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Bradley SM, Bohn CM, Malenka DJ, Graham MM, Bryson CL, McCabe JM, Curtis JP, Lambert-Kerzner A, Maynard C. Response to Letter Regarding Article, "Temporal Trends in Percutaneous Coronary Intervention Appropriateness: Insights From the Clinical Outcomes Assessment Program". Circulation 2016; 133:e424. [PMID: 26927015 DOI: 10.1161/circulationaha.115.019554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Chad M Bohn
- Dartmouth-Hitchcock Medical Center, Hanover, NH
| | | | - Michelle M Graham
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Chris L Bryson
- University of Washington, Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA
| | - James M McCabe
- University of Washington, Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, Yale University School of Medicine, New Haven, CT
| | | | - Charles Maynard
- University of Washington, Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA
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Lambert-Kerzner A, Havranek EP, Plomondon ME, Fagan KM, McCreight MS, Fehling KB, Williams DJ, Hamilton AB, Albright K, Blatchford PJ, Mihalko-Corbitt R, Bryson CL, Bosworth HB, Kirshner MA, Giacco EJD, Ho PM. Perspectives of patients on factors relating to adherence to post-acute coronary syndrome medical regimens. Patient Prefer Adherence 2015; 9:1053-9. [PMID: 26244013 PMCID: PMC4521673 DOI: 10.2147/ppa.s84546] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Poor adherence to cardioprotective medications after acute coronary syndrome (ACS) hospitalization is associated with increased risk of rehospitalization and mortality. Clinical trials of multifaceted interventions have improved medication adherence with varying results. Patients' perspectives on interventions could help researchers interpret inconsistent outcomes. Identifying factors that patients believe would improve adherence might inform the design of future interventions and make them more parsimonious and sustainable. The objective of this study was to obtain patients' perspectives on adherence to medical regimens after experiencing an ACS event and their participation in a medication adherence randomized control trial following their hospitalization. PATIENTS AND METHODS Sixty-four in-depth interviews were conducted with ACS patients who participated in an efficacious, multifaceted, medication adherence randomized control trial. Interview transcripts were analyzed using the constant comparative approach. RESULTS Participants described their post-ACS event experiences and how they affected their adherence behaviors. Patients reported that adherence decisions were facilitated by mutually respectful and collaborative provider-patient treatment planning. Frequent interactions with providers and medication refill reminder calls supported improved adherence. Additional facilitators included having social support, adherence routines, and positive attitudes toward an ACS event. The majority of patients expressed that being active participants in health care decision-making contributed to their health. CONCLUSION Our findings demonstrate that respectful collaborative communication can contribute to medication adherence after ACS hospitalization. These results suggest a potential role for training health-care providers, including pharmacists, social workers, registered nurses, etc, to elicit and acknowledge the patients' views regarding medication treatment in order to improve adherence. Future research is needed with providers to understand how they elicit and acknowledge patients' views, particularly in the face of nonadherence, and with patients to understand how to empower them to share their opinions with their providers.
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Affiliation(s)
- Anne Lambert-Kerzner
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Edward P Havranek
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
- Cardiology, Denver Health Medical Center, Denver, CO, USA
| | - Mary E Plomondon
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Katherine M Fagan
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
| | - Marina S McCreight
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
| | - Kelty B Fehling
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
| | - David J Williams
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Alison B Hamilton
- Health Services Research, Veterans Health Administration (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Karen Albright
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Patrick J Blatchford
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Renee Mihalko-Corbitt
- Internal Medicine, John L. McClellan Memorial Veterans Hospital, Little Rock, AR, USA
| | - Chris L Bryson
- Health Services Research, Veterans Health Administration (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Hayden B Bosworth
- Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Miriam A Kirshner
- Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Eric J Del Giacco
- Internal Medicine, John L. McClellan Memorial Veterans Hospital, Little Rock, AR, USA
| | - P Michael Ho
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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Bradley SM, Bohn CM, Malenka DJ, Graham MM, Bryson CL, McCabe JM, Curtis JP, Lambert-Kerzner A, Maynard C. Temporal Trends in Percutaneous Coronary Intervention Appropriateness: Insights From the Clinical Outcomes Assessment Program. Circulation 2015; 132:20-6. [PMID: 26022910 DOI: 10.1161/circulationaha.114.015156] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 04/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. METHODS AND RESULTS We applied appropriate use criteria to determine the appropriateness of all 51 872 PCI performed in Washington State from 2010 through 2013. We evaluated the number of PCIs performed from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Between 2010 and 2013, the overall number of PCI decreased by 6.8% (13 267 PCIs in 2010 to 12 193 in 2013) with a 43% decline in the number of PCIs for elective indications (3818 PCIs in 2010 to 2193 PCIs in 2013). The decline in the use of elective PCI was significantly larger after the onset of statewide PCI appropriateness assessment in 2010 (P=0.03). The proportion of elective PCIs classified as appropriate increased from 26% in 2010 to 38% in 2013, whereas the proportion of inappropriate PCIs decreased from 16% to 13% (P<0.001 for trends). Significant improvements in the proportion of inappropriate PCI were limited to the tertile of hospitals with the largest decline in PCIs classified as inappropriate (25% in 2010 to 12% in 2013; P=0.03). CONCLUSIONS In Washington State, the use of PCI for elective indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness.
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Affiliation(s)
- Steven M Bradley
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.).
| | - Chad M Bohn
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - David J Malenka
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Michelle M Graham
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Chris L Bryson
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - James M McCabe
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Jeptha P Curtis
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Anne Lambert-Kerzner
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
| | - Charles Maynard
- From VA Eastern Colorado Health Care System, Denver, and the University of Colorado School of Medicine, Aurora (S.M.B., A.L.-K.); Dartmouth-Hitchcock Medical Center, Hanover, NH (C.M.B., D.J.M.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.); University of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle (C.L.B., J.M.M.C.M.); and Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corp and the Yale University School of Medicine, CT (J.P.C.)
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Bradley SM, Bohn C, Malenka DJ, Graham MM, Bryson CL, McCabe JM, Curtis JP, Lambert-Kerzner A, Maynard C. Abstract 23: Temporal Trends in Percutaneous Coronary Intervention Appropriateness: Insights from the Clinical Outcomes Assessment Program. Circ Cardiovasc Qual Outcomes 2015. [DOI: 10.1161/circoutcomes.8.suppl_2.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
It is unknown if the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the rate of PCI use.
Methods:
We applied 2012 Appropriate Use Criteria to determine the appropriateness of all 51,872 PCI performed in Washington State from 2010 through 2013. PCI procedural rates were studied from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Procedural appropriateness and rates of use were determined separately for acute (ST segment elevation myocardial infarction, non-ST segment myocardial infarction, unstable angina) and elective (stable angina) indications.
Results:
Between 2010 and 2013, the overall rate of PCI decreased by 6.8% (13,267 PCI in 2010 to 12,193 in 2013) with a 43% decline in the rate of PCI for elective indications (3,818 PCI in 2010 to 2,193 PCI in 2013) (Figure). The rate of decline in elective PCI procedures was significantly larger following the onset of statewide PCI appropriateness assessment in 2010 (P = 0.03). The proportion of PCI for acute indications classified as appropriate remained >92% throughout the study period. The proportion of elective PCI classified as appropriate increased from 26% in 2010 to 38% in 2013 while the proportion of inappropriate PCI decreased from 16% to 13% (P<0.001 for trends) (Table). Improvements in the rate of inappropriate PCI were limited to the tertile of hospitals with the largest decline in PCI classified as inappropriate (25% in 2010 to 12% in 2013; P=0.03).
Conclusions:
In Washington State, the use of PCI for non-acute indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness.
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Affiliation(s)
- Steven M Bradley
- VA Eastern Colorado Health Care System and Univ of Colorado Sch of Medicine, Denver, CO
| | - Chad Bohn
- Dartmouth-Hitchcock Med Cntr, Hanover, NH
| | | | - Michelle M Graham
- Mazankowski Alberta Heart Institute, Univ of Alberta, Edmonton, Canada
| | - Chris L Bryson
- Univ of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA
| | - James M McCabe
- 4Univ of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA
| | - Jeptha P Curtis
- 5Cntr for Outcomes Rsch and Evaluation, Yale New Haven Health Services Corp and the Yale Univ Sch of Medicine, New Haven, CT
| | - Anne Lambert-Kerzner
- VA Eastern Colorado Health Care System and Univ of Colorado Sch of Medicine, Denver, CO
| | - Charles Maynard
- Univ of Washington and the Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA
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Marzec LN, Carey EP, Lambert-Kerzner AC, Del Giacco EJ, Melnyk SD, Bryson CL, Fahdi IE, Bosworth HB, Fiocchi F, Ho PM. Cognitive dysfunction and poor health literacy are common in veterans presenting with acute coronary syndrome: insights from the MEDICATION study. Patient Prefer Adherence 2015; 9:745-51. [PMID: 26089651 PMCID: PMC4467742 DOI: 10.2147/ppa.s75110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patient nonadherence to cardiac medications following acute coronary syndrome (ACS) is associated with increased risk of recurrent events. However, the prevalence of cognitive dysfunction and poor health literacy among ACS patients and their association with medication nonadherence are poorly understood. METHODS We assessed rates of cognitive dysfunction and poor health literacy among participants of a clinical trial that tested the effectiveness of an intervention to improve medication adherence in patients hospitalized with ACS. Of 254 patients, 249 completed the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) survey, an assessment of risk for poor literacy, and the St Louis University Mental Status (SLUMS) exam, a tool assessing for neurocognitive deficits, during ACS hospitalization. We assessed if SLUMS or REALM-R scores were associated with medication adherence. RESULTS Based on SLUMS score, 14% of patients were categorized as having dementia, and 52% with mild neurocognitive disorder (MNCD). Based on REALM-R score of ≤6, 34% of patients were categorized as at risk for poor health literacy. There was no association between poor health literacy and medication nonadherence. Of those with MNCD, 35.5% were nonadherent, compared to 17.5% with normal cognitive function and 6.7% with dementia. In multivariable analysis, cognitive dysfunction was associated with medication nonadherence (P=0.007), mainly due to an association between MNCD and nonadherence (odds ratio =12.2, 95% confidence interval =1.9 to 243; P=0.007). Cognitive status was not associated with adherence in patients randomized to the intervention. CONCLUSION Cognitive dysfunction and risk for poor health literacy are common in patients hospitalized with ACS. We found an association between MNCD and medication nonadherence in the usual care group but not in the intervention group. These findings suggest efforts to screen for MNCD are needed during ACS hospitalization to identify patients at risk for nonadherence and who may benefit from an adherence intervention.
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Affiliation(s)
- Lucas N Marzec
- Division of Cardiology, Denver VA Medical Center, Denver, CO, USA
- Correspondence: Lucas N Marzec, Academic Office 1, Room #7104, 12631 E 17th Avenue, Campus Box B-130, Aurora, CO 80045, USA, Tel +1 303 724 2105, Fax +1 303 724 2094, Email
| | - Evan P Carey
- Division of Cardiology, Denver VA Medical Center, Denver, CO, USA
| | | | - Eric J Del Giacco
- Department of Medicine, Little Rock VA Medical Center, Little Rock, AR, USA
| | | | - Chris L Bryson
- Department of Medicine, Puget Sound VA Medical Center, Seattle, WA, USA
| | - Ibrahim E Fahdi
- Department of Medicine, Little Rock VA Medical Center, Little Rock, AR, USA
| | | | - Fran Fiocchi
- American College of Cardiology, Washington, DC, USA
| | - P Michael Ho
- Division of Cardiology, Denver VA Medical Center, Denver, CO, USA
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Bradley SM, Spertus JA, Kennedy KF, Nallamothu BK, Chan PS, Patel MR, Bryson CL, Malenka DJ, Rumsfeld JS. Patient selection for diagnostic coronary angiography and hospital-level percutaneous coronary intervention appropriateness: insights from the National Cardiovascular Data Registry. JAMA Intern Med 2014; 174:1630-9. [PMID: 25156821 PMCID: PMC4276416 DOI: 10.1001/jamainternmed.2014.3904] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
IMPORTANCE Diagnostic coronary angiography in asymptomatic patients may lead to inappropriate percutaneous coronary intervention (PCI) due to a diagnostic-therapeutic cascade. Understanding the association between patient selection for coronary angiography and PCI appropriateness may inform strategies to minimize inappropriate procedures. OBJECTIVE To determine if hospitals that frequently perform coronary angiography in asymptomatic patients, a clinical scenario in which the benefit of angiography is less clear, are more likely to perform inappropriate PCI. DESIGN, SETTING, AND PARTICIPANTS Multicenter observational study of 544 hospitals participating in the CathPCI Registry between July 1, 2009, and September 30, 2013. MAIN OUTCOMES AND MEASURES Hospital proportion of asymptomatic patients at diagnostic coronary angiography and hospital rate of inappropriate PCI as defined by 2012 appropriate use criteria for coronary revascularization. RESULTS Of 1 225 562 patients who underwent elective coronary angiography, 308 083 (25.1%) were asymptomatic. The hospital proportion of angiography among asymptomatic patients ranged from 1.0% to 73.6% (median, 24.7%; interquartile range, 15.9%-35.9%). By hospital quartile of asymptomatic patients at angiography, hospitals with higher rates of asymptomatic patients at angiography had higher median rates of inappropriate PCI (14.8% vs 20.2% vs 24.0 vs 29.4% from lowest to highest quartile, P < .001 for trend). This outcome was attributable to more frequent use of inappropriate PCI in asymptomatic patients at hospitals with higher rates of angiography in asymptomatic patients (5.4% vs 9.9% vs 14.7% vs 21.6% from lowest to highest quartile, P < .001 for trend). Hospitals with higher rates of asymptomatic patients at angiography also had lower rates of appropriate PCI (38.7% vs 33.0% vs 32.3% vs 32.9% from lowest to highest quartile, P < .001 for trend). CONCLUSIONS AND RELEVANCE In a national sample of hospitals, performance of coronary angiography in asymptomatic patients was associated with higher rates of inappropriate PCI and lower rates of appropriate PCI. Improving preprocedural risk stratification and thresholds for coronary angiography may be one strategy to improve the appropriateness of PCI.
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Affiliation(s)
- Steven M Bradley
- Veterans Affairs Eastern Colorado Health Care System, Denver2University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora3Colorado Cardiovascular Outcomes Research Consortium, Denver
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City
| | | | - Paul S Chan
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City
| | | | | | | | - John S Rumsfeld
- Veterans Affairs Eastern Colorado Health Care System, Denver2University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora3Colorado Cardiovascular Outcomes Research Consortium, Denver
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Fagan KM, Lambert-Kerzner A, Carey EP, Del Giacco EJ, Mihalko-Corbitt R, Fahdi IE, Bosworth HB, Melnyk D, Bryson CL, Rumsfeld JS, Ho M. Abstract 112: Depression Does Not Predict Longitudinal Medication Adherence in an Acute Coronary Syndrome Population. Circ Cardiovasc Qual Outcomes 2014. [DOI: 10.1161/circoutcomes.7.suppl_1.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Prior studies have shown that depression may be associated with longitudinal medication non-adherence for patients with chronic cardiovascular disease. However, little is known about depression and medication adherence following acute coronary syndrome (ACS) hospitalization. Our objective was to assess whether depression was associated with longitudinal medication adherence following ACS among Veterans enrolled in a clinical trial designed to improve medication adherence.
Methods:
Patients included in the current analysis were enrolled in the MEDICATION study, which tested a multifaceted intervention versus usual care to improve medication adherence in the year following ACS hospitalization at 4 VA Medical Centers. Depression was assessed using the Patient Health Questionnaire (PHQ-9) prior to hospital discharge based on a score of ≥10. Medication adherence was assessed for 4 classes of cardioprotective medications (Statins, ACEI/ARBs, Clopidogrel, and Beta Blockers) in the 12-months following hospital discharge using pharmacy refill data. A proportion of days covered (PDC) was calculated based on the 4 classes of medications, and adherent patients were categorized based on a PDC ≥0.80. Then, we assessed the association between depression and medication adherence in the year after ACS hospitalization.
Results:
Of the 241 patients, the average age was 63.9 years, mean BMI was 30.9 kg/m
2
, and they had a number of comorbidities: 45.2% had diabetes and 65.6% had a history of coronary artery disease. The mean PHQ-9 score was 8.2 and 35.4% had depression (PHQ≥10) prior to discharge, with no difference in the prevalence of depression between treatment groups. In the year after ACS hospitalization, the mean PDC was 0.90 for all patients and there was no difference between depressed (PDC=0.91) and non-depressed patients (PDC=0.90). Among patients in the usual care group, there was also no difference in adherence between depressed (PDC=0.88) and non-depressed (PDC=0.86) patients.
Conclusions:
In this cohort of patients enrolled in a clinical trial, depression was present in 1 out of 3 patients during ACS hospitalization but not associated with medication adherence in the year after hospital discharge. A potential explanation for the lack of association between depression and adherence may be related to the overall high adherence rates found in the MEDICATION study. It will be important to assess whether depression is a marker of medication non-adherence in other ACS cohorts.
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Affiliation(s)
| | | | | | | | | | | | - Hayden B Bosworth
- Cntr for Health Services Rsch in Primary Care, Durham Veterans Affairs Med Cntr, Durham, NC
| | - Dee Melnyk
- Cntr for Health Services Rsch in Primary Care, Durham Veterans Affairs Med Cntr, Durham, NC
| | | | | | - Michael Ho
- Eastern Colorado Health Care System, Denver, CO
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Rittmueller SE, Frey MS, Williams EC, Sun H, Bryson CL, Bradley KA. Association between alcohol use and cardiovascular self-care behaviors among male hypertensive Veterans Affairs outpatients: a cross-sectional study. Subst Abus 2014; 36:6-12. [PMID: 24964087 DOI: 10.1080/08897077.2014.932318] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Alcohol use is associated with health behaviors that impact cardiovascular outcomes in patients with hypertension, including avoiding salt, exercising, weight management, and not smoking. This study examined associations between varying levels of alcohol use and self-reported cardiovascular health behaviors among hypertensive Veterans Affairs (VA) outpatients. METHODS Male outpatients with self-reported hypertension from 7 VA sites who returned mailed questionnaires (N = 11,927) were divided into 5 levels of alcohol use: nondrinking, low-level use, and mild, moderate, and severe alcohol misuse based on AUDIT-C (Alcohol Use Disorders Identification Test-Consumption) scores (0, 1-3, 4-5, 6-7, and 8-12, respectively). For each category, adjusted logistic regression models estimated the prevalence of patients who self-reported avoiding salt, exercising, controlling weight, or not smoking, and the composite of all four. RESULTS Increasing level of alcohol use was associated with decreasing prevalence of avoiding salt, controlling weight, not smoking, and the combination of all 4 behaviors (P values all <.001). A linear trend was not observed for exercise (P =.83), which was most common among patients with mild alcohol misuse (P =.01 relative to nondrinking). CONCLUSIONS Alcohol consumption is inversely associated with adherence to cardiovascular self-care behaviors among hypertensive VA outpatients. Clinicians should be especially aware of alcohol use level among hypertensive patients.
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Abstract
Background. Despite evidence demonstrating clinical benefits of oral hypoglycemic agents (OHAs), adherence to OHAs is generally poor. The economic benefit of OHA adherence among patients in the Veterans Affairs Health System (VA) is unknown. Objective. This study assessed the impact of OHA adherence on medical costs and hospitalization probability in a VA population. Methods. This retrospective cohort study included 26 051 VA patients with diabetes who completed the 2006 Survey of Health Care Experiences of Patients. We calculated total costs in fiscal year (FY) 2007 from the VA perspective as the sum of costs for all inpatient and outpatient services provided by VA. We measured adherence using the medication possession ratio (MPR), which reflected the proportion of days covered in FY2007. Patients were classified as adherent if MPR ≥80%. Analyses using instrumental variables (IVs) addressed potential biases from unobserved confounding. Results. On average, adherent patients incurred lower total medical costs ($4051 vs $5133, P < 0.001) and were less likely to be hospitalized (4.6% vs 7.2%, P < 0.001) compared with nonadherent patients. After covariate adjustment, adherence was associated with a $170 reduction in total costs ( P < 0.011) and a 1.5 percentage point decrease ( P < 0.001) in hospitalization probability. IV estimates indicated that the impacts of OHA adherence were larger in magnitude. Conclusion. On average, OHA adherence was associated with lower medical costs of at least $170 per patient over a 1-year period. Results from this study are important for informing policy decisions to broadly disseminate programs to promote diabetes medication adherence, particularly in a VA setting.
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Affiliation(s)
- Edwin S. Wong
- VA Puget Sound Health Care System, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Chris L. Bryson
- VA Puget Sound Health Care System, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Paul L. Hebert
- VA Puget Sound Health Care System, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Chuan-Fen Liu
- VA Puget Sound Health Care System, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
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Wong ES, Hebert PL, Maciejewski ML, Perkins M, Bryson CL, Au DH, Liu CF. Does Favorable Selection Among Medicare Advantage Enrollees Affect Measurement of Hospital Readmission Rates? Med Care Res Rev 2014; 71:367-83. [PMID: 24811933 DOI: 10.1177/1077558714533823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 03/13/2014] [Indexed: 11/16/2022]
Abstract
Literature indicates favorable selection among Medicare Advantage (MA) enrollees compared with fee-for-service (FFS) enrollees. This study examined whether favorable selection into MA affected readmission rates among Medicare-eligible veterans following hospitalization for congestive heart failure in the Veterans Affairs Health System (VA). We measured total (VA + Medicare FFS) 30-day all-cause readmission rates across hospitals and all of VA. We used Heckman's correction to adjust readmission rates to be representative of all Medicare-eligible veterans, not just FFS-enrolled veterans. The adjusted all-cause readmission rate among FFS veterans was 27.1% (95% confidence interval [CI] = 26.5% to 27.7%), while the adjusted readmission rate among Medicare-eligible veterans was 25.3% (95% CI = 23.6% to 27.1%) after correcting for favorable selection. Readmission rate estimates among FFS veterans generalize to all Medicare-eligible veterans only after accounting for favorable selection into MA. Estimation of quality metrics should carefully consider sample selection to produce valid policy inferences.
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Affiliation(s)
- Edwin S Wong
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | - Paul L Hebert
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | | | - Mark Perkins
- VA Puget Sound Health Care System, Seattle, WA, USA
| | - Chris L Bryson
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | - David H Au
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | - Chuan-Fen Liu
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
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Ho PM, Lambert-Kerzner A, Carey EP, Fahdi IE, Bryson CL, Melnyk SD, Bosworth HB, Radcliff T, Davis R, Mun H, Weaver J, Barnett C, Barón A, Del Giacco EJ. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge: a randomized clinical trial. JAMA Intern Med 2014; 174:186-93. [PMID: 24247275 DOI: 10.1001/jamainternmed.2013.12944] [Citation(s) in RCA: 177] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Adherence to cardioprotective medication regimens in the year after hospitalization for acute coronary syndrome (ACS) is poor. OBJECTIVE To test a multifaceted intervention to improve adherence to cardiac medications. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, 253 patients from 4 Department of Veterans Affairs medical centers located in Denver (Colorado), Seattle (Washington); Durham (North Carolina), and Little Rock (Arkansas) admitted with ACS were randomized to the multifaceted intervention (INT) or usual care (UC) prior to discharge. INTERVENTIONS The INT lasted for 1 year following discharge and comprised (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and a patient's primary care clinician and/or cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). MAIN OUTCOMES AND MEASURES The primary outcome of interest was proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) greater than 0.80 in the year after hospital discharge using pharmacy refill data for 4 cardioprotective medications (clopidogrel, β-blockers, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins], and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB]). Secondary outcomes included achievement of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) level targets. RESULTS Of 253 patients, 241 (95.3%) completed the study (122 in INT and 119 in UC). In the INT group, 89.3% of patients were adherent compared with 73.9% in the UC group (P = .003). Mean PDC was higher in the INT group (0.94 vs 0.87; P< .001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs 70.7%; P = .03), statins (93.2% vs 71.3%; P < .001), and ACEI/ARB (93.1% vs 81.7%; P = .03) but not β-blockers (88.1% vs 84.8%; P = .59). There were no statistically significant differences in the proportion of patients who achieved BP and LDL-C level goals. CONCLUSIONS AND RELEVANCE A multifaceted intervention comprising pharmacist-led medication reconciliation and tailoring, patient education, collaborative care between pharmacist and patients' primary care clinician and/or cardiologist, and voice messaging increased adherence to medication regimens in the year after ACS hospital discharge without improving BP and LDL-C levels. Understanding the impact of such improvement in adherence on clinical outcomes is needed prior to broader dissemination of the program. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00903032.
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Affiliation(s)
- P Michael Ho
- VA Eastern Colorado Health Care System, Denver2Department of Medicine, University of Colorado, Denver3Colorado Cardiovascular Outcomes Research Group, Denver
| | | | - Evan P Carey
- VA Eastern Colorado Health Care System, Denver4Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora
| | - Ibrahim E Fahdi
- John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas
| | | | - S Dee Melnyk
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina8School of Nursing, Duke University, Durham, North Carolina9Division of General Internal Medicine, Department of Medicine, Duke University
| | - Tiffany Radcliff
- Department of Health Policy and Management, Texas A&M School of Rural Public Health, College Station
| | - Ryan Davis
- VA Eastern Colorado Health Care System, Denver
| | - Howard Mun
- VA Puget Sound Health Care System, Seattle, Washington
| | - Jennifer Weaver
- John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas
| | - Casey Barnett
- John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas
| | - Anna Barón
- VA Eastern Colorado Health Care System, Denver4Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora
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Warren SA, Huszti E, Bradley SM, Chan PS, Bryson CL, Fitzpatrick AL, Nichol G. Adrenaline (epinephrine) dosing period and survival after in-hospital cardiac arrest: a retrospective review of prospectively collected data. Resuscitation 2013; 85:350-8. [PMID: 24252225 DOI: 10.1016/j.resuscitation.2013.10.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/21/2013] [Accepted: 10/02/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIM Expert guidelines for treatment of cardiac arrest recommend administration of adrenaline (epinephrine) every three to five minutes. However, the effects of different dosing periods of epinephrine remain unclear. We sought to evaluate the association between epinephrine average dosing period and survival to hospital discharge in adults with an in-hospital cardiac arrest (IHCA). METHODS We performed a retrospective review of prospectively collected data on 20,909 IHCA events from 505 hospitals participating in the Get With The Guidelines-Resuscitation (GWTG-R) quality improvement registry. Epinephrine average dosing period was defined as the time between the first epinephrine dose and the resuscitation endpoint, divided by the total number of epinephrine doses received subsequent to the first epinephrine dose. Associations with survival to hospital discharge were assessed by using generalized estimating equations to construct multivariable logistic regression models. RESULTS Compared to a referent epinephrine average dosing period of 4 to <5 min per dose, survival to hospital discharge was significantly higher in patients with the following epinephrine average dosing periods: for 6 to <7 min/dose, adjusted odds ratio [OR], 1.41 (95%CI: 1.12, 1.78); for 7 to <8 min/dose, adjusted OR, 1.30 (95%CI: 1.02, 1.65); for 8 to <9 min/dose, adjusted OR, 1.79 (95%CI: 1.38, 2.32); for 9 to <10 min/dose, adjusted OR, 2.17 (95%CI: 1.62, 2.92). This pattern was consistent for both shockable and non-shockable cardiac arrest rhythms. CONCLUSION Less frequent average epinephrine dosing than recommended by consensus guidelines was associated with improved survival of in-hospital cardiac arrest.
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Affiliation(s)
- Sam A Warren
- University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA, United States; Department of Medicine, Seattle, WA, United States; Department of Epidemiology, Seattle, WA, United States.
| | - Ella Huszti
- University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA, United States; Department of Medicine, Seattle, WA, United States
| | - Steven M Bradley
- Department of Medicine, Seattle, WA, United States; Health Services Research and Development Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
| | - Paul S Chan
- Saint Luke's Mid-America Heart and Vascular Institute, Kansas City, MO, United States; University of Missouri-Kansas City, Kansas City, MO, United States
| | - Chris L Bryson
- Department of Medicine, Seattle, WA, United States; Health Services Research and Development Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
| | - Annette L Fitzpatrick
- Department of Epidemiology, Seattle, WA, United States; University of Washington, Collaborative Health Studies Coordinating Center, United States; University of Washington, Department of Global Health, Seattle, WA, United States
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA, United States; Department of Medicine, Seattle, WA, United States; Clinical Trial Center, Department of Biostatistics, Seattle, WA, United States
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Berger D, Williams EC, Bryson CL, Rubinsky AD, Bradley KA. Alcohol questionnaires and HDL: screening scores as scaled markers of alcohol consumption. Alcohol 2013; 47:439-45. [PMID: 23886863 DOI: 10.1016/j.alcohol.2013.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 06/18/2013] [Accepted: 07/02/2013] [Indexed: 11/17/2022]
Abstract
Improving the quality of alcohol-related care requires practical approaches to assessing alcohol consumption to guide management and monitor outcomes. Given the increasing use of alcohol screening questionnaires to identify alcohol misuse it would be ideal if scores on screening questionnaires were also indicators of average alcohol consumption. However, the questionnaires were not designed for this purpose and include dimensions of drinking that may not reflect average consumption (e.g. heavy episodic drinking, alcohol-related problems). In a general population sample, scores on the AUDIT-C screen correlated with reports of alcohol consumption in detailed interviews, but the relationship is unknown for clinical populations and other questionnaires. Serum high-density lipoprotein cholesterol (HDL) is a biomarker routinely obtained in clinical care and is known to rise with average alcohol consumption. This cross-sectional study of 11,175 male U.S. Veterans Affairs patients enrolled in a primary care study used HDL as an objective biomarker to evaluate whether average alcohol consumption increased as scores increased on 3 brief alcohol screens - the AUDIT-C, AUDIT Question #3 (a single-item screen), and the CAGE questionnaire. Mean HDL progressively increased as screening scores increased for the AUDIT-C and AUDIT Question #3: about 12 mg/dL from the lowest to the highest scores. The association was much weaker for the CAGE questionnaire. Results were minimally affected by adjustment for covariates (e.g. age, race, medical comorbidity, smoking, medication count, and depression) but the association was modified (p = 0.008) and mildly attenuated by adherent use of lipid-lowering medications. This study using HDL as a biomarker of average alcohol consumption adds to evidence that some alcohol screening scores may also serve as scaled markers of average alcohol consumption.
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Affiliation(s)
- Douglas Berger
- General Medicine Service, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
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Abstract
BACKGROUND COPD and hypertension both increase the risk of congestive heart failure (CHF). Current clinical trials do not inform the selection of combination antihypertensive therapy among patients with COPD. We performed a comparative effectiveness study to investigate whether choice of dual agent antihypertensive therapy is associated with risk of hospitalization for CHF among patients with these two conditions. METHODS We identified a cohort of 7,104 patients with COPD and hypertension receiving care within Veterans Administration hospitals between January 2001 and December 2006, with follow-up through April 2009. We included only patients prescribed two antihypertensive medications. We used Cox proportional hazard models for statistical analysis. RESULTS Compared with β-blockers plus an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, patients prescribed a thiazide diuretic plus a β-blocker (adjusted hazard ratio [HR], 0.49; 95% CI, 0.32-0.75), a thiazide plus an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (adjusted HR, 0.50; 95% CI, 0.35-0.71), and a thiazide plus a calcium channel blocker (adjusted HR, 0.55; 95% CI, 0.35-0.88) had a significantly lower risk of hospitalization for CHF. After stratification by history of CHF, we found that this association was isolated to patients without a history of CHF. Adjustment for patient characteristics and comorbidities had a small effect on risk of hospitalization. Choice of antihypertensive medication combination had no significant association with risk of COPD exacerbation. CONCLUSIONS Among patients with comorbid hypertension and COPD requiring two antihypertensive agents, combination therapy that includes a thiazide diuretic was associated with a significantly lower risk of hospitalization for CHF among patients without a history of CHF.
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Affiliation(s)
- Melissa A Herrin
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA.
| | - Laura Cecere Feemster
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA; Division of Pulmonary and Critical Care Medicine, Seattle, WA
| | | | - Jane E Uman
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA
| | - Chris L Bryson
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA; Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - David H Au
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA; Division of Pulmonary and Critical Care Medicine, Seattle, WA
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Abstract
Patients who have access to different health care systems, such as Medicare-eligible veterans, may obtain services in either or both health systems. We examined whether quality of diabetes care was associated with care continuity or veterans’ usual source of primary care in a retrospective cohort study of 1,867 Medicare-eligible veterans with diabetes in 2001 to 2004. Underprovision of quality of diabetes care was more common than overprovision. In adjusted analyses, veterans who relied only on Medicare fee-for-service (FFS) for primary care were more likely to be underprovided HbA1c testing than veterans who relied only on Veteran Affairs (VA) for primary care. Dual users of VA and Medicare FFS primary care were significantly more likely to be overprovided HbA1c and microalbumin testing than VA-only users. VA and Medicare providers may need to coordinate more effectively to ensure appropriate diabetes care to Medicare-eligible veterans, because VA reliance was a stronger predictor than care continuity.
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Affiliation(s)
- Matthew L. Maciejewski
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - Virginia Wang
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - James F. Burgess
- Center for Organization, Leadership & Management Research, VA Boston Healthcare System, Boston, MA, USA
- Boston University, MA, USA
| | - Chris L. Bryson
- Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Mark Perkins
- Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA, USA
| | - Chuan-Fen Liu
- Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
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Bryson CL, Au DH, Maciejewski ML, Piette JD, Fihn SD, Jackson GL, Perkins M, Wong ES, Yano EM, Liu CF. Wide clinic-level variation in adherence to oral diabetes medications in the VA. J Gen Intern Med 2013; 28:698-705. [PMID: 23371383 PMCID: PMC3631064 DOI: 10.1007/s11606-012-2331-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 12/05/2012] [Accepted: 12/19/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND While there has been extensive research into patient-specific predictors of medication adherence and patient-specific interventions to improve adherence, there has been little examination of variation in clinic-level medication adherence. OBJECTIVE We examined the clinic-level variation of oral hypoglycemic agent (OHA) medication adherence among patients with diabetes treated in the Department of Veterans Affairs (VA) primary care clinics. We hypothesized that there would be systematic variation in clinic-level adherence measures, and that adherence within organizationally-affiliated clinics, such as those sharing local management and support, would be more highly correlated than adherence between unaffiliated clinics. DESIGN Retrospective cohort study. SETTING VA hospital and VA community-based primary care clinics in the contiguous 48 states. PATIENTS 444,418 patients with diabetes treated with OHAs and seen in 158 hospital-based clinics and 401 affiliated community primary care clinics during fiscal years 2006 and 2007. MAIN MEASURES Refill-based medication adherence to OHA. KEY RESULTS Adjusting for patient characteristics, the proportion of patients adherent to OHAs ranged from 57 % to 81 % across clinics. Adherence between organizationally affiliated clinics was high (Pearson Correlation = 0.82), and adherence between unaffiliated clinics was low (Pearson Correlation = 0.04). CONCLUSION The proportion of patients adherent to OHAs varied widely across VA primary care clinics. Clinic-level adherence was highly correlated to other clinics in the same organizational unit. Further research should identify which factors common to affiliated clinics influence medication adherence.
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Affiliation(s)
- Chris L Bryson
- Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Health Care System, Seattle, WA, USA.
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Bradley SM, Spertus JA, Nallamothu BK, Chan PS, Kennedy KF, Patel MR, Bryson CL, Malenka DJ, Rumsfeld JS. Abstract 1: The Association Between Patient Selection for Diagnostic Coronary Angiography and Hospital-Level PCI Appropriateness: Insights from the NCDR. Circ Cardiovasc Qual Outcomes 2013. [DOI: 10.1161/circoutcomes.6.suppl_1.a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background.
It is unknown if patient selection for diagnostic coronary angiography is associated with PCI quality as assessed by the Appropriate Use Criteria (AUC). We sought to determine if hospitals that frequently perform coronary angiography in asymptomatic patients, a clinical scenario where the benefit of angiography is less clear, are more likely to perform inappropriate PCI.
Methods.
We restricted our analyses to patients without known heart disease undergoing elective (non-acute) angiography or PCI at NCDR hospitals reporting at least 50 PCI procedures annually. As not all NCDR participating hospitals report diagnostic angiograms, we excluded hospitals reporting fewer diagnostic coronary angiograms than PCI. We identified 521,125 patients who underwent elective coronary angiography and 155,220 patients who underwent elective PCI at 553 hospitals reporting to the NCDR CathPCI Registry between July 2009 and June 2012. The association between hospital quartiles of the proportion of asymptomatic patients at angiography and the proportion of inappropriate PCI, per the 2012 AUC, was evaluated by Mantel-Haenszel trend test.
Results.
Overall, 132,613 patients (25.5%) who underwent coronary angiography were asymptomatic. The hospital proportion of asymptomatic patients at angiography ranged from 0.2% to 87.7%. Categorized as hospital quartiles, the median proportion of asymptomatic patients was 7.9% in hospitals of the lowest-quartile, 15.6% in the second lowest-quartile, 23.7% in the second highest-quartile and 35.5% in the highest-quartile. By hospital quartiles, the proportion of asymptomatic patients at angiography was significantly associated with the proportion of inappropriate PCI (median hospital proportion of inappropriate PCI; 17.7% vs. 22.6% vs. 26.5% vs. 28.9% from lowest to highest quartile, p<0.001 for trend; Figure 1).
Conclusions.
In a national sample of hospitals performing invasive coronary procedures, the proportion of coronary angiograms performed in asymptomatic patients was associated with the proportion of inappropriate PCI. Further study to clarify factors related to practice variability in processes of patient selection prior to the cardiac catheterization laboratory may optimize the use of both diagnostic angiography and PCI.
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Affiliation(s)
- Steven M Bradley
- VA Eastern Colorado Health Care System and Univ of Colorado - Denver, Denver, CO
| | - John A Spertus
- Saint Luke’s Mid America Heart Institute and Univ of Missouri, Kansas City, Kansas City, MO
| | | | - Paul S Chan
- Saint Luke’s Mid America Heart Institute and Univ of Missouri, Kansas City, Kansas City, MO
| | - Kevin F Kennedy
- Saint Luke’s Mid America Heart Institute and the Univ of Missouri, Kansas City, Kansas City, MO
| | | | - Chris L Bryson
- VA Puget Sound Health Care System and Univ of Washington, Seattle, WA
| | | | - John S Rumsfeld
- VA Eastern Colorado Health Care System and Univ of Colorado - Denver, Denver, CO
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Maynard C, Bradley SM, Bryson CL. The practice of transradial percutaneous coronary intervention in the Washington State Clinical Outcomes Assessment Program. Am Heart J 2013; 165:332-7. [PMID: 23453101 DOI: 10.1016/j.ahj.2012.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 09/25/2012] [Accepted: 11/11/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transradial percutaneous coronary intervention (tPCI) as opposed to the femoral approach (fPCI) is associated with lower rates of bleeding. The purposes of this study were to describe the use of tPCI in the Washington State Clinical Outcomes Assessment Program, identify the predictors of bleeding, and determine whether tPCI was associated with less bleeding in women vs men, age <75 years vs ≥75 years, and baseline creatinine <2.0 mg/dL vs ≥2.0 mg/dL. METHODS This study included 23,599 individuals who had a first tPCI or fPCI performed in 30 centers in Washington State in 2010 and 2011. Data were collected according to specifications from the American College of Cardiology National Cardiovascular Data Registry Cath-PCI version 4.3. The American College of Cardiology National Cardiovascular Data Registry bleeding model was used to calculate adjusted rates. RESULTS Transradial percutaneous coronary intervention was used in only 5% of procedures, and in just 3 centers, tPCI was used in >10% of cases. Patient demographics and medical histories were similar in tPCI and fPCI, although the percent of acute cases was higher in fPCI (68% vs 45%, P < .0001). The overall bleeding rate was 2.2%, and the 3 most important predictors of bleeding were acute procedure, women, and age ≥75 years. For women, unadjusted rates of bleeding were 1.4% for tPCI and 4.0% for fPCI (P = .013). Among women, adjusted rates were almost 20% lower for tPCI (3.3% vs 4.1%). CONCLUSION In Washington State, tPCI was used infrequently, although it was associated with lower bleeding rates in high-risk groups including women.
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Abstract
PURPOSE We examined how the choice of historic medication use criteria for identifying prevalent users may bias estimated adherence changes associated with a medication copayment increase. METHODS From pharmacy claims data in a retrospective cohort study, we identified 6,383 prevalent users of oral diabetes medications from four VA Medical Centers. Patients were included in this prevalent cohort if they had one fill both 3 months prior and 4-12 months prior to the index date, defined as the month in which medication copayments increased. To determine whether these historic medication use criteria introduced bias in the estimated response to a $5 medication copayment increase, we compared adherence trends from cohorts defined from different medication use criteria and from different index dates of copayment change. In an attempt to validate the prior observation of an upward trend in adherence prior to the date of the policy change, we replicated time series analyses varying the index dates prior to and following the date of the policy change, hypothesizing that the trend line associated with the policy change would differ from the trend lines that were not. RESULTS Medication adherence trends differed when different medication use criteria were applied. Contrary to our expectations, similar adherence trends were observed when the same medication use criteria were applied at index dates when no copayment changes occurred. CONCLUSION To avoid introducing bias due to study design in outcomes assessments of medication policy changes, historic medication use inclusion criteria must be chosen carefully when constructing cohorts of prevalent users. Furthermore, while pharmacy data have enormous potential for population research and monitoring, there may be inherent logical flaws that limit cohort identification solely through administrative pharmacy records.
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Affiliation(s)
- Matthew L Maciejewski
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC 27705, USA.
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Kocarnik BM, Liu CF, Wong ES, Perkins M, Maciejewski ML, Yano EM, Au DH, Piette JD, Bryson CL. Does the presence of a pharmacist in primary care clinics improve diabetes medication adherence? BMC Health Serv Res 2012; 12:391. [PMID: 23148570 PMCID: PMC3537712 DOI: 10.1186/1472-6963-12-391] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 11/04/2012] [Indexed: 11/30/2022] Open
Abstract
Background Although oral hypoglycemic agents (OHAs) are an essential element of therapy for the management of type 2 diabetes, OHA adherence is often suboptimal. Pharmacists are increasingly being integrated into primary care as part of the move towards a patient-centered medical home and may have a positive influence on medication use. We examined whether the presence of pharmacists in primary care clinics was associated with higher OHA adherence. Methods This retrospective cohort study analyzed 280,603 diabetes patients in 196 primary care clinics within the Veterans Affairs healthcare system. Pharmacists presence, number of pharmacist full-time equivalents (FTEs), and the degree to which pharmacy services are perceived as a bottleneck in each clinic were obtained from the 2007 VA Clinical Practice Organizational Survey—Primary Care Director Module. Patient-level adherence to OHAs using medication possession ratios (MPRs) were constructed using refill data from administrative pharmacy databases after adjusting for patient characteristics. Clinic-level OHA adherence was measured as the proportion of patients with MPR >= 80%. We analyzed associations between pharmacy measures and clinic-level adherence using linear regression. Results We found no significant association between pharmacist presence and clinic-level OHA adherence. However, adherence was lower in clinics where pharmacy services were perceived as a bottleneck. Conclusions Pharmacist presence, regardless of the amount of FTE, was not associated with OHA medication adherence in primary care clinics. The exact role of pharmacists in clinics needs closer examination in order to determine how to most effectively use these resources to improve patient-centered outcomes including medication adherence.
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Affiliation(s)
- Beverly Mielke Kocarnik
- Division of General Internal Medicine, University of Washington, 329 NinthAve, Campus Box 359780, Seattle, WA 98104, USA
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Thomas RM, Francis Gerstel PA, Williams EC, Sun H, Bryson CL, Au DH, Bradley KA. Association between alcohol screening scores and diabetic self-care behaviors. Fam Med 2012; 44:555-563. [PMID: 22930120] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Alcohol misuse is associated with poor adherence to recommended self-care behaviors, which are critical for diabetes management. This study investigated whether scores on a validated brief alcohol misuse screen are associated with diabetes self-care. METHODS Male outpatients (n=3,930) from seven Veterans Affairs sites returned the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) alcohol screen on mailed surveys and indicated they had diabetes. Patients were divided into five alcohol screening groups: no past year alcohol use (AUDIT-C 0), low-level alcohol use (AUDIT-C 1-3); and mild (AUDIT-C 4-5), moderate (AUDIT-C 6-7), and severe (AUDIT-C 8-12) misuse. Outcomes included self-report of monitoring blood glucose, maintaining normal blood glucose levels, inspecting feet, following a meal plan, not smoking, and laboratory data indicating that glycosylated hemoglobin A1c (HbA1c) had been tested in the past year. For each group, the proportion of patients adherent to each behavior were estimated from logistic regression models adjusted for demographics, comorbidity, and depressive symptoms. RESULTS Patients who did not drink were most likely to report adherence to self-care behaviors, except for past-year HbA1c testing. Compared to patients who did not drink, patients with AUDIT-C scores ?6 were significantly less likely to report maintaining normal blood glucose levels (eg, AUDIT-C 6-7 44% versus AUDIT-C 0 59%) or following a meal plan (48% versus 58%), and were more likely to smoke (71% abstained versus 85%) in adjusted analyses. CONCLUSIONS Results of this study indicate that higher alcohol screening scores are associated with poorer diabetes self-care.
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Affiliation(s)
- Rachel M Thomas
- Health Services Research and Development Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA 98101, USA.
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Bradley KA, Rubinsky AD, Sun H, Blough DK, Tønnesen H, Hughes G, Beste LA, Bishop MJ, Hawn MT, Maynard C, Harris AS, Hawkins EJ, Bryson CL, Houston TK, Henderson WG, Kivlahan DR. Prevalence of alcohol misuse among men and women undergoing major noncardiac surgery in the Veterans Affairs health care system. Surgery 2012; 152:69-81. [DOI: 10.1016/j.surg.2012.02.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 02/09/2012] [Indexed: 12/01/2022]
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Lambert-Kerzner A, Del Giacco EJ, Fahdi IE, Bryson CL, Melnyk SD, Bosworth HB, Davis R, Mun H, Weaver J, Barnett C, Radcliff T, Hubbard A, Bosket KD, Carey E, Virchow A, Mihalko-Corbitt R, Kaufman A, Marchant-Miros K, Ho PM. Patient-Centered Adherence Intervention After Acute Coronary Syndrome Hospitalization. Circ Cardiovasc Qual Outcomes 2012; 5:571-6. [DOI: 10.1161/circoutcomes.111.962290] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Adherence to cardioprotective medications in the year after acute coronary syndrome hospitalization is generally poor and is associated with increased risk of rehospitalization and mortality. Few interventions have specifically targeted this high-risk patient population to improve medication adherence. We hypothesize that a multifaceted patient-centered intervention could improve adherence to cardioprotective medications.
Methods and Results—
To evaluate this intervention, we propose enrolling 280 patients with a recent acute coronary syndrome event into a multicenter randomized, controlled trial. The intervention comprises4 main components: (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and primary care provider/cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). Patients in the intervention arm will visit with the study pharmacist ≈1 week post-hospital discharge. The pharmacist will work with the patient and collaborate with providers to reconcile medication issues. Voice messages will augment the educational process and remind patients to refill their cardioprotective medications. The study will compare the intervention versus usual care for 12 months. The primary outcome of interest is adherence using the ReComp method. Secondary and tertiary outcomes include achievement of targets for blood pressure and low-density lipoprotein, and reduction in the combined cardiovascular end points of myocardial infarction hospitalization, coronary revascularization, and all-cause mortality. Finally, we will also evaluate the cost-effectiveness of the intervention compared with usual care.
Conclusions—
If the intervention is effective in improving medication adherence and demonstrating a lower cost, the intervention has the potential to improve cardiovascular outcomes in this high-risk patient population.
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Affiliation(s)
- Anne Lambert-Kerzner
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Eric J. Del Giacco
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Ibrahim E. Fahdi
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Chris L. Bryson
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - S. Dee Melnyk
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Hayden B. Bosworth
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Ryan Davis
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Howard Mun
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Jennifer Weaver
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Casey Barnett
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Tiffany Radcliff
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Amanda Hubbard
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Kevin D. Bosket
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Evan Carey
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Allison Virchow
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Renee Mihalko-Corbitt
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Amy Kaufman
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - Kathy Marchant-Miros
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
| | - P. Michael Ho
- From the Denver VA Medical Center, Denver, CO (A.L.-K., R.D., T.R., E.C., A.V., M.H.); Little Rock VA Medical Center, Little Rock, AR (E.J., I.E.F., J.W., C.B., A.H., R.M.-C., K.M.-M.); Puget Sound VA Medical Center, Seattle, WA (C.L.B., H.M., K.D.B.); Durham VA Medical Center, Durham, NC (S.D.M., H.B.B., A.K.)
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Abstract
BACKGROUND In anticipation of applying Appropriate Use Criteria for percutaneous coronary intervention (PCI) quality improvement, we determined the prevalence of appropriate, uncertain, and inappropriate PCIs stratified by indication for all PCIs performed in the state of Washington. METHODS AND RESULTS Within the Clinical Outcomes Assessment Program, we assigned appropriateness ratings to all PCIs performed in 2010 in accordance with published Appropriate Use Criteria. Of 13 291 PCIs, we successfully mapped the clinical scenario to the Appropriate Use Criteria in 9924 (75%) cases. Of the 3367 PCIs not classified, common failures to map to the criteria included nonacute PCI without prior noninvasive stress results (n = 1906; 57%) and unstable angina without high-risk features (n = 902; 27%). Of mapped PCIs, 8010 (71%) were for acute indications, with 7887 (98%) rated as appropriate, 39 (<1%) as uncertain, and 84 (1%) as inappropriate. Of 1914 mapped nonacute indications, 847 (44%) were rated as appropriate, 748 (39%) as uncertain, and 319 (17%) as inappropriate. Assuming results for noninvasive stress tests when data were missing, in the best-case scenario, 319 (8%) of nonacute PCIs were classified as inappropriate compared with 1459 (38%) in the worst-case scenario. Variation in inappropriate PCIs by facility was greatest for mapped nonacute indications (median = 14%; 25(th) to 75(th) percentiles = 9% to 24%) and nonacute indications with missing data precluding appropriateness classification (median = 54%; 25(th) to 75(th) percentiles = 35% to 66%). CONCLUSIONS In a complete cohort of PCIs performed in Washington state, 1% of PCIs for acute indications and 17% of PCIs for nonacute indications were classified as inappropriate. Missing data on noninvasive stress tests present a challenge in the application of the criteria for quality improvement.
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Cecere LM, Slatore CG, Uman JE, Evans LE, Udris EM, Bryson CL, Au DH. Adherence to long-acting inhaled therapies among patients with chronic obstructive pulmonary disease (COPD). COPD 2012; 9:251-8. [PMID: 22497533 DOI: 10.3109/15412555.2011.650241] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Long-acting inhaled medications are an important component of the treatment of patients with chronic obstructive pulmonary disease (COPD), yet few studies have examined the determinants of medication adherence among this patient population. OBJECTIVE We sought to identify factors associated with adherence to long-acting beta-agonists (LABA) and inhaled corticosteroids (ICS) among patients with COPD. METHODS We performed secondary analysis of baseline data collected in a randomized trial of 376 Veterans with spirometrically confirmed COPD. We used electronic pharmacy records to assess adherence, defined as a medication possession ratio of ≥0.80. We investigated the following exposures: patient characteristics, disease severity, medication regimen complexity, health behaviors, confidence in self-management, and perceptions of provider skill. We performed multivariable logistic regression, clustered by provider, to estimate associations. RESULTS Of the 167 patients prescribed LABA, 54% (n = 90) were adherent to therapy while only 40% (n = 74) of 184 the patients prescribed ICS were adherent. Higher adherence to LABA and ICS was associated with patient perception of their provider as being an "expert" in diagnosing and managing lung disease [For LABA: OR = 21.70 (95% CI 6.79, 69.37); For ICS OR = 7.93 (95% CI 1.71, 36.67)]. Factors associated with adherence to LABA, but not ICS, included: age, education, race, COPD severity, smoking status, and confidence in self-management. CONCLUSIONS Adherence to long-acting inhaled medications among patients with COPD is poor, and determinants of adherence likely differ by medication class. Patient perception of clinician expertise in lung disease was the factor most highly associated with adherence to long-acting therapies.
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Affiliation(s)
- Laura M Cecere
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington 98101, USA.
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26
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27
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Abstract
Background.
The use of percutaneous coronary intervention (PCI) has increased dramatically in the past decade despite uncertainty regarding the appropriateness of these procedures. Methods. Within the Clinical Outcomes Assessment Program (COAP), a quality-improvement initiative that captures all revascularization procedures performed in Washington State, we assessed the appropriateness of PCI performed between June 2009 and September 2010 in accordance with published Appropriate Use Criteria. We report the appropriateness of PCI stratified by acute (acute myocardial infarction or unstable angina with high-risk features) or non-acute (stable angina) coronary presentation.
Results.
Of 12,528 PCI performed during the study period, we successfully mapped the PCI indication to the Appropriate Use Criteria in 9,025 (72%) of cases. Of the 3,521 PCI not classified, common failures to map to the criteria included acute PCI of multiple lesions without evidence of shock (n=517, 14.7%), unstable angina without high-risk features (n=918, 26.1%), or non-acute PCI without preprocedural non-invasive stress results (n=2,049, 58.2%). Of mapped PCI, 7,031 (77.9%) were for acute indications with 6,921 (98.4%) rated as “appropriate”, 40 (0.6%) as “uncertain”, and 70 (1.0%) as “inappropriate”. Of 1,987 non-acute coronary presentations, 788 (39.7%) were rated as appropriate, 812 (40.9%) as uncertain, and 387 (19.5%) as inappropriate (Table). Assuming non-acute PCI with missing data on non-invasive stress test were performed in the setting of high-risk non-invasive stress testing, 387 (9.8%) PCI were inappropriate.
Conclusion.
In a complete cohort of PCI performed in Washington State, 1.0% of PCI for acute indications and 9.8% of PCI for non-acute indications were classified as inappropriate after assumptions to maximize appropriateness. These findings suggest an opportunity to improve the selection of patients undergoing PCI to maximize anticipated benefit.
TABLE 1
Appropriateness of PCI in Washington State
PCI Indication
Total Cases
Appropriateness Rating by Indication, n (%)
Appropriate
Uncertain
Inappropriate
All PCI
9018
7708 (85.4)
853 (9.5)
464 (4.7)
Acute presentation
7031
6921 (98.4)
40 (0.6)
70 (1.0)
Non-acute presentation
1987
788 (39.7)
812 (40.9)
387 (19.5)
Acute presentation includes STEMI, NSTEMI, and unstable angina with high risk features. Non-acute presentation is limited to stable angina.
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Affiliation(s)
- Steven M Bradley
- VA Puget Sound Health Care System, Univ of Washington, Seattle, WA
| | - Charles Maynard
- VA Puget Sound Health Care System, Univ of Washington, Seattle, WA
| | - Chris L Bryson
- VA Puget Sound Health Care System, Univ of Washington, Clinical Outcomes Assessment Program, Seattle, WA
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Cecere LM, Littman AJ, Slatore CG, Udris EM, Bryson CL, Boyko EJ, Pierson DJ, Au DH. Obesity and COPD: associated symptoms, health-related quality of life, and medication use. COPD 2011; 8:275-84. [PMID: 21809909 PMCID: PMC3169653 DOI: 10.3109/15412555.2011.586660] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND There is little data about the combined effects of COPD and obesity. We compared dyspnea, health-related quality of life (HRQoL), exacerbations, and inhaled medication use among patients who are overweight and obese to those of normal weight with COPD. METHODS We performed secondary data analysis on 364 Veterans with COPD. We categorized subjects by body mass index (BMI). We assessed dyspnea using the Medical Research Council (MRC) dyspnea scale and HRQoL using the St. George's Respiratory Questionnaire. We identified treatment for an exacerbation and inhaled medication use in the past year. We used multiple logistic and linear regression models as appropriate, with adjustment for age, COPD severity, smoking status, and co-morbidities. RESULTS The majority of our population was male (n = 355, 98%) and either overweight (n = 115, 32%) or obese (n = 138, 38%). Obese and overweight subjects had better lung function (obese: mean FEV(1) 55.4% ±19.9% predicted, overweight: mean FEV(1) 50.0% ±20.4% predicted) than normal weight subjects (mean FEV(1) 44.2% ±19.4% predicted), yet obese subjects reported increased dyspnea [adjusted OR of MRC score ≥2 = 4.91 (95% CI 1.80, 13.39], poorer HRQoL, and were prescribed more inhaled medications than normal weight subjects. There was no difference in any outcome between overweight and normal weight patients. CONCLUSIONS Despite having less severe lung disease, obese patients reported increased dyspnea and poorer HRQoL than normal weight patients. The greater number of inhaled medications prescribed for obese patients may represent overuse. Obese patients with COPD likely need alternative strategies for symptom control in addition to those currently recommended.
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Affiliation(s)
- Laura M Cecere
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
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29
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Williams EC, Bryson CL, Sun H, Chew RB, Chew LD, Blough DK, Au DH, Bradley KA. Association between Alcohol Screening Results and Hospitalizations for Trauma in Veterans Affairs Outpatients. The American Journal of Drug and Alcohol Abuse 2011; 38:73-80. [DOI: 10.3109/00952990.2011.600392] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Emily C. Williams
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington,
Seattle, WA, USA
| | - Chris L. Bryson
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington,
Seattle, WA, USA
| | - Haili Sun
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Ryan B. Chew
- Overlake Hospitalist Practice, Overlake Hospital Medical Center,
Bellevue, WA, USA
| | - Lisa D. Chew
- Department of Medicine, University of Washington,
Seattle, WA, USA
- Adult Medicine Clinic, Harborview Medical Center,
Seattle, WA, USA
| | - David K. Blough
- Department of Pharmacy, University of Washington,
Seattle, WA, USA
| | - David H. Au
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington,
Seattle, WA, USA
| | - Katharine A. Bradley
- Health Services Research & Development (HSR&D) Northwest Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington,
Seattle, WA, USA
- Department of Medicine, University of Washington,
Seattle, WA, USA
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30
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Bradley SM, Bryson CL, Maynard C, Maddox TM, Fihn SD. Recent hospitalization for non-coronary events and use of preventive medications for coronary artery disease: an observational cohort study. BMC Cardiovasc Disord 2011; 11:42. [PMID: 21740591 PMCID: PMC3146403 DOI: 10.1186/1471-2261-11-42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 07/09/2011] [Indexed: 11/16/2022] Open
Abstract
Background High-quality systems have adopted a comprehensive approach to preventive care instead of diagnosis or procedure driven care. The current emphasis on prescribing medications to prevent complications of coronary artery disease (CAD) at discharge following an acute coronary syndrome (ACS) may exclude high-risk patients who are hospitalized with conditions other than ACS. Methods Among a sample of patients with CAD treated at Veterans Affairs medical centers between January, 2005 and November, 2006, we investigated whether recent non-ACS hospitalization was associated with prescriptions of preventive medications as compared with patients recently hospitalized with ACS. Results Of 13,211 patients with CAD, 58% received aspirin, 70% β-blocker, 60% angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB), and 65% lipid-lowering therapy. Twenty-five percent of eligible patients were receiving all four medications. Having been hospitalized for a non-ACS event in the prior 6 months did not substantially affect the adjusted proportion on preventive medications. In contrast, among patients hospitalized for ACS in the prior 6 months, the adjusted proportion prescribed aspirin was 21% higher (p < 0.001), β-blocker was 14% higher (p < 0.001), ACE-I or ARB was 9% higher (p < 0.001), lipid therapy was 12% higher (p < 0.001), and prescribed all four medications was 18% higher (p < 0.001) than among patients hospitalized for ACS more than 2 years earlier. Conclusions Being hospitalized for a non-ACS condition did not appear to influence preventive medication use among patients with CAD and represents a missed opportunity to improve patient care. The same protocols employed to improve use of preventive medications in patients discharged for ACS might be extended to CAD patients discharged for other conditions as well.
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Affiliation(s)
- Steven M Bradley
- Health Services Research & Development Northwest Center of Excellence, Veterans Affairs Puget Sound Health Care System, and University of Washington, Seattle, WA, USA.
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31
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Chew RB, Bryson CL, Au DH, Maciejewski ML, Bradley KA. Are smoking and alcohol misuse associated with subsequent hospitalizations for ambulatory care sensitive conditions? J Behav Health Serv Res 2011; 38:3-15. [PMID: 20464519 DOI: 10.1007/s11414-010-9215-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hospitalizations for ambulatory care sensitive conditions (ACSCs) are used to assess quality of care, but studies rarely adjust for health behaviors. This study evaluated whether results of smoking or alcohol screening were associated with hospitalizations for ACSCs. Participants included 33,273 male Veterans Affairs general medicine outpatients who returned mailed surveys. The main outcome was hospitalization with a primary discharge diagnosis for an ACSC in the year following screening. Analyses were adjusted for demographics, comorbidity, and other health behaviors. Current and previous smoking and abstaining from alcohol were associated with significantly increased risk of hospitalization for ACSCs, but alcohol misuse was not. However, severe alcohol misuse was associated with increased risk of hospitalizations with a primary or secondary ACSC discharge diagnosis. When ACSCs are used to evaluate the quality of care, health systems caring for populations with higher rates of smoking or nondrinking could falsely appear to have poorer quality care if alcohol and tobacco use are not considered.
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Affiliation(s)
- Ryan B Chew
- VA Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA 98101, USA.
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Burgess JF, Maciejewski ML, Bryson CL, Chapko M, Fortney JC, Perkins M, Sharp ND, Liu CF. Importance of health system context for evaluating utilization patterns across systems. Health Econ 2011; 20:239-251. [PMID: 20169587 DOI: 10.1002/hec.1588] [Citation(s) in RCA: 32] [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] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Measuring health services provided to patients can be difficult when patients see providers across multiple health systems and all visits are rarely captured in a single data source covering all systems where patients receive care. Studies that account for only one system will omit the out-of-system health-care use at the patient level. Combining data across systems and comparing utilization patterns across health systems creates complications for both aggregation and accuracy because data-generating processes (DGPs) tend to vary across systems. We develop a hybrid methodology for aggregation across systems, drawing on the strengths of the DGP in each system, and demonstrate its validity for answering research questions requiring cross-system assessments of health-care utilization. Positive and negative predictive probabilities can be useful to assess the impact of the hybrid methodology. We illustrate these issues comparing public sector (administrative records from the US Department of Veterans Affairs system) and private sector (billing records from the US Medicare system) patient level data to identify primary-care utilization. Understanding the context of a particular health system and its effect on the DGP is important in conducting effective valid evaluations.
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Affiliation(s)
- James F Burgess
- Center for Organization, Leadership and Management Research, Department of Veterans Affairs, Boston, MA, USA.
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Bradley KA, Rubinsky AD, Sun H, Bryson CL, Bishop MJ, Blough DK, Henderson WG, Maynard C, Hawn MT, Tønnesen H, Hughes G, Beste LA, Harris AHS, Hawkins EJ, Houston TK, Kivlahan DR. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. J Gen Intern Med 2011; 26:162-9. [PMID: 20878363 PMCID: PMC3019325 DOI: 10.1007/s11606-010-1475-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed. OBJECTIVE To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire-up to a year before surgery-were associated with the risk of postoperative complications. DESIGN This is a cohort study. SETTING AND PARTICIPANTS Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA's Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery. MAIN OUTCOME MEASURE One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews. RESULTS Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8-6.6%) in patients with AUDIT-C scores 1-4, to 7.9% (6.3-9.7%) in patients with AUDIT-Cs 5-8, 9.7% (6.6-14.1%) in patients with AUDIT-Cs 9-10 and 14.0% (8.9-21.3%) in patients with AUDIT-Cs 11-12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1-5.7%) in patients with AUDIT-C scores 1-4, to 6.9% (5.5-8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0-11.3%) among those with AUDIT-Cs 9-10. CONCLUSIONS AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.
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Affiliation(s)
- Katharine A Bradley
- Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA 98101, USA.
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Liu CF, Chapko M, Bryson CL, Burgess JF, Fortney JC, Perkins M, Sharp ND, Maciejewski ML. Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. Health Serv Res 2010; 45:1268-86. [PMID: 20831716 DOI: 10.1111/j.1475-6773.2010.01123.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients. DATA SOURCES/STUDY SETTING VA administrative and Medicare claims data from 2001 to 2004. STUDY DESIGN Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients. PRINCIPAL FINDINGS A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3-4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80). CONCLUSIONS Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care.
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Affiliation(s)
- Chuan-Fen Liu
- Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, HSR&D, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Slatore CG, Cecere LM, Reinke LF, Ganzini L, Udris EM, Moss BR, Bryson CL, Curtis JR, Au DH. Patient-clinician communication: associations with important health outcomes among veterans with COPD. Chest 2010; 138:628-34. [PMID: 20299633 DOI: 10.1378/chest.09-2328] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND High quality patient-clinician communication is widely advocated, but little is known about which health outcomes are associated with communication for patients with COPD. METHODS Using a cross-sectional study of 342 veterans enrolled in a randomized controlled trial, we evaluated the association of communication, measured with the quality of communication (QOC) instrument, with subject-reported quality of clinician care, breathing problem confidence, and general self-rated health. We measured these associations using general estimating equations and adjusted odds ratios (OR) of patient-reported outcomes associated with one-point changes in QOC scores. RESULTS Nearly one-half of the subjects reported receiving the best imaginable care (47%), whereas fewer reported being confident with their breathing problems all the time (29%) or in very good or excellent health (15%). General communication was associated with best-imagined quality of care (OR, 4.29; 95% CI, 2.84-6.48; P < .001) and confidence in dealing with breathing problems all the time (OR, 1.74; 95% CI, 1.34-2.25; P < .001) but not general self-rated health (OR, 1.19; 95% CI, 0.92-1.55; P = .19). Specific clinician behaviors with larger associations with higher quality care included listening, caring, and attentiveness. The associations between general communication and quality care increased over time (P for interaction .03). CONCLUSIONS Communication between patients and clinicians is associated with quality of care and confidence in dealing with breathing problems, and this association may change over time. Attention to specific communication strategies may lead to improvements in the care of patients with COPD.
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Affiliation(s)
- Christopher G Slatore
- Health Services Research and Development, Portland Veterans Affairs Medical Center, Portland, OR 97239, USA.
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Maciejewski ML, Bryson CL, Perkins M, Blough DK, Cunningham FE, Fortney JC, Krein SL, Stroupe KT, Sharp ND, Liu CF. Increasing copayments and adherence to diabetes, hypertension, and hyperlipidemic medications. Am J Manag Care 2010; 16:e20-e34. [PMID: 20059288] [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] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To examine the impact of a medication copayment increase on adherence to diabetes, hypertension, and hyperlipidemic medications. STUDY DESIGN Retrospective pre-post observational study. METHODS This study compared medication adherence at 4 Veterans Affairs medical centers between veterans who were exempt from copayments and propensity-matched veterans who were not exempt. The diabetes sample included 1069 exempt veterans and 1069 nonexempt veterans, the hypertension sample included 3545 exempt veterans and 3545 nonexempt veterans, and the sample of veterans taking statins included 2029 exempt veterans and 2029 nonexempt veterans. The main outcome measure was medication adherence 12 months before and 23 months after the copayment increase. Adherence differences were assessed in a difference-in-difference approach by using generalized estimating equations that controlled for time, copayment exemption, an interaction between time and copayment exemption, and patient demographics, site, and other factors. RESULTS Adherence to all medications increased in the short term for all veterans, but then declined in the longer term (February-December 2003). The change in adherence between the preperiod and the postperiod was significantly different for exempt and nonexempt veterans in all 3 cohorts, and nonadherence increased over time for veterans required to pay copayments. The impact of the copayment increase was particularly adverse for veterans with diabetes who were required to pay copayments. CONCLUSION A $5 copayment increase (from $2 to $7) adversely impacted medication adherence for veterans subject to copayments taking oral hypoglycemic agents, antihypertensive medications, or statins.
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Affiliation(s)
- Matthew L Maciejewski
- Center for Health Services Research in Primary Care (152), Durham VA Medical Center, 508 Fulton St, Durham, NC 27705, USA.
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Abstract
Medication adherence usually refers to whether patients take their medications as prescribed (eg, twice daily), as well as whether they continue to take a prescribed medication. Medication nonadherence is a growing concern to clinicians, healthcare systems, and other stakeholders (eg, payers) because of mounting evidence that it is prevalent and associated with adverse outcomes and higher costs of care. To date, measurement of patient medication adherence and use of interventions to improve adherence are rare in routine clinical practice. The goals of the present report are to address (1) different methods of measuring adherence, (2) the prevalence of medication nonadherence, (3) the association between nonadherence and outcomes, (4) the reasons for nonadherence, and finally, (5) interventions to improve medication adherence.
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Kinder LS, Bryson CL, Sun H, Williams EC, Bradley KA. Alcohol screening scores and all-cause mortality in male Veterans Affairs patients. J Stud Alcohol Drugs 2009; 70:253-60. [PMID: 19261237 DOI: 10.15288/jsad.2009.70.253] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Extensive research demonstrates a J- or U-shaped association between in-depth interview measures of alcohol consumption and mortality. Little is known about the relationship between alcohol screening questionnaires and mortality. This study examined the association between scores (ranging from 0 to 12) on the three-item Alcohol Use Disorder Identification Test-Consumption Questionnaire (AUDIT-C) and mortality. METHOD This cohort study included male outpatients from seven Veterans Affairs (VA) medical centers who completed the AUDIT-C on mailed surveys (1997-2000; n=34,292) and who were followed for a mean of 2.5 years. Death was ascertained from VA databases. RESULTS In analyses adjusted for demographics, a U-shaped relationship was observed between AUDIT-C scores and all-cause mortality. Nondrinkers (AUDIT-C 0) and heavy drinkers (AUDIT-C 8-9 and 10-12) had increased risk of death compared with drinkers who screened negative for alcohol misuse (AUDIT-C 1-3): hazard ratios (HR)=1.41 (95% confidence interval [CI]: 1.29-1.54), 1.32 (1.03-1.69), and 1.47 (1.14-1.91), respectively. This association differed across age groups (p=.003). For men younger than 50 years, AUDIT-C scores 10-12 were associated with increased mortality (HR=2.21, 95% CI: 1.29-3.77), whereas for men age 50 or older, self-reported abstinence (AUDIT-C 0) was associated with increased mortality, compared with drinkers with AUDIT-C scores 1-3: HR formen 50-64=1.45 (1.19-1.77); HR for men 65 or older=1.42 (1.28-1.58). CONCLUSIONS A U-shaped association between the AUDIT-C and mortality was observed, with important differences by age group. This is the first study to demonstrate that a clinical scaled screening measure of alcohol use has a similar association with mortality to that observed in epidemiological research with lengthier measures.
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Affiliation(s)
- Leslie S Kinder
- Northwest Center of Excellence for Health Services Research and Development, Department of Veterans Affairs, 1100 Olive Way, Suite 1400, Seattle, Washington 98101, USA
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Slatore CG, Bryson CL, Au DH. The association of inhaled corticosteroid use with serum glucose concentration in a large cohort. Am J Med 2009; 122:472-8. [PMID: 19375557 DOI: 10.1016/j.amjmed.2008.09.048] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Revised: 09/19/2008] [Accepted: 09/23/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND Inhaled corticosteroids (ICSs) are widely used in the treatment of obstructive lung disease. ICSs have been shown to be systemically absorbed. The association between ICS and serum glucose concentration is unknown. METHODS To explore the association of ICS dosing with serum glucose concentration, we used a prospective cohort study of US veterans enrolled in 7 primary care clinics between December 1996 and May 2001 with 1 or more glucose measurements while at least 80% adherent to ICS dosing. The association between ICS dose from pharmacy records standardized to daily triamcinolone equivalents and serum glucose concentration was examined with generalized estimating equations controlling for confounders, including systemic corticosteroid use. RESULTS Of the 1698 subjects who met inclusion criteria, 19% had self-reported diabetes. The mean daily dose of ICS in triamcinolone equivalents was 621 microg (standard deviation 555) and 610 microg (standard deviation 553) for subjects with and without diabetes, respectively. After controlling for systemic corticosteroid use and other potential confounders, no association between ICS and serum glucose was found for subjects without diabetes. However, among subjects with self-reported diabetes, every additional 100 microg of ICS dose was associated with an increased glucose concentration of 1.82 mg/dL (P value .007; 95% confidence interval [CI], 0.49-3.15). Subjects prescribed antiglycemic medications had an increase in serum glucose of 2.65 mg/dL (P value .003; 95% CI, 0.88-4.43) for every additional 100 microg ICS dose. CONCLUSION Among diabetic patients, ICS use is associated with an increased serum glucose concentration in a dose-response manner.
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Affiliation(s)
- Christopher G Slatore
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Wash. 98101, USA.
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40
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Abstract
The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; 0-12 points) was included on health surveys in a cohort of 32,622 general medicine outpatients from seven US Department of Veterans Affairs (VA) hospitals. Cox proportional hazards models were used to estimate the risk of fracture (mean follow-up = 1.6 years) by AUDIT-C category. After adjusting for confounders, AUDIT-C scores of 8-9 and 10-12 were associated with significantly increased risks for subsequent fractures, HR (95% CI) = 1.37 (1.03 to 1.83) and 1.79 (1.38 to 2.33) respectively. These results can be used to provide feedback to patients linking their alcohol screening scores to medical outcomes-a critical component of evidence-based brief counseling for alcohol misuse. The study's limitations are noted.
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Affiliation(s)
- Alex H S Harris
- Center for Health Care Evaluation (MC152), VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA.
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Abstract
BACKGROUND Medication nonadherence is common and is associated with adverse outcomes. Alcohol misuse may be a risk factor for nonadherence; however, evidence is limited. OBJECTIVE To identify whether alcohol misuse, as identified by a simple screening tool, is associated in a dose-response manner with increased risk for medication nonadherence in veterans attending primary care clinics. DESIGN Secondary analysis of cohort data collected prospectively from 1997 to 2000 as part of a randomized, controlled trial. SETTING 7 Veterans Affairs primary care clinics. PARTICIPANTS 5473 patients taking a statin, 3468 patients taking oral hypoglycemic agents, and 13 729 patients taking antihypertensive medications. MEASUREMENTS Patients completed the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) questionnaire, a validated 3-question alcohol misuse screening test. Their scores were categorized into nondrinkers; low-level alcohol use; and mild, moderate, and severe alcohol misuse. Medication adherence, defined as having medications available for at least 80% of the observation days, was measured from pharmacy records for either 90 days or 1 year after the alcohol screening date. Logistic regression was used to estimate the predicted proportions of adherent patients in each AUDIT-C group and adjusted for demographic and clinical covariates. RESULTS The proportion of patients treated for hypertension and hyperlipidemia who were nonadherent increased with higher AUDIT-C scores. For 1-year adherence to statins, the percentage of adherent patients was lower in the 2 highest alcohol misuse groups (adjusted percentage of adherent patients, 58% [95% CI, 52% to 65%] and 55% [CI, 47% to 63%]) than in the nondrinker group (66% [CI, 64% to 68%]). For 1-year adherence to antihypertensive regimens, the percentage of adherent patients was lower in the 3 highest alcohol misuse groups (adjusted percentage of adherent patients, 61% [CI, 58% to 64%]; 60% [CI, 56% to 63%]; and 56% [CI, 52% to 60%]) than in the nondrinker group (64% [CI, 63% to 65%]). No statistically significant differences were observed for oral hypoglycemics in adjusted analyses. LIMITATION This observational study cannot address whether changes in drinking lead to changes in adherence and may not be generalizable to other populations. CONCLUSION Alcohol misuse, as measured by a brief screening questionnaire, was associated with increased risk for medication nonadherence.
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Affiliation(s)
- Chris L Bryson
- Health Services Research & Development Northwest Center of Excellence, Veterans Affairs Puget Sound Health Care System, and University of Washington, Seattle, Washington 98101, USA
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Greene CC, Bradley KA, Bryson CL, Blough DK, Evans LE, Udris EM, Au DH. The association between alcohol consumption and risk of COPD exacerbation in a veteran population. Chest 2008; 134:761-767. [PMID: 18625671 DOI: 10.1378/chest.07-3081] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Alcohol has been associated with COPD-related mortality but has not yet been demonstrated to be an independent risk factor for COPD exacerbation. Our objective was to evaluate the association between alcohol consumption and the subsequent risk of COPD exacerbation. METHODS A prospective cohort study of general medicine outpatients seen at one of seven Veterans Affairs (VA) medical centers who returned health screening questionnaires. Three screening questionnaires, AUDIT-C (0 to 12 points), CAGE (0 to 4 points), and a single item about the frequency of drinking six or more drinks on an occasion (binge drinking), were used to classify alcohol consumption. The main outcome, COPD exacerbation, was based on primary VA discharge diagnosis (International Classification of Diseases, Ninth Revision) or outpatient diagnosis of COPD accompanied by prescriptions for either antibiotics or prednisone within 2 days. RESULTS Among the 30,503 patients followed up for a median of 3.35 years, those patients with AUDIT-C scores > or = 6, CAGE scores > or = 2, or who reported binge drinking at least weekly were at an increased risk of COPD exacerbation in age-adjusted analysis. Adjusted hazard ratios were 1.4 (95% confidence interval [CI], 1.1 to 1.7) for AUDIT-C score > or = 6, 1.4 (95% CI, 1.3 to 1.5) for CAGE score > or = 2, and 1.6 (95% CI, 1.2 to 2.2) for those who reported binge drinking daily or almost daily. However, with adjustment for measures of tobacco use, the association between alcohol consumption and increased risk of COPD exacerbation was no longer evident. CONCLUSIONS Alcohol consumption, whether quantified by AUDIT-C, CAGE score, or binge drinking, was not associated with an increased risk of COPD exacerbation independent of tobacco use.
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Affiliation(s)
| | | | | | - David K Blough
- Department of Pharmacy, University of Washington, Seattle, WA
| | - Laura E Evans
- Department of Medicine, New York University, New York, NY
| | | | - David H Au
- Health Services Research and Development, Seattle, WA
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Au DH, Chien JW, Bryson CL. Inhaled Corticosteroids Might Not Protect against Lung Cancer. Am J Respir Crit Care Med 2008. [DOI: 10.1164/ajrccm.177.11.1290a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- David H. Au
- VA Puget Sound Health Care System
and
University of Washington
Seattle, Washington
| | - Jason W. Chien
- Fred Hutchinson Cancer Research Center
and
University of Washington
Seattle, Washington
| | - Chris L. Bryson
- VA Puget Sound Health Care System
and
University of Washington
Seattle, Washington
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Ioannou GN, Bryson CL, Boyko EJ. Prevalence and trends of insulin resistance, impaired fasting glucose, and diabetes. J Diabetes Complications 2007; 21:363-70. [PMID: 17967708 DOI: 10.1016/j.jdiacomp.2006.07.005] [Citation(s) in RCA: 43] [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] [Received: 04/17/2006] [Revised: 07/06/2006] [Accepted: 07/11/2006] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Our aim was to measure the prevalence and time trends of diabetes, impaired fasting glucose, and insulin resistance in the United States during the periods 1988-1994 and 1999-2002. MATERIALS AND METHODS Data were derived from two nationally representative samples of the adult U.S. population collected as part of the National Health and Nutrition Examination Surveys of 1988-1994 (n=18,800) and 1999-2002 (n=10,283). We compared these two samples with respect to the following outcomes: previously diagnosed diabetes defined by self-report; undiagnosed diabetes defined as fasting plasma glucose > or =126 mg/dl; impaired fasting glucose defined as fasting plasma glucose 100-125 mg/dl; and insulin resistance calculated using the homeostasis model assessment as {[fasting serum insulin (microU/ml)] x [fasting plasma glucose (mmol/L)]/22.5}. RESULTS The age- and sex-adjusted prevalence of diagnosed diabetes increased from 5.5% in 1988-1994 to 6.8% in 1999-2002 (change 1.3%, 95% confidence interval 0.5-2.1). Little change occurred in the adjusted prevalence of undiagnosed diabetes (from 3.0 to 3.0%) and impaired fasting glucose (from 26.2 to 26.9%). Mean insulin resistance and the proportion with high insulin resistance increased significantly both among normoglycemic persons (mean: from 2.0 to 2.2; proportion >2.35: from 26.2 to 32.2%) and among persons with undiagnosed diabetes or impaired fasting glucose (mean: from 4.0 to 4.5; proportion >4.4: from 24.8 to 31.1%). In 1999 to 2002, diagnosed and undiagnosed diabetes were most common in non-Hispanic blacks, whereas impaired fasting glucose was most common in Mexican Americans. CONCLUSIONS Diabetes, impaired fasting glucose, and insulin resistance are common in the United States and their prevalence continues to increase.
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Affiliation(s)
- George N Ioannou
- Research Enhancement Award Program, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA 98108, USA.
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Bryson CL, Boyko EJ. Review: glycated haemoglobin A1c and fasting plasma glucose screening tests have similar sensitivities and specificities for early detection of type 2 diabetes. ACTA ACUST UNITED AC 2007; 12:152. [PMID: 17909243 DOI: 10.1136/ebm.12.5.152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Chris L Bryson
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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Abstract
BACKGROUND There are many measures of refill adherence available, but few have been designed or validated for use with repeated measures designs and short observation periods. OBJECTIVE To design a refill-based adherence algorithm suitable for short observation periods, and compare it to 2 reference measures. METHODS A single composite algorithm incorporating information on both medication gaps and oversupply was created. Electronic Veterans Affairs pharmacy data, clinical data, and laboratory data from routine clinical care were used to compare the new measure, ReComp, with standard reference measures of medication gaps (MEDOUT) and adherence or oversupply (MEDSUM) in 3 different repeated measures medication adherence-response analyses. These analyses examined the change in low density lipoprotein (LDL) with simvastatin use, blood pressure with antihypertensive use, and heart rate with beta-blocker use for 30- and 90-day intervals. Measures were compared by regression based correlations (R2 values) and graphical comparisons of average medication adherence-response curves. RESULTS In each analysis, ReComp yielded a significantly higher R2 value and more expected adherence-response curve regardless of the length of the observation interval. For the 30-day intervals, the highest correlations were observed in the LDL-simvastatin analysis (ReComp R2 = 0.231; [95% CI, 0.222-0.239]; MEDSUM R2 = 0.054; [95% CI, 0.049-0.059]; MEDOUT R2 = 0.053; [95% CI, 0.048-0.058]). CONCLUSIONS ReComp is better suited to shorter observation intervals with repeated measures than previously used measures.
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Affiliation(s)
- Chris L Bryson
- Health Services Research and Development Northwest Center of Excellence, Seattle, Washington 98101, USA.
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Parimon T, Chien JW, Bryson CL, McDonell MB, Udris EM, Au DH. Inhaled corticosteroids and risk of lung cancer among patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2007; 175:712-9. [PMID: 17185647 PMCID: PMC1899285 DOI: 10.1164/rccm.200608-1125oc] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Accepted: 12/21/2006] [Indexed: 12/13/2022] Open
Abstract
RATIONALE AND OBJECTIVES Lung cancer is a frequent cause of death among patients with chronic obstructive pulmonary disease (COPD). We examined whether the use of inhaled corticosteroids among patients with COPD was associated with a decreased risk of lung cancer. METHODS We performed a cohort study of United States veterans enrolled in primary care clinics between December 1996 and May 2001. Participants had received treatment for, had an International Classification of Disease, 9th edition, diagnosis of, or a self-reported diagnosis of COPD. Patients with a history of lung cancer were excluded. To be exposed, patients must have been at least 80% adherent to inhaled corticosteroids. We used Cox regression models to estimate the risk of cancer and adjust for potential confounding factors. FINDINGS We identified 10,474 patients with a median follow-up of 3.8 years. In comparison to nonusers of inhaled corticosteroids, adjusting for age, smoking status, smoking intensity, previous history of non-lung cancer malignancy, coexisting illnesses, and bronchodilator use, there was a dose-dependent decreased risk of lung cancer associated with inhaled corticosteroids (ICS dose < 1,200 mug/d: adjusted HR, 1.3; 95% confidence interval, 0.67-1.90; ICS dose >or= 1,200 microg/d: adjusted HR, 0.39; 95% confidence interval, 0.16-0.96). Changes in cohort definitions had minimal effects on the estimated risk. Analyses examining confounding by indication suggest biases in the opposite direction of the described effects. INTERPRETATION Results suggest that inhaled corticosteroids may have a potential role in lung cancer prevention among patients with COPD. These initial findings require confirmation in separate and larger cohorts.
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Affiliation(s)
- Tanyalak Parimon
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Bryson CL, Fihn SD. Simvastatin was cost effective across a broad range of risk and age groups. Evid Based Med 2007; 12:58. [PMID: 17400650 DOI: 10.1136/ebm.12.2.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Affiliation(s)
- Chris L Bryson
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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Bryson CL, Fihn SD. Discontinuation of medications 1 month after an acute myocardial infarction increased risk for death at 12 months. ACP J Club 2007; 146:47. [PMID: 17335170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Affiliation(s)
- Chris L Bryson
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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50
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Bryson CL, Fihn SD. Simvastatin was cost-effective across a broad range of risk and age groups. ACP J Club 2007; 146:50. [PMID: 17335173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Affiliation(s)
- Chris L Bryson
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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