from -37.3% (PGY 4) to -75.5% (PGY 3). Mean work portion of relative value unit saw steady increase with PGY level (8.4 ± 3.5 in PGY 1 to 10.8 ± 5.7 in PGY 5, P < 0.001) and did not show a trend over time. CONCLUSIONS Surgical resident operative autonomy has markedly decreased over time across all PGY levels. This effect is most profound at the PGY 3 level, while more senior residents are affected to a lesser degree. Case complexity show PGY level-appropriate increase in resident autonomous cases. Decrease in resident autonomy over time is not associated with changes in case complexity.
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Affiliation(s)
- Yasong Yu
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Alvand J Sehat
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
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Baldomero AK, Kunisaki KM, Wendt CH, Henning-Smith C, Hagedorn HJ, Bangerter A, Dudley RA. Guideline-discordant inhaler regimens after COPD hospitalization: associations with rurality, drive time to care, and fragmented care - a United States cohort study. Lancet Reg Health Am 2023; 26:100597. [PMID: 37766800 PMCID: PMC10520452 DOI: 10.1016/j.lana.2023.100597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023]
Abstract
Background Many patients receive guideline-discordant inhaler regimens after chronic obstructive pulmonary disease (COPD) hospitalization. Geography and fragmented care across multiple providers likely influence prescription of guideline-discordant inhaler regimens, but these have not been comprehensively studied. We assessed patient-level differences in guideline-discordant inhaler regimens by rurality, drive time to pulmonary specialty care, and fragmented care. Methods Retrospective cohort analysis using national Veterans Health Administration (VA) data among patients who received primary care and prescriptions from the VA. Patients hospitalized for COPD exacerbation between 2017 and 2020 were assessed for guideline-discordant inhaler regimens in the subsequent 3 months. Guideline-discordant inhaler regimens were defined as short-acting inhaler/s only, inhaled corticosteroid (ICS) monotherapy, long-acting beta-agonist (LABA) monotherapy, ICS + LABA, long-acting muscarinic antagonist (LAMA) monotherapy, or LAMA + ICS. Rural residence and drive time to the closest pulmonary specialty care were obtained from geocoded addresses. Fragmented care was defined as hospitalization outside the VA. We used multivariable logistic regression models to assess associations between rurality, drive time, fragmentated care, and guideline-discordant inhaler regimens. Models were adjusted for age, sex, race/ethnicity, Charlson Comorbidity Index, Area Deprivation Index, and region. Findings Of 33,785 patients, 16,398 (48.6%) received guideline-discordant inhaler regimens 3 months after hospitalization. Rural residents had higher odds of guideline-discordant inhalers regimens compared to their urban counterparts (adjusted odds ratio [aOR] 1.18 [95% CI: 1.12-1.23]). The odds of receiving guideline-discordant inhaler regimens increased with longer drive time to pulmonary specialty care (aOR 1.38 [95% CI: 1.30-1.46] for drive time >90 min compared to <30 min). Fragmented care was also associated with higher odds of guideline-discordant inhaler regimens (aOR 1.56 [95% CI: 1.48-1.63]). Interpretation Rurality, long drive time to care, and fragmented care were associated with greater prescription of guideline-discordant inhaler regimens after COPD hospitalization. These findings highlight the need to understand challenges in delivering evidence-based care. Funding NIHNCATS grants KL2TR002492 and UL1TR002494.
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Affiliation(s)
- Arianne K. Baldomero
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Ken M. Kunisaki
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Chris H. Wendt
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Carrie Henning-Smith
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Hildi J. Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Ann Bangerter
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - R. Adams Dudley
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
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Panchal SA, Kaplan DE, Goldberg DS, Mahmud N. Algorithms to Identify Alcoholic Hepatitis Hospitalizations in Patients with Cirrhosis. Dig Dis Sci 2022; 67:4395-4402. [PMID: 35022905 PMCID: PMC9276834 DOI: 10.1007/s10620-021-07321-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/08/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Alcoholic hepatitis (AH) is a clinically diagnosed syndrome with high short-term mortality for which liver transplantation may be curative. A lack of validated algorithms to identify AH hospitalizations has hindered clinical epidemiology research. METHODS This was a retrospective cohort study of patients with cirrhosis using Veterans Health Administration (VHA) data from 2008 to 2015. We randomly sampled hospitalizations based upon abnormal liver tests and administrative codes for acute hepatitis or alcohol-associated liver disease (ALD). Hospitalizations were manually adjudicated for AH per society guidelines. A priori algorithms were evaluated to compute positive predicted value (PPV) and positive likelihood ratio (LR+), and were tested in an external University of Pennsylvania Health System (UPHS) cohort. RESULTS Of 368 hospitalizations, 142 (38.6%) were adjudicated as AH. AH patients were younger (55 vs. 58 years, p < 0.001), less likely to have prior cirrhosis decompensation (57% vs. 73.9%, p < 0.001), and had higher AST-to-ALT ratios (median 2.9 vs. 1.9 mg/dL, p < 0.001) and higher bilirubin levels (median 2.9 vs. 1.9 mg/dL, p < 0.001). Algorithms combining clinical laboratory criteria (AST > 85 U/L but < 450 U/L, AST-to-ALT ratio > 2, total bilirubin > 5 mg/dL) and administrative coding criteria yielded the highest PPV (96.4%, 95% CI 87.7-99.6) and the highest LR+ (43.0, 95% CI 10.6-173.5). Several algorithms demonstrated 100% PPV for definite AH in the UPHS external cohort. CONCLUSION We have identified algorithms for AH hospitalizations with excellent PPV and LR+. These high-specificity algorithms may be used in VHA datasets to identify patients with high likelihood of AH, but should not be used to study AH incidence.
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Affiliation(s)
- Sarjukumar A Panchal
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA, 19104, USA.
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA.
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Sehat AJ, Oliver JB, Yu Y, Kunac A, Anjaria DJ. Increasing volume but declining resident autonomy in laparoscopic inguinal hernia repair: an inverse relationship. Surg Endosc 2022; 37:3119-3126. [PMID: 35931892 DOI: 10.1007/s00464-022-09476-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION With improved technology and technique, laparoscopic inguinal hernia repair (LIHR) has become a valid option for repairing both initial and recurrent inguinal hernia. Surgical residents must learn both techniques to prepare for future practice. We examined resident operative autonomy between LIHR and open inguinal hernia repair (OIHR) across the Veterans Affairs (VA) system. METHODS Utilizing the VA Surgical Quality Improvement Program database, we examined inguinal hernia repairs based on the principal procedure code at all teaching VA hospitals from July 2004 to September 2019. All VA cases are coded for level of supervision at the time of surgery: attending primary surgeon (AP); attending scrubbed but resident is a primary surgeon (AR), and resident primary with attending supervising but not scrubbed (RP). Primary outcomes were the proportion of LIHR versus OIHR and resident autonomy over time. RESULTS A total of 127,497 hernia repair cases were examined (106,892 OIHR and 20,605 LIHR). There was a higher proportion of RP (8.7% vs 2.2%) and lower proportion of AP (23.9% vs 28.4%) within OIHR compared to LIHR (p < 0.001). The overall proportion of LIHR repairs increased from 9 to 28% (p < 0.001). RP cases decreased for LIHR from 9 to 1% and for OIHR from 17 to 4%, while AP cases increased for LIHR from 16 to 42% and for OIHR from 18 to 30% (all p < 0.001). For RP cases, mortality (0 vs 0.2%, p > 0.99) and complication rates (1.1% vs. 1.7%, p = 0.35) were no different. CONCLUSIONS LIHR at VA hospitals has tripled over the past 15 years, now compromising nearly one-third of all inguinal hernia repairs; the majority are initial hernias. Despite this increase, resident autonomy in LIHR cases declined alarmingly. The results demonstrate an urgent need to integrate enhanced minimally invasive training into a general surgery curriculum to prepare residents for future independent practice.
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Affiliation(s)
- Alvand J Sehat
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US
| | - Joseph B Oliver
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US.,Department of Surgery, VA New Jersey Health Care System, 385 Tremont Ave, East Orange, New Jersey, US
| | - Yasong Yu
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US.,Department of Surgery, VA New Jersey Health Care System, 385 Tremont Ave, East Orange, New Jersey, US
| | - Anastasia Kunac
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US.,Department of Surgery, VA New Jersey Health Care System, 385 Tremont Ave, East Orange, New Jersey, US
| | - Devashish J Anjaria
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, US. .,Department of Surgery, VA New Jersey Health Care System, 385 Tremont Ave, East Orange, New Jersey, US.
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Gerlach LB, Myra Kim H, Ignacio RV, Strominger J, Maust DT. Use of Benzodiazepines and Risk of Incident Dementia: A Retrospective Cohort Study. J Gerontol A Biol Sci Med Sci 2022; 77:1035-1041. [PMID: 34410381 PMCID: PMC9071459 DOI: 10.1093/gerona/glab241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Previous findings regarding the association between benzodiazepine exposure and dementia have conflicted, though many have not accounted for anticholinergic exposure. The goal of this study was to evaluate the association of benzodiazepine exposure with the risk of developing dementia, accounting for the anticholinergic burden. METHODS Using a retrospective cohort design, we identified veterans 65 or older without dementia during a 10-year baseline period and then followed participants for 5 years to evaluate the risk of dementia diagnosis. The primary exposure was cumulative benzodiazepine exposure. Cox proportional hazards survival model was used to examine the association between benzodiazepine exposure and dementia, adjusting for anticholinergic burden and other demographic and clinical characteristics associated with increased dementia risk. RESULTS Of the 528 006 veterans in the study cohort, 28.5% had at least one fill for a benzodiazepine. Overall, 7.9% developed a diagnosis of dementia during the observation period. Compared to veterans with no exposure to benzodiazepines, the adjusted hazard ratios for dementia risk were 1.06 (95% confidence interval [CI] 1.02-1.10) for low benzodiazepine exposure, 1.05 (95% CI 1.01-1.09) for medium benzodiazepine exposure, and 1.05 (95% CI 1.02-1.09) for high benzodiazepine exposure. CONCLUSIONS Cumulative benzodiazepine exposure was minimally associated with increased dementia risk when compared with nonuse but did not increase in a dose-dependent fashion with higher exposure. Veterans with low benzodiazepine exposure had essentially the equivalent risk of developing dementia as veterans with high exposure. While benzodiazepines are associated with many side effects for older adults, higher cumulative use does not appear to increase dementia risk.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA
| | - Hyungjin Myra Kim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Michigan, USA
| | - Rosalinda V Ignacio
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Michigan, USA
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Michigan, USA
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Michigan, USA
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Chapman AB, Jones A, Kelley AT, Jones B, Gawron L, Montgomery AE, Byrne T, Suo Y, Cook J, Pettey W, Peterson K, Jones M, Nelson R. ReHouSED: A novel measurement of Veteran housing stability using natural language processing. J Biomed Inform 2021; 122:103903. [PMID: 34474188 PMCID: PMC8608249 DOI: 10.1016/j.jbi.2021.103903] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/07/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
Housing stability is an important determinant of health. The US Department of Veterans Affairs (VA) administers several programs to assist Veterans experiencing unstable housing. Measuring long-term housing stability of Veterans who receive assistance from VA is difficult due to a lack of standardized structured documentation in the Electronic Health Record (EHR). However, the text of clinical notes often contains detailed information about Veterans' housing situations that may be extracted using natural language processing (NLP). We present a novel NLP-based measurement of Veteran housing stability: Relative Housing Stability in Electronic Documentation (ReHouSED). We first develop and evaluate a system for classifying documents containing information about Veterans' housing situations. Next, we aggregate information from multiple documents to derive a patient-level measurement of housing stability. Finally, we demonstrate this method's ability to differentiate between Veterans who are stably and unstably housed. Thus, ReHouSED provides an important methodological framework for the study of long-term housing stability among Veterans receiving housing assistance.
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Affiliation(s)
- Alec B Chapman
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States.
| | - Audrey Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Barbara Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of Pulmonary and Critical Care Medicine, University of Utah and VA Healthcare System, Salt Lake City, UT, United States
| | - Lori Gawron
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Ann Elizabeth Montgomery
- Birmingham Veterans Administration Medical Center, Birmingham, AL, United States; School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States; U.S. Department of Veterans Affairs, National Center on Homelessness among Veterans, Tampa, FL, United States
| | - Thomas Byrne
- U.S. Department of Veterans Affairs, National Center on Homelessness among Veterans, Tampa, FL, United States; U.S. Department of Veterans Affairs, Center for Healthcare Outcomes and Implementation Research, Edith Nourse Rodgers VA Medical Center, Bedford, MA, United States; Boston University School of Social Work, Boston, MA, United States
| | - Ying Suo
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - James Cook
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Warren Pettey
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Kelly Peterson
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States; Veterans Health Administration Office of Analytics and Performance Integration, United States
| | - Makoto Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Richard Nelson
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake City, UT, United States; Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States; U.S. Department of Veterans Affairs, National Center on Homelessness among Veterans, Tampa, FL, United States
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10
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Appaneal HJ, Shireman TI, Lopes VV, Mor V, Dosa DM, LaPlante KL, Caffrey AR. Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study. BMC Geriatr 2021; 21:436. [PMID: 34301192 PMCID: PMC8299613 DOI: 10.1186/s12877-021-02378-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment. METHODS We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment. RESULTS Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44). CONCLUSION In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA. .,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA. .,College of Pharmacy, University of Rhode Island, Kingston, RI, USA. .,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Theresa I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Vincent Mor
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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11
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Muzzio K, Chandler M, Painter JT, Dragic L. Characterizing Patients after Opioid Taper in a VA Medical Center. J Pain Palliat Care Pharmacother 2021; 35:84-90. [PMID: 33956566 DOI: 10.1080/15360288.2021.1900492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
To identify potential areas for intervention and gain insight on current practice in patients who are tapered to zero morphine equivalent daily doses (MEDD) through the Pharmacy Pain E-Consult at a Veterans Healthcare System. This was done by describing the types of follow-up care and resources utilized by patients. This project is a retrospective chart review of Veterans with non-cancer pain on chronic-opioid therapy consulted to the pharmacy e-consult service and tapered to 0 MEDD. Descriptive statistics are collected one year pre-taper and one year post-taper. One year post-taper, approximately one-third of the patients were re-started on opioid therapy. However, average MEDD overall was significantly decreased one year post-taper compared to pre-taper. Average pain scores were not significantly different pre-taper compared to post-taper. Non-opioid medications generally increased post-taper. Follow-up with mental health and pain management clinical pharmacy specialists decreased post-taper. Tapering to zero MEDD did not lead to a significant increase in pain one-year post-taper; however, approximately 33% of patients were re-started on opioids within one year post-taper. Average MEDD scores decreased post-taper as expected but with effects on mental health being largely unknown, we believe that further study in this area will help us better support patients.
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Affiliation(s)
- Kathryn Muzzio
- Kathryn Muzzio, PharmD, BCPS, Michael Chandler, PharmD, BCGP, and Lisa Dragic, PharmD, BCPS, are with the Pharmacy, Central Arkansas Veterans Healthcare System, John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas, USA; Jacob T. Painter, PharmD, MBA, PhD, is with the Core Investigator, Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR Director and Associate Professor, Division of Pharmaceutical Evaluation & Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Michael Chandler
- Kathryn Muzzio, PharmD, BCPS, Michael Chandler, PharmD, BCGP, and Lisa Dragic, PharmD, BCPS, are with the Pharmacy, Central Arkansas Veterans Healthcare System, John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas, USA; Jacob T. Painter, PharmD, MBA, PhD, is with the Core Investigator, Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR Director and Associate Professor, Division of Pharmaceutical Evaluation & Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jacob T Painter
- Kathryn Muzzio, PharmD, BCPS, Michael Chandler, PharmD, BCGP, and Lisa Dragic, PharmD, BCPS, are with the Pharmacy, Central Arkansas Veterans Healthcare System, John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas, USA; Jacob T. Painter, PharmD, MBA, PhD, is with the Core Investigator, Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR Director and Associate Professor, Division of Pharmaceutical Evaluation & Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Lisa Dragic
- Kathryn Muzzio, PharmD, BCPS, Michael Chandler, PharmD, BCGP, and Lisa Dragic, PharmD, BCPS, are with the Pharmacy, Central Arkansas Veterans Healthcare System, John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas, USA; Jacob T. Painter, PharmD, MBA, PhD, is with the Core Investigator, Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR Director and Associate Professor, Division of Pharmaceutical Evaluation & Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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12
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Varady NH, Worsham CM, Jena AB. Analysis of institutional conflict of interest and bias in research findings and reporting. Healthc (Amst) 2021; 9:100515. [PMID: 33517178 DOI: 10.1016/j.hjdsi.2020.100515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/08/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Affiliation(s)
| | - Christopher M Worsham
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Health Care Policy, Harvard Medical School, Department of Medicine, Massachusetts General Hospital, Both in Boston, MA, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Department of Medicine, Massachusetts General Hospital, Both in Boston, MA, USA; National Bureau of Economic Research, Cambridge, MA, USA.
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13
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Kong J, Shahait A, Girten K, Baldawi M, Hasnain MR, Saleh KJ, Gruber SA, Weaver D, Mostafa G. Recent trends in cholecystectomy in US veterans. Surg Endosc 2020; 35:5558-5566. [PMID: 33025254 DOI: 10.1007/s00464-020-08056-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We hypothesize that the recent trend in performing cholecystectomy in US Veterans shows wide adoption of the laparoscopic technique and improvement in the outcome following both laparoscopic (LC) and open cholecystectomy (OC). This study utilizes the Veterans Affairs Surgical Quality Improvement Program database to examine the status and outcome of cholecystectomy. METHODS A retrospective review of veterans who underwent cholecystectomy between 2008 and 2015 was performed. Data analysis included patient demographics, operations, and postoperative outcomes. Cochran-Armitage trend analysis was used to assess significant changes in outcome over the study period. p ≤ 0.05 was considered significant. RESULTS A total of 40,722 patients (average age of 61 years) were included in the study (males 85.6%). LC was performed in the majority of patients (86.4%). Patients in the OC group (13.6%) were more likely to have advanced age (≥ 65 years) (47.6% vs 32.0%, p < 0.001) and higher ASA class (III-V) (81.9% vs 65.4%, p < 0.001) than those in the LC group. Compared with LC, OC had higher mortality rates at 30 days (1.3% vs 0.3%; OR = 1.6, p = 0.03), 3 months (2.6% vs 0.7%; OR = 1.7, p < 0.001), 6 months (3.9% vs 1.1%; OR = 1.5, p < 0.001) and 1 year (5.7% vs 2.0%; OR = 1.5, p < 0.001); higher rates of morbidity, including pneumonia (OR = 1.9, p < 0.001), deep venous thrombosis (OR = 2.4, p = 0.02), reoperation (OR = 1.8, p < 0.001), and superficial (OR = 4.9, p < 0.001) and deep (OR = 1.5, p = 0.01) surgical site infections; and a longer length of stay (6.5 days vs 2.6 days, p < 0.001). Trend analysis showed a significant decrease in both mortality (p = 0.02) and morbidity (p < 0.001) for LC over the study period, but no improvement in mortality (p = 0.35) and a only a minimal improvement in morbidity (p = 0.04) for OC. CONCLUSION In the recent era, LC has been widely performed in the VA with significant improvement in outcome. Efforts are needed to adopt alternative approaches to planned OC and to improve postoperative outcomes.
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Affiliation(s)
- Joshua Kong
- Michael and Marian Ilitch Department of Surgery, Wayne State University/Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI48201, USA.,Department of Surgery, John D. Dingell Veteran Affairs Medical Center, Detroit, MI, 48201, USA
| | - Awni Shahait
- Michael and Marian Ilitch Department of Surgery, Wayne State University/Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI48201, USA.,Department of Surgery, John D. Dingell Veteran Affairs Medical Center, Detroit, MI, 48201, USA
| | - Kara Girten
- Department of Surgery, John D. Dingell Veteran Affairs Medical Center, Detroit, MI, 48201, USA
| | - Mohanad Baldawi
- Department of Surgery, John D. Dingell Veteran Affairs Medical Center, Detroit, MI, 48201, USA
| | - Mustafa Rashad Hasnain
- Department of Surgery, John D. Dingell Veteran Affairs Medical Center, Detroit, MI, 48201, USA
| | - Khaled J Saleh
- Department of Surgery, John D. Dingell Veteran Affairs Medical Center, Detroit, MI, 48201, USA
| | - Scott A Gruber
- Michael and Marian Ilitch Department of Surgery, Wayne State University/Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI48201, USA.,Department of Surgery, John D. Dingell Veteran Affairs Medical Center, Detroit, MI, 48201, USA
| | - Donald Weaver
- Michael and Marian Ilitch Department of Surgery, Wayne State University/Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI48201, USA
| | - Gamal Mostafa
- Michael and Marian Ilitch Department of Surgery, Wayne State University/Detroit Medical Center, 6C, University Health Center, 4201 St. Antoine, Detroit, MI48201, USA. .,Department of Surgery, John D. Dingell Veteran Affairs Medical Center, Detroit, MI, 48201, USA.
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Nguyen TH, Mallepally N, Hammad T, Liu Y, Thrift AP, El-Serag HB, Tan MC. Prevalence of Helicobacter pylori Positive Non-cardia Gastric Adenocarcinoma Is Low and Decreasing in a US Population. Dig Dis Sci 2020; 65:2403-2411. [PMID: 31728790 PMCID: PMC7220821 DOI: 10.1007/s10620-019-05955-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 11/09/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Helicobacter pylori infection is an established causal factor for non-cardia gastric cancer. H. pylori negative gastric cancer prevalence among US patients is unclear. METHODS This retrospective cohort study examined H. pylori prevalence among consecutive patients with incident non-cardia gastric adenocarcinoma at the Houston VA Hospital (11/2007-10/2018). H. pylori positivity was defined by H. pylori on histopathology, positive antibody serology, stool antigen, or urea breath testing. We examined for trends in H. pylori negative gastric cancer based on year of diagnosis. Associations between histopathologic and cancer-related outcomes with H. pylori positivity were determined using regression models. RESULTS Of 91 patients with gastric adenocarcinoma, most were men (N = 87, 95.6%), black (N = 47, 51.6%), with mean age at diagnosis of 68.0 years (SD 10.8). In addition to gastric cancer biopsy histopathology, 74 patients (81.3%) had ≥ 1 testing for H. pylori, including antibody serology (n = 34), non-cancer gastric biopsy histopathology (n = 63), or stool antigen (n = 1). The overall prevalence of H. pylori infection was 38.5% and 45.9% among patients with ≥ 2 H. pylori tests. The proportions of H. pylori positive gastric cancer decreased from 50.0% (2007-2010) to 43.4% (2011-2014) and 29.3% (2015-2018) (p = 0.096). Active/acute gastritis (adjOR 3.74), atrophic gastritis (adjOR 15.30), and gastric intestinal metaplasia (adjOR 3.65) were associated with H. pylori positive gastric cancer. DISCUSSION The prevalence of H. pylori infection among patients with non-cardia gastric adenocarcinoma is relatively low (38.5-45.9%) and decreasing over time. This finding suggests there may be other important causal factors apart from H. pylori for gastric adenocarcinoma.
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Affiliation(s)
- Theresa H Nguyen
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 285, Houston, TX, 77030-3498, USA
| | - Niharika Mallepally
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 285, Houston, TX, 77030-3498, USA
| | - Tariq Hammad
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 285, Houston, TX, 77030-3498, USA
| | - Yan Liu
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 285, Houston, TX, 77030-3498, USA
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 285, Houston, TX, 77030-3498, USA
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Mimi C Tan
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, MS: BCM 285, Houston, TX, 77030-3498, USA.
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16
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Baker S, Malone E, Graham L, Dasinger E, Wahl T, Titan A, Richman J, Copeland L, Burns E, Whittle J, Hawn M, Morris M. Patient-reported health literacy scores are associated with readmissions following surgery. Am J Surg 2020; 220:1138-1144. [PMID: 32682501 DOI: 10.1016/j.amjsurg.2020.06.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/05/2020] [Accepted: 06/26/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Health literacy (HL) impacts medical care. We hypothesized that patients with low HL would have higher readmission rates following surgery. METHODS We conducted a prospective, multi-institutional study from 8/2015-6/2017 within the Veterans Affairs (VA) System including veterans who underwent general, vascular, or thoracic surgery. HL was assessed by Brief Health Literacy Screener and stratified into adequate vs. low. Patients were followed for 30 days post-discharge. Multivariable analyses examined correlations and logistic regression models adjusted for covariates. RESULTS 736 patients were enrolled in the study; 98% (n = 722) completed the HL survey. At discharge, 33.2% of patients had low HL. The overall 30-day readmission rate was 16.3%, with a significant difference by HL (Adequate HL: 13.3% vs. Low HL: 22.5%, p < 0.01). After adjusting for clinical and demographic covariates, patients with low HL were 59% more likely to be readmitted (OR = 1.59, 95% CI = 1.02-2.50). CONCLUSION Low HL is common among VA surgery patients and is associated with readmission. Future studies should be focused on interventions to target this vulnerable patient population.
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Affiliation(s)
- Samantha Baker
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA.
| | - Emily Malone
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
| | - Laura Graham
- VA Palo Alto Healthcare Systems, Palo Alto, CA, USA; Stanford University, Stanford, CA, USA
| | - Elise Dasinger
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
| | - Tyler Wahl
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
| | - Ashley Titan
- VA Palo Alto Healthcare Systems, Palo Alto, CA, USA; Stanford University, Stanford, CA, USA
| | - Joshua Richman
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
| | - Laurel Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
| | - Edith Burns
- Milwaukee VA Medical Center, Milwaukee, WI, USA
| | | | - Mary Hawn
- VA Palo Alto Healthcare Systems, Palo Alto, CA, USA; Stanford University, Stanford, CA, USA
| | - Melanie Morris
- University of Alabama at Birmingham, Birmingham, AL, USA; VA Birmingham Healthcare System, Birmingham, AL, USA
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17
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Slade AN, Dahman B, Chang MG. Racial differences in the PSA bounce in predicting prostate cancer outcomes after brachytherapy: Evidence from the Department of Veterans Affairs. Brachytherapy 2019; 19:6-12. [PMID: 31611160 DOI: 10.1016/j.brachy.2019.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE African American men have historically had poorer prostate cancer biochemical and survival outcomes than Caucasians. However, emerging data suggest nononcologic factors drive much of this disparity. Prior evidence has suggested an association between a transient prostate specific antigen (PSA) bounce and improved biochemical control. However, racial differences in this relationship have remained relatively unexplored. METHODS AND MATERIALS We identified 4477 men treated for low- or intermediate-risk prostate cancer within the U.S. Department of Veterans Affairs (VA) from 2000 to 2010 with brachytherapy alone or in combination with external beam radiotherapy without androgen deprivation. Longitudinal PSA data were used to define to biochemical failure and PSA bounce. Cox proportional hazard models were used explore racial differences in the relationship between the PSA bounce and time to biochemical failure. RESULTS Thirty-one percent of our sample experienced a PSA bounce, with African Americans more likely to experience a bounce (42%) compared with Caucasians (29%); p < 0.001. Despite this, African Americans had a higher likelihood of biochemical failure (hazard ratio [HR] 1.4; p = 0.006). However, African American men experiencing a PSA bounce were less likely to experience a biochemical failure (HR = 0.64; p = 0.046), whereas this relationship was not statistically significant for Caucasians (HR = 0.78; p = 0.092). On multivariate analysis, African Americans receiving brachytherapy alone were most sensitive to the protective benefit of the PSA bounce (HR = 0.64). CONCLUSIONS A PSA bounce was associated with improved biochemical control among patients receiving brachytherapy as part of their treatment for low- or intermediate-risk prostate cancer at the VA. African American men treated with brachytherapy had a particularly pronounced biochemical control benefit of a PSA bounce.
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Affiliation(s)
- Alexander N Slade
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Massey Cancer Center, Richmond, VA.
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | - Michael G Chang
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Massey Cancer Center, Richmond, VA; Department of Radiation Oncology, Hunter Holmes McGuire VA Medical Center, Richmond VA
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Abstract
This study examined potential differences in bleeding between apixaban and rivaroxaban, the most commonly utilized direct oral anticoagulants at the Richard L. Roudebush VA Medical Center. Additionally, the analysis included a comparison between observed and literature-reported bleeding rates. This retrospective chart review examined 452 (39%) Veterans receiving rivaroxaban and 716 (61%) Veterans receiving apixaban. Bleeding rates were expressed per 100 patient-years and the overall rates were analyzed as the primary analysis. Secondary objectives included comparisons based on indication and severity, as well as comparisons to literature-reported bleed rates, time to bleeding event, and location of the bleed. The analysis did not detect any statistically significant differences between apixaban and rivaroxaban in terms of overall, (ARR 0.90% per 100 patient-years, 95% CI - 0.58 to 2.38%, p > 0.05) major, (ARR 0.22% per 100 patient-years, 95% CI - 0.74 to 1.17%, p > 0.05) or non-major clinically relevant (ARR 0.35% per 100 patient-years, 95% CI - 0.57 to 1.27%, p > 0.05) bleeding. Observed bleeding for both rivaroxaban and apixaban in the Veteran population exceeded the rates reported by the literature when used for atrial fibrillation (1.96% vs. 0.15%, p < 0.05; 1.08% vs. 0.16%, p < 0.05) but the opposite was seen for long term venous thromboembolism (VTE) treatment (3.97% vs. 8.03%, p < 0.0001; 0.14% vs. 15.51%, p < 0.0001) or extended VTE prophylaxis (0.07% vs 5.98%, p < 0.0001; 0.07% vs 1.88%, p < 0.01). Results from this study suggest these agents impart similar levels of risk, but variations in bleeding risk between the Veteran population and the patients in the original clinical trials may exist.
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Khader K, Thomas A, Jones M, Toth D, Stevens V, Samore MH. Variation and trends in transmission dynamics of Methicillin-resistant Staphylococcus aureus in veterans affairs hospitals and nursing homes. Epidemics 2019; 28:100347. [PMID: 31171468 PMCID: PMC7006838 DOI: 10.1016/j.epidem.2019.100347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/25/2019] [Accepted: 05/28/2019] [Indexed: 02/02/2023] Open
Abstract
Variation and differences of MRSA transmission within and between healthcare settings are not well understood. This variability is critical for understanding the potential impact of infection control interventions and could aid in the evaluation of future intervention strategies. We fit a Bayesian transmission model to detailed individual-level MRSA surveillance data from over 230 Veterans Affairs (VA) hospitals and nursing homes. Our approach disentangles the effects of potential confounders, including length of stay, admission prevalence, and clearance, estimating dynamic transmission model parameters and temporal trends. The median baseline transmission rate in hospitals was approximately four-fold higher than in nursing homes, and declined in 46% of hospitals and 9% of nursing homes, resulting in a median transmission rate reduction of 43% across hospitals and an increase of 2% in nursing homes. For first admissions into an acute care facility, the median (range) importation probability was 10.5% (5.9%–18.4%), and was nearly twice as large, 18.7% (9.2%–37.4%), in nursing homes. This analysis found differences within and between hospitals and nursing homes. The transmission rate declined substantially in hospitals and remained stable in nursing homes, while admission prevalence was considerably higher in nursing homes than in hospitals.
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Affiliation(s)
- Karim Khader
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Alun Thomas
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Makoto Jones
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Damon Toth
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Vanessa Stevens
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Matthew H Samore
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) 2.0 Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT, 84148, USA; Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
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Boyd JS, LoPresti CM, Core M, Schott C, Mader MJ, Lucas BP, Haro EK, Finley EP, Restrepo MI, Kessler C, Colon-Molero A, Pugh J, Soni NJ. Current use and training needs of point-of-care ultrasound in emergency departments: A national survey of VA hospitals. Am J Emerg Med 2019; 37:1794-1797. [PMID: 30878406 DOI: 10.1016/j.ajem.2019.02.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jeremy S Boyd
- VA Tennessee Valley Healthcare System-Nashville, Department of Emergency Medicine, Nashville, TN, USA; Vanderbilt University, Department of Emergency Medicine, Nashville, TN, USA.
| | - Charles M LoPresti
- Louis Stokes Cleveland VA Medical Center, Medicine Service, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Department of Medicine, Cleveland, OH, USA.
| | - Megan Core
- Orlando VA Medical Center, Department of Emergency Medicine, Orlando, FL, USA; University of Central Florida College of Medicine, Department of Medicine, Orlando, FL, USA
| | - Christopher Schott
- VA Pittsburgh Health Care Systems, Critical Care Service, Pittsburgh, PA, USA; University of Pittsburgh, Departments of Critical Care Medicine and Emergency Medicine, Pittsburgh, PA, USA.
| | - Michael J Mader
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA.
| | - Brian P Lucas
- White River Junction VA Medical Center, Medicine Service, White River, Junction, VT, USA; Dartmouth Geisel School of Medicine, Department of Medicine, Hanover, NH, USA.
| | - Elizabeth K Haro
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA; (m) UT Health San Antonio, Division of Pulmonary & Critical Care Medicine, San Antonio, TX, USA.
| | - Erin P Finley
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA.
| | - Marcos I Restrepo
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; (m) UT Health San Antonio, Division of Pulmonary & Critical Care Medicine, San Antonio, TX, USA.
| | - Chad Kessler
- Durham VA Health Care System, Primary Care Service, Durham, NC, USA; Duke University School of Medicine, Department of Medicine, Durham, NC, USA.
| | | | - Jacqueline Pugh
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA.
| | - Nilam J Soni
- South Texas Veterans Health Care System, Medicine Service, San Antonio, TX, USA; UT Health San Antonio, Division of General & Hospital Medicine, San Antonio, TX, USA; (m) UT Health San Antonio, Division of Pulmonary & Critical Care Medicine, San Antonio, TX, USA.
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Rivich J, McCauliff J, Schroeder A. Impact of multidisciplinary chart reviews on opioid dose reduction and monitoring practices. Addict Behav 2018; 86:40-3. [PMID: 29752012 DOI: 10.1016/j.addbeh.2018.04.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 04/06/2018] [Accepted: 04/25/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The Veterans Affairs (VA) Eastern Colorado Health Care System implemented an Opioid Safety Initiative (OSI); this included multidisciplinary chart reviews of patients with chronic, non-malignant pain on high-dose opioid therapy to provide safety recommendations to prescribers through the electronic medical record. Our study objective was to evaluate the impact of these documented recommendations. Outcomes included change in total daily opioid dose, concurrent prescribing of opioids and benzodiazepines, adherence to local VA/Veterans Integrated Service Network (VISN) policy, and monitoring practices. METHODS This retrospective chart review of patients prescribed ≥200 mg of morphine equivalent daily dose (MEDD) collected data from OSI chart reviews conducted between January 1, 2015 and March 31, 2015. Outcomes were assessed during the 12 months following initial review. Primary outcomes included: opioid dose reduction, discontinuation of concurrent benzodiazepines, and adherence to VA/VISN policy, including documentation of signed informed Consent for Long-Term Opioid Therapy for Pain, biannual urine drug screens (UDS), and follow-up every six months with primary opioid prescriber. RESULTS Of 147 patients meeting inclusion criteria, 50 patients (34%) reduced opioid dose with the baseline median MEDD decreasing from 315 mg to 278 mg. Of the 48 patients prescribed benzodiazepines and opioids, 10 patients discontinued benzodiazepines (21%). Completion of informed consents increased from 31% to 48%, biannual UDS increased from 44% to 61%, and follow-up with opioid prescriber was unchanged. CONCLUSION After completion of OSI chart reviews, reduction in opioid dose and concurrent prescribing of benzodiazepines was observed. VA/VISN policy and monitoring adherence also showed improvement.
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Wong ES, Maciejewski ML, Hebert PL, Fortney JC, Liu CF. Spillover Effects of Massachusetts Health Reform on Mental Health Use by VA and Medicare Dual Enrollees. Adm Policy Ment Health 2018; 46:145-153. [PMID: 30343347 DOI: 10.1007/s10488-018-0900-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Older veterans can obtain care from the Veterans Affairs Health System (VA), Medicare or both. We examined whether their use of mental health care was impacted by capacity effects stemming from younger, uninsured veterans' enrolling in VA to satisfy the individual mandate within Massachusetts Health Reform (MHR). Using administrative data, we applied a difference-in-difference approach to compare pre-post changes in mental health use following MHR implementation. Findings indicated MHR was associated with increases in use through Medicare and the probability of dual VA-Medicare use. These results provide support for the possibility that limited capacity led to care seeking outside VA.
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Affiliation(s)
- Edwin S Wong
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, HSR&D MS-152, Seattle, WA, 98108, USA. .,Department of Health Services, University of Washington, Seattle, WA, USA.
| | - Matthew L Maciejewski
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Paul L Hebert
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, HSR&D MS-152, Seattle, WA, 98108, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | - John C Fortney
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, HSR&D MS-152, Seattle, WA, 98108, USA.,Department of Psychiatry, University of Washington, Seattle, WA, USA
| | - Chuan-Fen Liu
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, HSR&D MS-152, Seattle, WA, 98108, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
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Mohr DC, Eaton JL, Meterko M, Stolzmann KL, Restuccia JD. Factors associated with internal medicine physician job attitudes in the Veterans Health Administration. BMC Health Serv Res 2018; 18:244. [PMID: 29622008 PMCID: PMC5885351 DOI: 10.1186/s12913-018-3015-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 03/15/2018] [Indexed: 11/10/2022] Open
Abstract
Background US healthcare organizations increasingly use physician satisfaction and attitudes as a key performance indicator. Further, many health care organizations also have an academically oriented mission. Physician involvement in research and teaching may lead to more positive workplace attitudes, with subsequent decreases in turnover and beneficial impact on patient care. This article aimed to understand the influence of time spent on academic activities and perceived quality of care in relation to job attitudes among internal medicine physicians in the Veterans Health Administration (VHA). Methods A cross-sectional survey was conducted with inpatient attending physicians from 36 Veterans Affairs Medical Centers. Participants were surveyed regarding demographics, practice settings, workplace staffing, perceived quality of care, and job attitudes. Job attitudes consisted of three measures: overall job satisfaction, intent to leave the organization, and burnout. Analysis used a two-level hierarchical model to account for the nesting of physicians within medical centers. The regression models included organizational-level characteristics: inpatient bed size, urban or rural location, hospital teaching affiliation, and performance-based compensation. Results A total of 373 physicians provided useable survey responses. The majority (72%) of respondents reported some level of teaching involvement. Almost half (46%) of the sample reported some level of research involvement. Degree of research involvement was a significant predictor of favorable ratings on physician job satisfaction and intent to leave. Teaching involvement did not have a significant impact on outcomes. Perceived quality of care was the strongest predictor of physician job satisfaction and intent to leave. Perceived levels of adequate physician staffing was a significant contributor to all three job attitude measures. Conclusions Expanding opportunities for physician involvement with research may lead to more positive work experiences, which could potentially reduce turnover and improve system performance. Electronic supplementary material The online version of this article (10.1186/s12913-018-3015-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), Boston VA Healthcare System, 150 South Huntington Ave, 152M, Boston, MA, 02130, USA. .,Boston University School of Public Health, Boston, MA, USA.
| | - Jennifer L Eaton
- Department of Veterans Affairs, Office of Patient Care Services, Occupational Health Services, Washington, DC, USA
| | - Mark Meterko
- VA Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID -10EA), Field-based at the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - Kelly L Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), Boston VA Healthcare System, 150 South Huntington Ave, 152M, Boston, MA, 02130, USA
| | - Joseph D Restuccia
- Center for Healthcare Organization and Implementation Research (CHOIR), Boston VA Healthcare System, 150 South Huntington Ave, 152M, Boston, MA, 02130, USA.,Boston University Questrom School of Business, Boston, MA, USA
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Malhotra A, Phatharacharukul P, Thongprayoon C. Risk factors for 90-day readmission in veterans with inflammatory bowel disease-Does post-discharge follow-up matter? Mil Med Res 2018; 5:5. [PMID: 29502532 DOI: 10.1186/s40779-018-0153-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 01/23/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Repeat hospitalizations in veterans with inflammatory bowel disease (IBD) are understudied. The early readmission rate and potentially modifiable risk-factors for 90-day readmission in veterans with IBD were studied to avert avoidable readmissions. METHODS A retrospective cohort study was conducted using the data from veterans who were admitted to the Minneapolis VA Medical Center (MVMC) between January 1, 2007, and December 31, 2013, for an IBD-related problem. All-cause readmissions within 30 and 90 days were recorded to calculate early readmission rates. The multivariate logistic regression was used to identify the potential risk factors for 90-day readmission. RESULTS There were 130 unique patients (56.9% with Crohn's disease and 43.1% with ulcerative colitis) with 202 IBD-related index admissions. The mean age at the time of index admission was 59.8 ± 15.2 years. The median time to re-hospitalization was 26 days (IQR 10-49), with 30- and 90-day readmission rates of 17.3% (35/202) and 29.2% (59/202), respectively. Reasons for all-cause readmission were IBD-related (71.2%), scheduled surgery (3.4%) and non-gastrointestinal causes (25.4%). The following reasons were independently associated with 90-day readmission: Crohn's disease (OR 3.90; 95% CI 1.82-8.90), use of antidepressants (OR 2.19; 95% CI 1.12-4.32), and lack of follow-up within 90 days with a primary care physician (PCP) (OR 2.63; 95% CI 1.32-5.26) or a gastroenterologist (GI) (OR 2.44; 95% CI 1.20-5.00). 51.0% and 49.0% of patients had documentation of a recommended outpatient follow-up with PCP and/or GI, respectively. CONCLUSIONS Early readmission in IBD is common. Independent risk factors for 90-day readmission included Crohn's disease, use of antidepressants and lack of follow-up visit with PCP or GI. Further research is required to determine if the appropriate timing of post-discharge follow-up can reduce IBD readmissions.
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Eisenberg D, Lohnberg JA, Kubat EP, Bates CC, Greenberg LM, Frayne SM. Systems innovation model: an integrated interdisciplinary team approach pre- and post-bariatric surgery at a veterans affairs (VA) medical center. Surg Obes Relat Dis 2016; 13:600-606. [PMID: 28089437 DOI: 10.1016/j.soard.2016.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/05/2016] [Accepted: 11/08/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Provision of bariatric surgery in the Veterans Health Administration must account for obese veterans' co-morbidity burden and the geographically dispersed location of patients relative to Veterans Affairs (VA) bariatric centers. OBJECTIVES To evaluate a collaborative, integrated, interdisciplinary bariatric team of surgeons, bariatricians, psychologists, dieticians, and physical therapists working in a hub-and-spokes care model, for pre- and post-bariatric surgery assessment and management. METHODS This is a description of an interdisciplinary clinic and bariatric program at a VA healthcare system and a report on program evaluation findings. Retrospective data of a prospective database was abstracted. For program evaluation, we abstracted charts to characterize patient data and conducted a patient survey. RESULTS Since 2009, 181 veterans have undergone bariatric surgery. Referrals came from 7 western U.S. states. Mean preoperative body mass index was 46 kg/m2 (maximum 71). Mean age was 53 years, with 33% aged>60 years; 79% were male. Medical co-morbidity included diabetes (70%), hypertension (85%), and lower back or extremity joint pain (84%). A psychiatric diagnosis was present in 58%. At 12 months, follow-up was 81% and percent excess body mass index loss was 50.5%. Among 54 sequential clinic patients completing anonymous surveys, overall satisfaction with the interdisciplinary team approach and improved quality of life were high (98% and 94%, respectively). CONCLUSION The integrated, interdisciplinary team approach using a hub-and-spokes model is well suited to the VA bariatric surgery population, with its heavy burden of medical and mental health co-morbidity and its system of geographically dispersed patients receiving treatment at specialty centers. As the VA seeks to expand the use of bariatric surgery as an option for obese veterans, interdisciplinary models crafted to address case complexity, care coordination, and long-term outcomes should be part of policy planning efforts.
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Affiliation(s)
- Dan Eisenberg
- Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA; Department of Surgery, Stanford School of Medicine, Stanford, CA.
| | - Jessica A Lohnberg
- Psychology Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA
| | - Eric P Kubat
- Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA; Department of Surgery, Stanford School of Medicine, Stanford, CA
| | - Cheryl C Bates
- Medicine Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA
| | - Lauren M Greenberg
- Psychology Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA; War Related Illness and Injury Study Center, East Orange, NJ
| | - Susan M Frayne
- VA Health Services Research & Development Center for Innovation to Implementation (Ci2 i), Palo Alto Veterans Affairs Health Care System, Palo Alto, CA; Department of Medicine, Stanford School of Medicine, Stanford, CA
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Cannon GW, DuVall SL, Haroldsen CL, Caplan L, Curtis JR, Michaud K, Mikuls TR, Reimold A, Collier DH, Joseph GJ, Harrison DJ, Sauer BC. Clinical Outcomes and Biologic Costs of Switching Between Tumor Necrosis Factor Inhibitors in US Veterans with Rheumatoid Arthritis. Adv Ther 2016; 33:1347-59. [PMID: 27352377 PMCID: PMC4969320 DOI: 10.1007/s12325-016-0371-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Indexed: 11/26/2022]
Abstract
Introduction The purpose of this study was to evaluate clinical outcomes and drug/administration costs of treatment with tumor necrosis factor inhibitor (TNFi) agents in US veterans with rheumatoid arthritis (RA) initiating TNFi therapy. The analysis compared patients initiating and continuing a single TNFi with patients who subsequently switched to a different TNFi. Methods Data from patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry who initiated treatment with adalimumab, etanercept, or infliximab from 2003 to 2010 were analyzed. Outcomes included duration of therapy, Disease Activity Score based on 28 joints (DAS28), and direct drug and drug administration costs. Results Of 563 eligible patients, 262 initiated a single TNFi therapy, 142 restarted their initial TNFi after a ≥90-day gap in treatment (interrupted therapy), and 159 switched to a different TNFi. Patients who switched had higher mean DAS28 before starting TNFi therapy than patients with single or interrupted therapy: 5.3 vs 4.5 or 4.6, respectively. Mean duration of the first course was 34.3 months for single therapy, 18.3 months for interrupted therapy, and 17.7 months for switched therapy. Mean post-treatment DAS28 was highest for patients who switched TNFi. Mean annualized costs for first course were $13,800 for single therapy, $13,200 for interrupted therapy, and $14,200 for switched therapy; mean annualized costs for second course were $12,800 for interrupted therapy and $15,100 for switched therapy. Conclusion Patients who switched TNFi had higher pre-treatment DAS28 and higher overall costs than patients who received the same TNFi as either single or interrupted therapy. Funding This research was funded by Immunex Corp., a fully owned subsidiary of Amgen Inc., and by VA HSR&D Grant SHP 08-172.
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Affiliation(s)
- Grant W Cannon
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Scott L DuVall
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Candace L Haroldsen
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Liron Caplan
- Denver VA and University of Colorado School of Medicine, Denver, CO, USA
| | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, NE, USA
- National Data Bank for Rheumatic Diseases, Wichita, KS, USA
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, NE, USA
| | - Andreas Reimold
- Dallas VA and University of Texas Southwestern, Dallas, TX, USA
| | | | | | | | - Brian C Sauer
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
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Groessl EJ, Schmalzl L, Maiya M, Liu L, Goodman D, Chang DG, Wetherell JL, Bormann JE, Atkinson JH, Baxi S. Yoga for veterans with chronic low back pain: Design and methods of a randomized clinical trial. Contemp Clin Trials 2016; 48:110-8. [PMID: 27103548 DOI: 10.1016/j.cct.2016.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/06/2016] [Accepted: 04/10/2016] [Indexed: 11/24/2022]
Abstract
Chronic low back pain (CLBP) afflicts millions of people worldwide, with particularly high prevalence in military veterans. Many treatment options exist for CLBP, but most have limited effectiveness and some have significant side effects. In general populations with CLBP, yoga has been shown to improve health outcomes with few side effects. However, yoga has not been adequately studied in military veteran populations. In the current paper we will describe the design and methods of a randomized clinical trial aimed at examining whether yoga can effectively reduce disability and pain in US military veterans with CLBP. A total of 144 US military veterans with CLBP will be randomized to either yoga or a delayed treatment comparison group. The yoga intervention will consist of 2× weekly yoga classes for 12weeks, complemented by regular home practice guided by a manual. The delayed treatment group will receive the same intervention after six months. The primary outcome is the change in back pain-related disability measured with the Roland-Morris Disability Questionnaire at baseline and 12-weeks. Secondary outcomes include pain intensity, pain interference, depression, anxiety, fatigue/energy, quality of life, self-efficacy, sleep quality, and medication usage. Additional process and/or mediational factors will be measured to examine dose response and effect mechanisms. Assessments will be conducted at baseline, 6-weeks, 12-weeks, and 6-months. All randomized participants will be included in intention-to-treat analyses. Study results will provide much needed evidence on the feasibility and effectiveness of yoga as a therapeutic modality for the treatment of CLBP in US military veterans.
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Nelson RE, Stevens VW, Jones M, Samore MH, Rubin MA. Health care-associated methicillin-resistant Staphylococcus aureus infections increases the risk of postdischarge mortality. Am J Infect Control 2015; 43:38-43. [PMID: 25564122 DOI: 10.1016/j.ajic.2014.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 09/17/2014] [Accepted: 09/18/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although many studies have estimated the impact of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections on mortality during initial hospitalization, little is known about the long-term risk of death in these patients. The purpose of this study was to quantify the effect of MRSA health care-acquired infections (HAIs) on mortality after hospital discharge. METHODS Our study cohort consisted of patients with inpatient admission within the U.S. Department of Veterans Affairs system between October 1, 2007, and September 30, 2010. Of these patients, we identified those with a positive MRSA culture from electronic microbiology reports. We constructed multivariable Cox proportional hazards regressions to assess the impact of a positive culture on postdischarge mortality in the 365 days following discharge using both the full cohort and a propensity score-matched subsample. RESULTS In our analysis cohort of 369,743 inpatients, positive MRSA cultures were recorded in 3,599 (1.0%) patients. We found that positive cultures resulted in an increased risk of postdischarge mortality both in the full cohort (hazard ratio = 1.42, P < .001) and in the subset of propensity score-matched patients (hazard ratio = 1.37, P < .0001). CONCLUSION We found that MRSA HAIs significantly elevate the long-term risk of mortality. These results underscore the importance of infection prevention efforts in the hospital.
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Affiliation(s)
- Richard E Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health System, Salt Lake City, UT; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT.
| | - Vanessa W Stevens
- IDEAS Center, Veterans Affairs Salt Lake City Health System, Salt Lake City, UT; Department of Pharmacotherapy, Pharmacotherapy Outcomes Research Center, University of Utah College of Pharmacy, Salt Lake City, UT
| | - Makoto Jones
- IDEAS Center, Veterans Affairs Salt Lake City Health System, Salt Lake City, UT; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Matthew H Samore
- IDEAS Center, Veterans Affairs Salt Lake City Health System, Salt Lake City, UT; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael A Rubin
- IDEAS Center, Veterans Affairs Salt Lake City Health System, Salt Lake City, UT; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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