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Khalaf N, Xu A, Nguyen Wenker T, Kramer JR, Liu Y, Singh H, El-Serag HB, Kanwal F. The Impact of Race on Pancreatic Cancer Treatment and Survival in the Nationwide Veterans Affairs Healthcare System. Pancreas 2024; 53:e27-e33. [PMID: 37967826 PMCID: PMC10883640 DOI: 10.1097/mpa.0000000000002272] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVES Among patients with pancreatic cancer, studies show racial disparities at multiple steps of the cancer care pathway. Access to healthcare is a frequently cited cause of these disparities. It remains unclear if racial disparities exist in an integrated, equal access public system such as the Veterans Affairs healthcare system. METHODS We identified all patients diagnosed with pancreatic adenocarcinoma in the national Veterans Affairs Central Cancer Registry from January 2010 to December 2018. We examined the independent association between race and 3 endpoints: stage at diagnosis, receipt of treatment, and survival while adjusting for sociodemographic factors and medical comorbidities. RESULTS We identified 8529 patients with pancreatic adenocarcinoma, of whom 79.5% were White and 20.5% were Black. Black patients were 19% more likely to have late-stage disease and 25% less likely to undergo surgical resection. Black patients had 13% higher mortality risk compared with White patients after adjusting for sociodemographic characteristics and medical comorbidities. This difference in mortality was no longer statistically significant after additionally adjusting for cancer stage and receipt of potentially curative treatment. CONCLUSIONS Equal access to healthcare might have reduced but failed to eliminate disparities. Dedicated efforts are needed to understand reasons underlying these disparities in an attempt to close these persistent gaps.
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Affiliation(s)
| | - Ann Xu
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | | | | | | | - Hashem B El-Serag
- From the Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Nik-Ahd F, De Hoedt A, Butler C, Anger JT, Carroll PR, Cooperberg MR, Freedland SJ. Prostate Cancer in Transgender Women in the Veterans Affairs Health System, 2000-2022. JAMA 2023; 329:1877-1879. [PMID: 37119522 PMCID: PMC10148974 DOI: 10.1001/jama.2023.6028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/28/2023] [Indexed: 05/01/2023]
Abstract
This case series investigates the rate of prostate cancer diagnoses among transgender women treated in the Veterans Affairs health system.
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Affiliation(s)
| | - Amanda De Hoedt
- Division of Urology, Veterans Affairs Health Care System, Durham, North Carolina
| | - Christi Butler
- Department of Urology, University of California, San Francisco
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Kelly JD, Leonard S, Hoggatt KJ, Boscardin WJ, Lum EN, Moss-Vazquez TA, Andino R, Wong JK, Byers A, Bravata DM, Tien PC, Keyhani S. Incidence of Severe COVID-19 Illness Following Vaccination and Booster With BNT162b2, mRNA-1273, and Ad26.COV2.S Vaccines. JAMA 2022; 328:1427-1437. [PMID: 36156706 PMCID: PMC9513709 DOI: 10.1001/jama.2022.17985] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/14/2022] [Indexed: 11/14/2022]
Abstract
Importance Evidence describing the incidence of severe COVID-19 illness following vaccination and booster with BNT162b2, mRNA-1273, and Ad26.COV2.S vaccines is needed, particularly for high-risk populations. Objective To describe the incidence of severe COVID-19 illness among a cohort that received vaccination plus a booster vaccine dose. Design, Setting, and Participants Retrospective cohort study of adults receiving care at Veterans Health Administration facilities across the US who received a vaccination series plus 1 booster against SARS-CoV-2, conducted from July 1, 2021, to May 30, 2022. Patients were eligible if they had received a primary care visit in the prior 2 years and had documented receipt of all US Food and Drug Administration-authorized doses of the initial mRNA vaccine or viral vector vaccination series after December 11, 2020, and a subsequent documented booster dose between July 1, 2021, and April 29, 2022. The analytic cohort consisted of 1 610 719 participants. Exposures Receipt of any combination of mRNA-1273 (Moderna), BNT162b2 (Pfizer-BioNTech), and Ad26.COV2.S (Janssen/Johnson & Johnson) primary vaccination series and a booster dose. Main Outcomes and Measures Outcomes were breakthrough COVID-19 (symptomatic infection), hospitalization with COVID-19 pneumonia and/or death, and hospitalization with severe COVID-19 pneumonia and/or death. A subgroup analysis of nonoverlapping populations included those aged 65 years or older, those with high-risk comorbid conditions, and those with immunocompromising conditions. Results Of 1 610 719 participants, 1 100 280 (68.4%) were aged 65 years or older and 132 243 (8.2%) were female; 1 133 785 (70.4%) had high-risk comorbid conditions, 155 995 (9.6%) had immunocompromising conditions, and 1 467 879 (91.1%) received the same type of mRNA vaccine (initial series and booster). Over 24 weeks, 125.0 (95% CI, 123.3-126.8) per 10 000 persons had breakthrough COVID-19, 8.9 (95% CI, 8.5-9.4) per 10 000 persons were hospitalized with COVID-19 pneumonia or died, and 3.4 (95% CI, 3.1-3.7) per 10 000 persons were hospitalized with severe pneumonia or died. For high-risk populations, incidence of hospitalization with COVID-19 pneumonia or death was as follows: aged 65 years or older, 1.9 (95% CI, 1.4-2.6) per 10 000 persons; high-risk comorbid conditions, 6.7 (95% CI, 6.2-7.2) per 10 000 persons; and immunocompromising conditions, 39.6 (95% CI, 36.6-42.9) per 10 000 persons. Subgroup analyses of patients hospitalized with COVID-19 pneumonia or death by time after booster demonstrated similar incidence estimates among those aged 65 years or older and with high-risk comorbid conditions but not among those with immunocompromising conditions. Conclusions and Relevance In a US cohort of patients receiving care at Veterans Health Administration facilities during a period of Delta and Omicron variant predominance, there was a low incidence of hospitalization with COVID-19 pneumonia or death following vaccination and booster with any of BNT162b2, mRNA-1273, or Ad26.COV2.S vaccines.
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Affiliation(s)
- J. Daniel Kelly
- San Francisco VA Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco
- F. I. Proctor Foundation, University of California, San Francisco
| | - Samuel Leonard
- San Francisco VA Medical Center, San Francisco, California
| | - Katherine J. Hoggatt
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco
| | - W. John Boscardin
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Emily N. Lum
- San Francisco VA Medical Center, San Francisco, California
| | | | - Raul Andino
- Department of Microbiology and Immunology, University of California, San Francisco
| | - Joseph K. Wong
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco
| | - Amy Byers
- San Francisco VA Medical Center, San Francisco, California
| | - Dawn M. Bravata
- Department of Veterans Affairs Health Services and Development Center for Health Information and Communication and Department of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Phyllis C. Tien
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco
| | - Salomeh Keyhani
- San Francisco VA Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco
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Abstract
IMPORTANCE The racial and ethnic diversity of the US, including among patients receiving their care at the Veterans Health Administration (VHA), is increasing. Dementia is a significant public health challenge and may have greater incidence among older adults from underrepresented racial and ethnic minority groups. OBJECTIVE To determine dementia incidence across 5 racial and ethnic groups and by US geographical region within a large, diverse, national cohort of older veterans who received care in the largest integrated health care system in the US. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study within the VHA of a random sample (5% sample selected for each fiscal year) of 1 869 090 participants aged 55 years or older evaluated from October 1, 1999, to September 30, 2019 (the date of final follow-up). EXPOSURES Self-reported racial and ethnic data were obtained from the National Patient Care Database. US region was determined using Centers for Disease Control and Prevention (CDC) regions from residential zip codes. MAIN OUTCOMES AND MEASURES Incident diagnosis of dementia (9th and 10th editions of the International Classification of Diseases). Fine-Gray proportional hazards models were used to examine time to diagnosis, with age as the time scale and accounting for competing risk of death. RESULTS Among the 1 869 090 study participants (mean age, 69.4 [SD, 7.9] years; 42 870 women [2%]; 6865 American Indian or Alaska Native [0.4%], 9391 Asian [0.5%], 176 795 Black [9.5%], 20 663 Hispanic [1.0%], and 1 655 376 White [88.6%]), 13% received a diagnosis of dementia over a mean follow-up of 10.1 years. Age-adjusted incidence of dementia per 1000 person-years was 14.2 (95% CI, 13.3-15.1) for American Indian or Alaska Native participants, 12.4 (95% CI, 11.7-13.1) for Asian participants, 19.4 (95% CI, 19.2-19.6) for Black participants, 20.7 (95% CI, 20.1-21.3) for Hispanic participants, and 11.5 (95% CI, 11.4-11.6) for White participants. Compared with White participants, the fully adjusted hazard ratios were 1.05 (95% CI, 0.98-1.13) for American Indian or Alaska Native participants, 1.20 (95% CI, 1.13-1.28) for Asian participants, 1.54 (95% CI, 1.51-1.57) for Black participants, and 1.92 (95% CI, 1.82-2.02) for Hispanic participants. Across most US regions, age-adjusted dementia incidence rates were highest for Black and Hispanic participants, with rates similar among American Indian or Alaska Native, Asian, and White participants. CONCLUSIONS AND RELEVANCE Among older adults who received care at VHA medical centers, there were significant differences in dementia incidence based on race and ethnicity. Further research is needed to understand the mechanisms responsible for these differences.
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Affiliation(s)
- Erica Kornblith
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Amber Bahorik
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Northern California Institute for Research and Education, San Francisco
| | - W John Boscardin
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Medicine, University of California, San Francisco
| | - Feng Xia
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Northern California Institute for Research and Education, San Francisco
| | - Deborah E Barnes
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kristine Yaffe
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Northern California Institute for Research and Education, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Neurology, University of California, San Francisco
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Rosen AK, Beilstein-Wedel EE, Harris AHS, Shwartz M, Vanneman ME, Wagner TH, Giori NJ. Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care. Med Care 2022; 60:178-186. [PMID: 35030566 DOI: 10.1097/mlr.0000000000001678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care. OBJECTIVE We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels. METHODS Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics. PRINCIPAL FINDINGS Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers. CONCLUSIONS Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.
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Affiliation(s)
- Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Erin E Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Alex H S Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Livermore
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System
- Departments of Internal Medicine and Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Todd H Wagner
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Livermore
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- VA Health Economics Resource Center (HERC), Menlo Park, CA
| | - Nicholas J Giori
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Livermore
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA
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Carrel M, Clore GS, Kim S, Vaughan Sarrazin M, Tate E, Perencevich EN, Goto M. Health Care Utilization Among Texas Veterans Health Administration Enrollees Before and After Hurricane Harvey, 2016-2018. JAMA Netw Open 2021; 4:e2138535. [PMID: 34889944 PMCID: PMC8665372 DOI: 10.1001/jamanetworkopen.2021.38535] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Hurricanes and flooding can interrupt health care utilization. Understanding the magnitude and duration of interruptions, as well as how they vary according to hazard exposure, race, and income, are important for identifying populations in need of greater retention in care. OBJECTIVE To determine how the differential exposure to Hurricane Harvey in August 2017 is associated with changes in utilization of Veterans Health Administration health care. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective cohort analysis of primary care practitioner (PCP) visits, emergency department visits, and inpatient admissions in the Veterans Health Administration among Texas veterans residing in counties impacted by Hurricane Harvey from 2016 to 2018. Data analysis was performed from September 2020 to May 2021. EXPOSURES Residential flooding after Hurricane Harvey. MAIN OUTCOMES AND MEASURES Interrupted time series analysis measured changes in health care utilization over time, stratified by residential flood exposure, race, and income. RESULTS Of the 99 858 patients in the cohort, 89 931 (90.06%) were male, and their median (range) age was 58 (21 to 102) years. Compared with veterans in nonflooded areas, veterans living in flooded areas were more likely to be Black (24 715 veterans [33.80%] vs 4237 veterans [15.85%]) and low-income (14 895 veterans [20.37%] vs 4853 veterans [18.15%]). Rates of PCP visits decreased by 49.78% (95% CI, -64.52% to -35.15%) for veterans in flooded areas and by 45.89% (95% CI, -61.93% to -29.91%) for veterans in nonflooded areas and did not rebound until more than 8 weeks after the hurricane. Rates of PCP visits in flooded areas remained lower than expected for 11 weeks among White veterans (-6.99%; 95% CI, -14.36% to 0.81%) and for 13 weeks among racial minority veterans (-7.22%; 95% CI, -14.11% to 0.30%). Low-income veterans, regardless of flood status, experienced greater suppression of PCP visits in the 8 weeks following the hurricane (-13.72%; 95% CI, -20.51% to -6.68%) compared with their wealthier counterparts (-9.63%; 95% CI, -16.74% to -2.26%). CONCLUSIONS AND RELEVANCE These findings suggest that flood disasters such as Hurricane Harvey may be associated with declines in health care utilization that differ according to flood status, race, and income strata. Patients most exposed to the disaster also had the greatest delay or nonreceipt of care.
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Affiliation(s)
- Margaret Carrel
- Department of Geographical and Sustainability Sciences, University of Iowa, Iowa City
| | - Gosia S. Clore
- Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Seungwon Kim
- Department of Geographical and Sustainability Sciences, University of Iowa, Iowa City
| | - Mary Vaughan Sarrazin
- Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Eric Tate
- Department of Geographical and Sustainability Sciences, University of Iowa, Iowa City
| | - Eli N. Perencevich
- Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Michihiko Goto
- Department of Internal Medicine, University of Iowa, Iowa City
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
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Manhapra A, Stefanovics EA, Rhee TG, Rosenheck RA. Who Uses Veterans Mental Health Services?: A National Observational Study of Male Veteran and Nonveteran Mental Health Service Users. J Nerv Ment Dis 2021; 209:702-709. [PMID: 33993183 DOI: 10.1097/nmd.0000000000001369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Mental health (MH) research among veterans receiving services from the Veterans Health Administration (VHA) is extensive and growing and informs many clinical practice guidelines. We used nationally representative survey data to examine the generalizability of this extensive body of research by comparing sociodemographic and clinical characteristics of male veteran veterans health service (VHS) users (n = 491) with veteran non-VHS users (n = 840) and nonveteran (n = 6300) MH service users. VHS users were older, more often reported Black race, and less likely to have private or Medicaid insurance, but had similar prevalence of psychiatric or substance use disorder diagnoses but with a greater prevalence of posttraumatic stress disorder (PTSD). VHS users reported higher rates of medical diagnoses, pain interference, and poorer physical and MH status. These results suggest that VHA MH research may be reasonably generalizable to US mental health service users with caveats regarding age, PTSD diagnosis, pain, and racial distribution.
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Abstract
This cross-sectional study assesses changes in health care delivery methods, including all forms of care either purchased or provided by the Veterans Health Administration (VHA), for VHA enrollees in response to the COVID-19 pandemic.
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Affiliation(s)
- Liam Rose
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, California
| | - Linda Diem Tran
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford University, Stanford, California
| | - Steven M. Asch
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford Medicine, Stanford University, Stanford, California
| | - Anita Vashi
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Department of Emergency Medicine, University of California, San Francisco
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Gawron AJ, Yao Y, Gupta S, Cole G, Whooley MA, Dominitz JA, Kaltenbach T. Simplifying Measurement of Adenoma Detection Rates for Colonoscopy. Dig Dis Sci 2021; 66:3149-3155. [PMID: 33029706 DOI: 10.1007/s10620-020-06627-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/16/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Adenoma detection rate (ADR) is the colonoscopy quality metric with the strongest association to interval or "missed" cancer. Accurate measurement of ADR can be laborious and costly. AIMS Our aim was to determine if administrative procedure codes for colonoscopy and text searches of pathology results for adenoma mentions could estimate ADR. METHODS We identified US Veterans with a colonoscopy using Current Procedure Terminology (CPT) codes between January 2013 and December 2016 at ten Veterans Affairs sites. We applied simple text searches using Microsoft SQL Server full-text searches to query all pathology notes for "adenoma(s)" or "adenomatous" text mentions to calculate ADRs. To validate our identification of colonoscopy procedures, endoscopists of record, and adenoma detection from the electronic health record, we manually reviewed a random sample of 2000 procedure and pathology notes from the 10 sites. RESULTS Structured data fields were accurate in identification of colonoscopies being performed (PPV = 0.99; 95% CI 0.99-1.00) and identifying the endoscopist of record (PPV of 0.95; 95% CI 0.94-0.96) for ADR measurement. Simple text searches of pathology notes for adenoma mentions had excellent performance statistics as follows: sensitivity 0.99 (95% CI 0.98-1.00), specificity 0.93 (95% CI 0.92-0.95), NPV 0.99 (95% CI 0.98-1.00), and PPV 0.93 (0.91-0.94) for measurement of ADR. There was no clinically significant difference in the estimates of overall ADR vs. screening ADR (p > 0.05). CONCLUSIONS Measuring ADR using administrative codes and text searches from pathology results is an efficient method to broadly survey colonoscopy quality.
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Affiliation(s)
- Andrew J Gawron
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Yiwen Yao
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Samir Gupta
- San Diego Veterans Affairs Health Care System, San Diego, CA, USA
- Division of Gastroenterology and the Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Garrett Cole
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mary A Whooley
- Measurement Science QUERI, San Francisco, CA, USA
- University of California San Francisco, San Francisco, CA, USA
| | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, WA, USA
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, USA
| | - Tonya Kaltenbach
- Measurement Science QUERI, San Francisco, CA, USA
- University of California San Francisco, San Francisco, CA, USA
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Hynes DM, Edwards S, Hickok A, Niederhausen M, Weaver FM, Tarlov E, Gordon H, Jacob RL, Bartle B, O’Neill A, Young R, Laliberte A. Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice. Med Care 2021; 59:S292-S300. [PMID: 33976079 PMCID: PMC8132904 DOI: 10.1097/mlr.0000000000001554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Indexed: 01/10/2023]
Abstract
BACKGROUND The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers. OBJECTIVES The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider. RESEARCH DESIGN This was a retrospective, observational over fiscal years (FY) 2015-2018. SUBJECTS Veterans receiving primary care services paid for by the VA. MEASURES Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year. RESULTS There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care. CONCLUSION As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.
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Affiliation(s)
- Denise M. Hynes
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
- College of Public Health and Human Sciences, Oregon State University, Corvallis
- School of Nursing
| | - Samuel Edwards
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
- School of Medicine, Oregon Health and Science University
| | - Alex Hickok
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Meike Niederhausen
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
- Oregon Health and Science University, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR
| | - Frances M. Weaver
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
- Parkinson School of Health Sciences and Public Health, Loyola University, Maywood
| | - Elizabeth Tarlov
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
- University of Illinois at Chicago, College of Nursing
| | - Howard Gordon
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
- US Department of Veterans Affairs, Jesse Brown VA Medical Center and University of Illinois at Chicago, College of Medicine, Chicago, IL
| | - Reside L. Jacob
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Brian Bartle
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
| | - Allison O’Neill
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Rebecca Young
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Avery Laliberte
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
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Pettey WB, Wagner TH, Rosen AK, Beilstein-Wedel E, Shwartz M, Vanneman ME. Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery. Med Care 2021; 59:S307-S313. [PMID: 33976081 PMCID: PMC8132907 DOI: 10.1097/mlr.0000000000001491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Veterans Choice Act of 2014 increased the number of Veterans eligible for Department of Veterans Affairs (VA)-purchased care delivered in non-VA community care (CC) facilities. Driving >40 miles from home to a VA facility is a key eligibility criterion for CC. It remains unclear whether this policy change improved geographical access by reducing drive distance for Veterans. OBJECTIVES Describe the driving distance for Veterans receiving cataract surgery in VA and CC facilities, and if they visited the closest-to-home facility or if they drove to farther facilities. SUBJECTS Veterans who had cataract surgery in federal fiscal year 2015. MEASURES We calculated driving miles to the Closest VA and CC facilities that performed cataract surgeries, and to the location where Veterans received care. RESULTS A total of 61,746 Veterans received 83,875 cataract surgeries. More than 50% of CC surgeries occurred farther than the Closest CC facility providing cataract surgery (median Closest CC facility 8.7 miles vs. Actual CC facility, 19.7 miles). Most (57%) Veterans receiving cataract surgery at a VA facility used the Closest VA facility (median Closest VA facility 28.1 miles vs. Actual VA facility at 31.2 miles). In all, 26.1% of CC procedures occurred in facilities farther away than the Closest VA facility. CONCLUSIONS Although many Veterans drove farther than needed to get cataract surgery in CC, this was not true for obtaining care in the VA. Our findings suggest that there may be additional reasons, besides driving distance, that affect whether Veterans choose CC and, if they do, where they seek CC.
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Affiliation(s)
- Warren B.P. Pettey
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Todd H. Wagner
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Erin Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT
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Donnelly JP, Wang XQ, Iwashyna TJ, Prescott HC. Readmission and Death After Initial Hospital Discharge Among Patients With COVID-19 in a Large Multihospital System. JAMA 2021; 325:304-306. [PMID: 33315057 PMCID: PMC7737131 DOI: 10.1001/jama.2020.21465] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/13/2020] [Indexed: 02/05/2023]
Affiliation(s)
- John P. Donnelly
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
| | - Xiao Qing Wang
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor
| | - Theodore J. Iwashyna
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
| | - Hallie C. Prescott
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan
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Kaimal G, Dieterich-Hartwell R. Grappling with Gulf War Illness: Perspectives of Gulf War Providers. Int J Environ Res Public Health 2020; 17:ijerph17228574. [PMID: 33227919 PMCID: PMC7699279 DOI: 10.3390/ijerph17228574] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/16/2020] [Accepted: 11/06/2020] [Indexed: 11/16/2022]
Abstract
Background: Although the Gulf War occurred almost 30 years ago, the chronic symptoms of Gulf War illness (GWI), which include respiratory, gastrointestinal, and skin problems, as well as fatigue, pain, and mood alterations, currently affect over 200,000 veterans. Meanwhile, healthcare providers lack clear guidelines about how to best treat this illness. The objective in this study was to learn about the perceptions and experiences of healthcare providers of GWI veterans in terms of medical symptoms, resources for treatment, and quality of care. Methods: We interviewed 10 healthcare providers across the United States and subsequently conducted a qualitative grounded theory study which entailed both systematic data analysis and generating a grounded theory framework. Results: Our findings indicated multiple challenges for providers of veterans with GWI, including gaps in knowledge about GWI, lack of treatment options, absence of consistent communication within the Department of Veterans Affairs (VA) system, and personalized care that was limited to validation. Conclusion: While this study had several limitations, it supported the notion that healthcare providers have inadequate knowledge and awareness about GWI, which leads to continued uncertainty about how to best care for GWI veterans. This could be remedied by the creation of a comprehensive curriculum for a Massive Open Online Course (MOOC) to serve as an educational tool for those attending to this largely overlooked veteran population.
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Baum A, Wisnivesky J, Basu S, Siu AL, Schwartz MD. Association of Geographic Differences in Prevalence of Uncontrolled Chronic Conditions With Changes in Individuals' Likelihood of Uncontrolled Chronic Conditions. JAMA 2020; 324:1429-1438. [PMID: 33048153 PMCID: PMC8094427 DOI: 10.1001/jama.2020.14381] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE The prevalence of leading risk factors for morbidity and mortality in the US significantly varies across regions, states, and neighborhoods, but the extent these differences are associated with a person's place of residence vs the characteristics of the people who live in different places remains unclear. OBJECTIVE To estimate the degree to which geographic differences in leading risk factors are associated with a person's place of residence by comparing trends in health outcomes among individuals who moved to different areas or did not move. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study estimated the association between the differences in the prevalence of uncontrolled chronic conditions across movers' destination and origin zip codes and changes in individuals' likelihood of uncontrolled chronic conditions after moving, adjusting for person-specific fixed effects, the duration of time since the move, and secular trends among movers and those who did not move. Electronic health records from the Veterans Health Administration were analyzed. The primary analysis included 5 342 207 individuals with at least 1 Veterans Health Administration outpatient encounter between 2008 and 2018 who moved zip codes exactly once or never moved. EXPOSURES The difference in the prevalence of uncontrolled chronic conditions between a person's origin zip code and destination zip code (excluding the individual mover's outcomes). MAIN OUTCOMES AND MEASURES Prevalence of uncontrolled blood pressure (systolic blood pressure level >140 mm Hg or diastolic blood pressure level >90 mm Hg), uncontrolled diabetes (hemoglobin A1c level >8%), obesity (body mass index >30), and depressive symptoms (2-item Patient Health Questionnaire score ≥2) per quarter-year during the 3 years before and the 3 years after individuals moved. RESULTS The study population included 5 342 207 individuals (mean age, 57.6 [SD, 17.4] years, 93.9% men, 72.5% White individuals, and 12.7% Black individuals), of whom 1 095 608 moved exactly once and 4 246 599 never moved during the study period. Among the movers, the change after moving in the prevalence of uncontrolled blood pressure was 27.5% (95% CI, 23.8%-31.3%) of the between-area difference in the prevalence of uncontrolled blood pressure. Similarly, the change after moving in the prevalence of uncontrolled diabetes was 5.0% (95% CI, 2.7%-7.2%) of the between-area difference in the prevalence of uncontrolled diabetes; the change after moving in the prevalence of obesity was 3.1% (95% CI, 2.0%-4.2%) of the between-area difference in the prevalence of obesity; and the change after moving in the prevalence of depressive symptoms was 15.2% (95% CI, 13.1%-17.2%) of the between-area difference in the prevalence of depressive symptoms. CONCLUSIONS AND RELEVANCE In this retrospective cohort study of individuals receiving care at Veterans Health Administration facilities, geographic differences in prevalence were associated with a substantial percentage of the change in individuals' likelihood of poor blood pressure control or depressive symptoms, and a smaller percentage of the change in individuals' likelihood of poor diabetes control and obesity. Further research is needed to understand the source of these associations with a person's place of residence.
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Affiliation(s)
- Aaron Baum
- Department of Health System Design and Global Health and Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York
- Veterans Affairs New York Harbor Healthcare System, New York, New York
| | - Juan Wisnivesky
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sanjay Basu
- Collective Health, San Francisco, California
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts
- School of Public Health, Imperial College London, London, England
| | - Albert L. Siu
- Departments of Geriatrics and Palliative Medicine, Medicine, and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
- James J. Peters VA Medical Center, Bronx, New York
| | - Mark D. Schwartz
- Veterans Affairs New York Harbor Healthcare System, New York, New York
- Department of Population Health, New York University School of Medicine, New York, New York
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Vu M, Tortorice K, Zacher J, Dong D, Hur K, Zhang R, Good CB, Glassman PA, Cunningham FE. Assessment of Use and Safety of Edaravone for Amyotrophic Lateral Sclerosis in the Veterans Affairs Health Care System. JAMA Netw Open 2020; 3:e2014645. [PMID: 33017028 PMCID: PMC7536587 DOI: 10.1001/jamanetworkopen.2020.14645] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Using real-world data, the US Department of Veterans Affairs (VA) initiated a surveillance evaluation of edaravone after its approval for amyotrophic lateral sclerosis (ALS) in 2017. The use and safety of edaravone for patients with ALS in the VA health care system remain to be assessed. OBJECTIVE To describe a pharmacovigilance surveillance initiative with edaravone to monitor patient characteristics, utilization (edaravone cycles and riluzole use), and safety and to evaluate safety/effectiveness. DESIGN, SETTING, AND PARTICIPANTS This propensity score-matched cohort study used data on 369 patients with documented definite or probable ALS in the Veterans Health Administration (VHA) with at least 1 prescription for edaravone between August 1, 2017, and September 30, 2019. The analysis compared edaravone (alone or with riluzole) with riluzole only. For chronic users (≥6 months of drug), a time-to-event model evaluated ALS-related outcomes, with censoring at outcome, death, or end of evaluation. Patients with Parkinson disease, dementia, schizophrenia, or significant respiratory insufficiency per diagnosis codes within 2 years before prescription initiation were excluded. In overall matched cohorts, 223 patients treated with edaravone were 1:3 propensity score matched based on predefined confounders. For the chronic user subgroup analysis, 96 patients receiving edaravone and 424 patients receiving riluzole only were included. EXPOSURES Edaravone (alone or with riluzole) vs riluzole only. MAIN OUTCOMES AND MEASURES Patient characteristics, ALS drug use, and mortality. Acute outcomes (within 6 months of index) included proportion and mean time to event for death, discontinuation, or all-cause hospitalization, and outcomes for chronic users (receiving >6 months of treatment) included hazard ratios of outcomes related to disease-state progression. RESULTS Of 369 patients who received edaravone, most were older (mean [SD] age, 64.6 [11.3] years), male (346 [93.8%]), and White (261 [70.7%]). As of September 2019, 59.9% of edaravone patients had discontinued treatment; of those, 49.5% (108 of 218) received only 1 to 3 treatment cycles. Approximately 30% (110 patients) died. In a matched evaluation, significantly more acute all-cause hospitalization events occurred with edaravone (35.4% vs 22.0% for riluzole only); 72.6% of the edaravone cohort received edaravone with riluzole. Among chronic users, edaravone patients (70.8% edaravone with riluzole) had an increased hazard ratio of ALS-associated hospitalization (2.51; 95% CI, 1.18-8.16). The death rate was lower with edaravone but the difference was not statistically significant. CONCLUSIONS AND RELEVANCE Early edaravone discontinuation was common in the VA. Although outcomes favored use of riluzole only in the matched analysis, results should be interpreted with caution, as unmeasured bias in observational data is likely.
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Affiliation(s)
- Michelle Vu
- Pharmacy Benefits Management Services, Center for Medication Safety, Department of Veterans Affairs, Hines, Illinois
- Center for Health Equity Research and Promotion, Department of Veterans Affairs, Pittsburgh, Pennsylvania
| | - Kathryn Tortorice
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois
| | - Jennifer Zacher
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois
| | - Diane Dong
- Pharmacy Benefits Management Services, Center for Medication Safety, Department of Veterans Affairs, Hines, Illinois
| | - Kwan Hur
- Pharmacy Benefits Management Services, Center for Medication Safety, Department of Veterans Affairs, Hines, Illinois
| | - Rongping Zhang
- Pharmacy Benefits Management Services, Center for Medication Safety, Department of Veterans Affairs, Hines, Illinois
| | - Chester B. Good
- Pharmacy Benefits Management Services, Center for Medication Safety, Department of Veterans Affairs, Hines, Illinois
- Center for Health Equity Research and Promotion, Department of Veterans Affairs, Pittsburgh, Pennsylvania
- Division of Insurance, UPMC Health Plan, Pittsburgh, Pennsylvania
| | - Peter A. Glassman
- Pharmacy Benefits Management Services, Center for Medication Safety, Department of Veterans Affairs, Hines, Illinois
- Greater Los Angeles Healthcare System, Department of Veterans Affairs, Los Angeles, California
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington, DC
| | - Francesca E. Cunningham
- Pharmacy Benefits Management Services, Center for Medication Safety, Department of Veterans Affairs, Hines, Illinois
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16
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Lee M, Leonard C, Greene P, Kenney R, Whittington MD, Kirsh S, Ho PM, Sayre G, Simonetti J. Perspectives of VA Primary Care Clinicians Toward Electronic Consultation-Related Workload Burden: A Qualitative Analysis. JAMA Netw Open 2020; 3:e2018104. [PMID: 33125494 PMCID: PMC7599439 DOI: 10.1001/jamanetworkopen.2020.18104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Electronic consultation (e-consultation) is increasingly being adopted to expand access to specialty care and reduce health care costs. Little is known about clinicians' perceptions of using e-consultations, which may be associated with program adoption. OBJECTIVE To identify perceptions of primary care clinicians in the US Veterans Health Administration (VHA) system about e-consultation and workload. DESIGN, SETTING, AND PARTICIPANTS A qualitative study using semistructured interviews was conducted from September 2017 through March 2018 in a national sample of VHA primary care clinics in the US. Participants were primary care clinicians who had at least 300 total patient encounters from July 2016 to June 2017, including at least 1 e-consultation request. A convenience sample of participants was recruited using email invitations. Deductive and inductive content analysis were used to identify themes. Data were analyzed from October 2017 to April 2018. EXPOSURES Use of e-consultation. MAIN OUTCOMES AND MEASURES Primary care clinician perspectives regarding e-consultation and their workload. RESULTS A total of 34 primary care clinicians enrolled working across 27 VHA clinical sites were included; 9 (26%) were between ages 40-49 years; 23 (68%) were female. Three themes were identified. First, the process of entering, tracking, and following up on e-consultations added a time burden to primary care clinicians. Second, e-consultation was perceived to shift diagnostic and follow-up responsibilities from specialists to primary care clinicians. Third, e-consultations were thought to improve the timeliness and quality of care provided despite a perceived increase in workload. CONCLUSIONS AND RELEVANCE In this study, participants perceived e-consultation as valuable for patient care but also as an increase in their workload. Further work is warranted to quantify the workload increase on clinician burnout, job satisfaction, and turnover.
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Affiliation(s)
- Marcie Lee
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
| | - Chelsea Leonard
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
| | - Preston Greene
- Department of Health Services, University of Washington, Seattle
| | - Rachael Kenney
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
| | - Melanie D. Whittington
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | - Susan Kirsh
- Office of Specialty Care and Specialty Care Transformation, Washington, DC
| | - P. Michael Ho
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - George Sayre
- Department of Health Services, University of Washington, Seattle
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Joseph Simonetti
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora
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Ioannou GN, Tang W, Beste LA, Tincopa MA, Su GL, Van T, Tapper EB, Singal AG, Zhu J, Waljee AK. Assessment of a Deep Learning Model to Predict Hepatocellular Carcinoma in Patients With Hepatitis C Cirrhosis. JAMA Netw Open 2020; 3:e2015626. [PMID: 32870314 PMCID: PMC7489819 DOI: 10.1001/jamanetworkopen.2020.15626] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Deep learning, a family of machine learning models that use artificial neural networks, has achieved great success at predicting outcomes in nonmedical domains. OBJECTIVE To examine whether deep learning recurrent neural network (RNN) models that use raw longitudinal data extracted directly from electronic health records outperform conventional regression models in predicting the risk of developing hepatocellular carcinoma (HCC). DESIGN, SETTING, AND PARTICIPANTS This prognostic study included 48 151 patients with hepatitis C virus (HCV)-related cirrhosis in the national Veterans Health Administration who had at least 3 years of follow-up after the diagnosis of cirrhosis. Patients were identified by having at least 1 positive HCV RNA test between January 1, 2000, to January 1, 2016, and were followed up from the diagnosis of cirrhosis to January 1, 2019, for the development of incident HCC. A total of 3 models predicting HCC during a 3-year period were developed and compared, as follows: (1) logistic regression (LR) with cross-sectional inputs (cross-sectional LR); (2) LR with longitudinal inputs (longitudinal LR); and (3) RNN with longitudinal inputs. Data analysis was conducted from April 2018 to August 2020. EXPOSURES Development of HCC. MAIN OUTCOMES AND MEASURES Area under the receiver operating characteristic curve, area under the precision-recall curve, and Brier score. RESULTS During a mean (SD) follow-up of 11.6 (5.0) years, 10 741 of 48 151 patients (22.3%) developed HCC (annual incidence, 3.1%), and a total of 52 983 samples (51 948 [98.0%] from men) were collected. Patients who developed HCC within 3 years were older than patients who did not (mean [SD] age, 58.2 [6.6] years vs 56.9 [6.9] years). RNN models had superior mean (SD) area under the receiver operating characteristic curve (0.759 [0.009]) and mean (SD) Brier score (0.136 [0.003]) than cross-sectional LR (0.689 [0.009] and 0.149 [0.003], respectively) and longitudinal LR (0.682 [0.007] and 0.150 [0.003], respectively) models. Using the RNN model, the samples with the mean (SD) highest 51% (1.5%) of HCC risk, in which 80% of all HCCs occurred, or the mean (SD) highest 66% (1.2%) of HCC risk, in which 90% of all HCCs occurred, could potentially be targeted. Among samples from patients who achieved sustained virologic response, the performance of the RNN models was even better (mean [SD] area under receiver operating characteristic curve, 0.806 [0.025]; mean [SD] Brier score, 0.117 [0.007]). CONCLUSIONS AND RELEVANCE In this study, deep learning RNN models outperformed conventional LR models, suggesting that RNN models could be used to identify patients with HCV-related cirrhosis with a high risk of developing HCC for risk-based HCC outreach and surveillance strategies.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - Weijing Tang
- Department of Statistics, University of Michigan, Ann Arbor
| | - Lauren A. Beste
- Division of General Internal Medicine, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Monica A. Tincopa
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor
| | - Grace L. Su
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, Ann Arbor, Michigan
| | - Tony Van
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor
| | - Elliot B. Tapper
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, Ann Arbor, Michigan
| | - Amit G. Singal
- Division of Gastroenterology, Department of Medicine, University of Texas Southwestern, Dallas
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor
| | - Akbar K. Waljee
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor
- VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, Ann Arbor, Michigan
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor
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18
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Low EE, Demb J, Liu L, Earles A, Bustamante R, Williams CD, Provenzale D, Kaltenbach T, Gawron AJ, Martinez ME, Gupta S. Risk Factors for Early-Onset Colorectal Cancer. Gastroenterology 2020; 159:492-501.e7. [PMID: 31926997 PMCID: PMC7343609 DOI: 10.1053/j.gastro.2020.01.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 12/31/2019] [Accepted: 01/03/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) incidence and mortality are increasing among persons younger than 50 years old in the United States, but risk factors associated with early-onset CRC (EOCRC) have not been widely studied. METHODS We conducted a case-control study of US veterans 18 to 49 years old who underwent colonoscopy examinations from 1999 through 2014. EOCRC cases were identified from a national cancer registry; veterans who were free of CRC at their baseline colonoscopy through 3 years of follow-up were identified as controls. We collected data on age, sex, race/ethnicity, body weight, body mass index (BMI), diabetes, smoking status, and aspirin use. Multivariate-adjusted EOCRC odds were estimated for each factor, with corresponding 95% confidence interval (CI) values. RESULTS Our final analysis included 651 EOCRC cases and 67,416 controls. Median age was 45.3 years, and 82.3% were male. Higher proportions of cases were older, male, current smokers, nonaspirin users, and had lower BMIs, compared with controls (P < .05). In adjusted analyses, increasing age and male sex were significantly associated with increased risk of EOCRC, whereas aspirin use and being overweight or obese (relative to normal BMI) were significantly associated with decreased odds of EOCRC. In post hoc analyses, weight loss of 5 kg or more within the 5-year period preceding colonoscopy was associated with higher odds of EOCRC (odds ratio 2.23; 95% CI 1.76-2.83). CONCLUSIONS In a case-control study of veterans, we found increasing age and male sex to be significantly associated with increased risk of EOCRC, and aspirin use to be significantly associated with decreased risk; these factors also affect risk for CRC onset after age 50. Weight loss may be an early clinical sign of EOCRC. More intense efforts are required to identify the factors that cause EOCRC and signs that can be used to identify individuals at highest risk.
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Affiliation(s)
- Eric E Low
- Department of Internal Medicine, University of California San Diego, San Diego, California; Division of Gastroenterology, University of California San Diego, San Diego, California; Veteran Affairs San Diego Healthcare System, San Diego, California
| | - Joshua Demb
- Division of Gastroenterology, University of California San Diego, San Diego, California; Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Lin Liu
- Veteran Affairs San Diego Healthcare System, San Diego, California; Moores Cancer Center, University of California San Diego, La Jolla, California; Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Ashley Earles
- Veterans Medical Research Foundation, San Diego, California
| | - Ranier Bustamante
- Veteran Affairs San Diego Healthcare System, San Diego, California; Moores Cancer Center, University of California San Diego, La Jolla, California
| | - Christina D Williams
- Cooperative Studies Program Epidemiology Center, Durham, North Carolina; Durham Veterans Affairs Medical Center, Durham, North Carolina; Duke Cancer Institute, Durham, North Carolina
| | - Dawn Provenzale
- Cooperative Studies Program Epidemiology Center, Durham, North Carolina; Durham Veterans Affairs Medical Center, Durham, North Carolina; Duke Cancer Institute, Durham, North Carolina
| | - Tonya Kaltenbach
- San Francisco Veterans Affairs Medical Center, San Francisco, California; University of California San Francisco, San Francisco, California
| | - Andrew J Gawron
- Salt Lake City VA Healthcare System, Salt Lake City, Utah; University of Utah, Salt Lake City, Utah
| | - Maria Elena Martinez
- Moores Cancer Center, University of California San Diego, La Jolla, California; Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Samir Gupta
- Department of Internal Medicine, University of California San Diego, San Diego, California; Division of Gastroenterology, University of California San Diego, San Diego, California; Veteran Affairs San Diego Healthcare System, San Diego, California; Moores Cancer Center, University of California San Diego, La Jolla, California.
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19
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Annis A, Freitag MB, Evans RR, Wiitala WL, Burns J, Raffa SD, Spohr SA, Damschroder LJ. Construction and Use of Body Weight Measures from Administrative Data in a Large National Health System: A Systematic Review. Obesity (Silver Spring) 2020; 28:1205-1214. [PMID: 32478469 PMCID: PMC7384104 DOI: 10.1002/oby.22790] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/29/2020] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Administrative data are increasingly used in research and evaluation yet lack standardized guidelines for constructing measures using these data. Body weight measures from administrative data serve critical functions of monitoring patient health, evaluating interventions, and informing research. This study aimed to describe the algorithms used by researchers to construct and use weight measures. METHODS A structured, systematic literature review of studies that constructed body weight measures from the Veterans Health Administration was conducted. Key information regarding time frames and time windows of data collection, measure calculations, data cleaning, treatment of missing and outlier weight values, and validation processes was collected. RESULTS We identified 39 studies out of 492 nonduplicated records for inclusion. Studies parameterized weight outcomes as change in weight from baseline to follow-up (62%), weight trajectory over time (21%), proportion of participants meeting weight threshold (46%), or multiple methods (28%). Most (90%) reported total time in follow-up and number of time points. Fewer reported time windows (54%), outlier values (51%), missing values (34%), or validation strategies (15%). CONCLUSIONS A high variability in the operationalization of weight measures was found. Improving methods to construct clinical measures will support transparency and replicability in approaches, guide interpretation of findings, and facilitate comparisons across studies.
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Affiliation(s)
- Ann Annis
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- College of NursingMichigan State UniversityEast LansingMichiganUSA
| | - Michelle B. Freitag
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Richard R. Evans
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Wyndy L. Wiitala
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Jennifer Burns
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Susan D. Raffa
- National Center for Health Promotion and Disease PreventionVeterans Health AdministrationDurhamNorth CarolinaUSA
- Department of Psychiatry & Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Stephanie A. Spohr
- National Center for Health Promotion and Disease PreventionVeterans Health AdministrationDurhamNorth CarolinaUSA
| | - Laura J. Damschroder
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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Chang ET, Zulman DM, Nelson KM, Rosland AM, Ganz DA, Fihn SD, Piegari R, Rubenstein LV. Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans. JAMA Netw Open 2020; 3:e208120. [PMID: 32597993 PMCID: PMC7324956 DOI: 10.1001/jamanetworkopen.2020.8120] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described. OBJECTIVE To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA). DESIGN, SETTING, AND PARTICIPANTS This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019. EXPOSURES Risk of hospitalization and assignment to general vs specialized primary care. MAIN OUTCOME AND MEASURES High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care). RESULTS The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall. CONCLUSIONS AND RELEVANCE The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.
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Affiliation(s)
- Evelyn T. Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, David Geffen School of Medicine at UCLA (University of California at Los Angeles), Los Angeles
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Karin M. Nelson
- Seattle-Denver Health Services Research & Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, Washington
- General Internal Medicine Service, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Ann-Marie Rosland
- VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David A. Ganz
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- VA Greater Los Angeles Geriatric Research, Education and Clinical Center, Los Angeles, California
- UCLA Multicampus Program in Geriatric Medicine and Gerontology, Los Angeles, California
| | - Stephan D. Fihn
- Department of Medicine, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Rebecca Piegari
- VA Office of Clinical Systems Development & Evaluation, Washington, DC
| | - Lisa V. Rubenstein
- Division of General Internal Medicine, David Geffen School of Medicine at UCLA (University of California at Los Angeles), Los Angeles
- Fielding School of Public Health, UCLA, Los Angeles, California
- RAND Corporation, Santa Monica, California
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Anderson TS, Lee S, Jing B, Fung K, Ngo S, Silvestrini M, Steinman MA. Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals. JAMA Netw Open 2020; 3:e201511. [PMID: 32207832 PMCID: PMC7093767 DOI: 10.1001/jamanetworkopen.2020.1511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home. OBJECTIVE To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013. MAIN OUTCOMES AND MEASURES Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics. RESULTS Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels. CONCLUSIONS AND RELEVANCE In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sei Lee
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Sarah Ngo
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Molly Silvestrini
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Michael A. Steinman
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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Gard LA, Cooper AJ, Youmans Q, Didwania A, Persell SD, Jean-Jacques M, Ravenna P, Goel MS, O'Brien MJ. Identifying and addressing social determinants of health in outpatient practice: results of a program-wide survey of internal and family medicine residents. BMC Med Educ 2020; 20:18. [PMID: 31948434 PMCID: PMC6966817 DOI: 10.1186/s12909-020-1931-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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] [Received: 07/09/2019] [Accepted: 01/09/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Up to 60% of preventable mortality is attributable to social determinants of health (SDOH), yet training on SDOH competencies is not widely implemented in residency. The objective of this study was to assess internal and family medicine residents' competence at identifying and addressing SDOH. METHODS Residents' perceived competence at identifying, discussing, and addressing SDOH in outpatient settings was assessed using a single questionnaire administered in March 2017. In this cross-sectional analysis, bivariate associations of resident characteristics with the following outcomes were examined: identifying, discussing, and addressing patients' challenges related to SDOH through referrals. RESULTS The survey was completed by 129 (84%) residents. Twenty residents (16%) reported an annual income of less than $50,000 during childhood. Overall, 108 residents (84%) reported previous SDOH training. Two-thirds had outpatient practices in Veterans Affairs or safety-net clinics. Thirty-nine (30%) intended to pursue a career in primary care. The following numbers of residents reported high levels of competence for performing these outcomes: identifying patients' challenges related to SDOH: 37 (29%); discussing them with patients: 18 (14%); and addressing these challenges through referrals to internal and external resources: 13 (10%) and 11 (9%), respectively. Factors associated with higher competence included older age, lower childhood household income, prior education about SDOH, primary practice site and intention to practice primary care. CONCLUSIONS Most residents had previous SDOH training, yet only a small proportion of residents reported being highly competent at identifying or addressing SDOH. Providing opportunities for practical training may be a key component in preparing medical residents to identify and address SDOH effectively in outpatient practice.
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Affiliation(s)
- Lauren A Gard
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive, Chicago, IL, USA
| | - Andrew J Cooper
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive, Chicago, IL, USA
| | - Quentin Youmans
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Aashish Didwania
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive, Chicago, IL, USA
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics; Center for Primary Care Innovation, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Muriel Jean-Jacques
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive, Chicago, IL, USA
| | - Paul Ravenna
- Department of Family and Community Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mita Sanghavi Goel
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive, Chicago, IL, USA
| | - Matthew J O'Brien
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 North Lake Shore Drive, Chicago, IL, USA.
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Slobodnick A, Krasnokutsky S, Lehmann RA, Keenan RT, Quach J, Francois F, Pillinger MH. Colorectal Cancer Among Gout Patients Undergoing Colonoscopy. J Clin Rheumatol 2019; 25:335-340. [PMID: 31764494 DOI: 10.1097/rhu.0000000000000893] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVE The connection between gout and various cancers remains unclear. We assessed the relationship between gout and colorectal cancer in a population of veterans. METHODS We reviewed the Computerized Patient Record System of the VA New York Harbor Health Care System to assess the 10-year occurrence of colorectal cancer in patients with gout undergoing colonoscopy, versus patients with osteoarthritis but no gout. RESULTS Gout and osteoarthritis subjects were similar in age, ethnicity, body mass index, and smoking history. Among 581 gout and 598 osteoarthritis subjects with documented colonoscopies, the 10-year prevalence of colorectal cancer was significantly lower in gout (0.8%) versus osteoarthritis (3.7%) (p = 0.0008) patients. Differences in colorectal cancer rates remained significant after stratifying for nonsteroidal anti-inflammatory drug use. Among gout subjects, use of colchicine and/or allopurinol, as well as the presence/absence of concomitant osteoarthritis, did not influence colorectal cancer occurrence. On subanalysis, differences in colorectal cancer occurrence between gout and osteoarthritis subjects persisted among those who underwent diagnostic (0.5% in gout vs 4.6% in osteoarthritis subjects, p < 0.001) but not screening (0.9% in gout subjects vs 1% in osteoarthritis subjects, p = 1.0) colonoscopy. There was no significant difference in nonmalignant colorectal polyp occurrence between gout and osteoarthritis subjects. CONCLUSIONS Subjects with gout had decreased colonoscopy-documented occurrence of colorectal cancer compared with osteoarthritis subjects, suggesting a possible protective effect.
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Affiliation(s)
- Anastasia Slobodnick
- From the Section of Rheumatology, VA New York Harbor Health Care System, New York Campus
- Crystal Diseases Study Group, Division of Rheumatology, New York University School of Medicine, New York, NY
| | - Svetlana Krasnokutsky
- From the Section of Rheumatology, VA New York Harbor Health Care System, New York Campus
- Crystal Diseases Study Group, Division of Rheumatology, New York University School of Medicine, New York, NY
| | - Robert A Lehmann
- From the Section of Rheumatology, VA New York Harbor Health Care System, New York Campus
- Crystal Diseases Study Group, Division of Rheumatology, New York University School of Medicine, New York, NY
| | - Robert T Keenan
- Division of Rheumatology, Duke University School of Medicine, Durham, NC
| | - Jonathan Quach
- Section of Gastroenterology, VA New York Harbor Health Care System, New York Campus
- Division of Gastroenterology, New York University School of Medicine, New York, NY
| | - Fritz Francois
- Section of Gastroenterology, VA New York Harbor Health Care System, New York Campus
- Division of Gastroenterology, New York University School of Medicine, New York, NY
| | - Michael H Pillinger
- From the Section of Rheumatology, VA New York Harbor Health Care System, New York Campus
- Crystal Diseases Study Group, Division of Rheumatology, New York University School of Medicine, New York, NY
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24
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Bravata DM, Myers LJ, Reeves M, Cheng EM, Baye F, Ofner S, Miech EJ, Damush T, Sico JJ, Zillich A, Phipps M, Williams LS, Chaturvedi S, Johanning J, Yu Z, Perkins AJ, Zhang Y, Arling G. Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke. JAMA Netw Open 2019; 2:e196716. [PMID: 31268543 PMCID: PMC6613337 DOI: 10.1001/jamanetworkopen.2019.6716] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. OBJECTIVE To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. MAIN OUTCOMES AND MEASURES Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. RESULTS Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. CONCLUSIONS AND RELEVANCE Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.
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Affiliation(s)
- Dawn M. Bravata
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Laura J. Myers
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Mathew Reeves
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Epidemiology, Michigan State University, East Lansing
| | - Eric M. Cheng
- Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
| | - Fitsum Baye
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Susan Ofner
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Edward J. Miech
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Teresa Damush
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Jason J. Sico
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Alan Zillich
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana
| | - Michael Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Linda S. Williams
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Jason Johanning
- Omaha Division, VA Nebraska-Western Iowa Health Care System, Omaha
- Department of Surgery, University of Nebraska, Lincoln
| | - Zhangsheng Yu
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Anthony J. Perkins
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Ying Zhang
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Greg Arling
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Purdue University School of Nursing, Lafayette, Indiana
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25
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Alexopoulos AS, Jackson GL, Edelman D, Smith VA, Berkowitz TSZ, Woolson SL, Bosworth HB, Crowley MJ. Clinical factors associated with persistently poor diabetes control in the Veterans Health Administration: A nationwide cohort study. PLoS One 2019; 14:e0214679. [PMID: 30925177 PMCID: PMC6440639 DOI: 10.1371/journal.pone.0214679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/18/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Patients with persistent poorly-controlled diabetes mellitus (PPDM) despite engagement in clinic-based care are at particularly high risk for diabetes complications and costs. Understanding this population's demographics, comorbidities and care utilization could guide strategies to address PPDM. We characterized factors associated with PPDM in a large sample of Veterans with type 2 diabetes. METHODS We identified a cohort of Veterans with medically treated type 2 diabetes, who received Veterans Health Administration primary care during fiscal years 2012 and 2013. PPDM was defined by hemoglobin A1c levels uniformly >8.5% during fiscal year (FY) 2012, despite engagement with care during this period. We used FY 2012 demographic, comorbidity and medication data to describe PPDM in relation to better-controlled diabetes patients and created multivariable models to examine associations between clinical factors and PPDM. We also constructed multivariable models to explore the association between PPDM and FY 2013 care utilization. RESULTS In our cohort of diabetes patients (n = 435,820), 12% met criteria for PPDM. Patients with PPDM were younger than better-controlled patients, less often married, and more often Black/African-American and Hispanic or Latino/Latina. Of included comorbidities, only retinopathy (OR 1.68, 95% confidence interval (CI): 1.63,1.73) and nephropathy (OR 1.26, 95% CI: 1.19,1.34) demonstrated clinically significant associations with PPDM. Complex insulin regimens such as premixed (OR 10.80, 95% CI: 10.11,11.54) and prandial-containing regimens (OR 18.74, 95% CI: 17.73,19.81) were strongly associated with PPDM. Patients with PPDM had higher care utilization, particularly endocrinology care (RR 3.56, 95% CI: 3.47,3.66); although only 26.4% of patients saw endocrinology overall. CONCLUSION PPDM is strongly associated with complex diabetes regimens, although heterogeneity in care utilization exists. While there is evidence of underutilization, inadequacy of available care may also contribute to PPDM. Our findings should inform tailored approaches to meet the needs of PPDM, who are among the highest-risk, highest-cost patients with diabetes.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Division of Endocrinology, Duke University, Durham, NC, United States of America
| | - George L. Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
| | - Theodore S. Z. Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Sandra L. Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Hayden B. Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
- Department of Psychiatry & Behavioral Sciences, Duke University, Durham NC, United States of America
| | - Matthew J. Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Division of Endocrinology, Duke University, Durham, NC, United States of America
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Toprover M, Crittenden DB, Modjinou DV, Oh C, Krasnokutsky S, Fisher MC, Keenan RT, Pillinger MH. Low-Dose Allopurinol Promotes Greater Serum Urate Lowering in Gout Patients with Chronic Kidney Disease Compared with Normal Kidney Function. Bull Hosp Jt Dis (2013) 2019; 77:87-91. [PMID: 31140959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Gout patients with chronic kidney disease (CKD) accumulate the active allopurinol metabolite oxypurinol, suggesting that allopurinol may promote greater serum urate (sU) lowering in CKD patients. METHODS We identified all patientswith gout diagnoses on either 100 mg or 300 mg of allopurinol daily, with available pre- and on-treatment sU levels, in our system in a 1-year period. Mean sU decrement by dosing per CKD groups was determined by CKD stage. RESULTS Of 1,288 subjects with gout, 180 met entry criteria, with 83 subjects receiving 100 mg and 97 receiving 300 mg allopurinol. Subjects with CKD stage 1 experienced less sU lowering with 100 mg than 300 mg of allopurinol. Subjects with stage 4 and 5 CKD had equivalent sU decreases across the 100 mg and 300 mg allopurinol groups. However, the 100 mg group started at a higher pre-treatment sU and ended at a higher final sU than the 300 mg group. CONCLUSIONS The strategy of titrating allopurinol to sU in patients with kidney impairment may result in greater sU lowering at lower doses than in patients without CKD but may also pose a treatment challenge from a possible drug ceiling effect.
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