Multiple domains of social support are associated with diabetes self-management among Veterans

Objectives

To examine, among Veterans, relationships of general social support and diabetes-specific social support for physical activity and healthy eating with diabetes self-management behaviors.

Methods

Patients from VA Puget Sound, Seattle completed a cross-sectional survey in 2012–2013 ( N = 717). We measured (a) general social support and (b) diabetes-specific social support for healthy eating and physical activity with domains reflecting support person participation, encouragement, and sharing ideas. Among 189 self-reporting diabetes patients, we fit linear and modified Poisson regression models estimating associations of social support with diabetes self-management behaviors: adherence to general and diabetes-specific diets and blood glucose monitoring (days/week); physical activity (< vs. ≥150 min/week); and smoking status (smoker/non-smoker).

Results

General social support was not associated with diabetes self-management. For diabetes-specific social support, higher healthy eating support scores across all domains were associated with better adherence to general and diabetes-specific diets. Higher physical activity support scores were positively associated with ≥150 min/week of physical activity only for the participation domain.

Discussion

Diabetes-specific social support was a stronger and more consistent correlate of improved self-management than general social support, particularly for lifestyle behaviors. Incorporating family/friends into Veterans’ diabetes self-management routines may lead to better self-management and improvements in disease control and outcomes.

Using Video Telehealth to Facilitate Inhaler Training in Rural Patients with Obstructive Lung Disease

BACKGROUND

Proper inhaler technique is important for effective drug delivery and symptom control in chronic obstructive pulmonary disease (COPD) and asthma, yet not all patients receive inhaler instructions.

INTRODUCTION

Using a retrospective chart review of participants in a video telehealth inhaler training program, the study compared inhaler technique within and between monthly telehealth visits and reports associated with patient satisfaction.

MATERIALS AND METHODS

Seventy-four (N = 74) rural patients prescribed ≥1 inhaler participated in three to four pharmacist telehealth inhaler training sessions using teach-to-goal (TTG) methodology. Within and between visit inhaler technique scores are compared, with descriptive statistics of pre- and postprogram survey results including program satisfaction and computer technical issues. Healthcare utilization is compared between pre- and post-training periods.

RESULTS

Sixty-nine (93%) patients completed all three to four video telehealth inhaler training sessions. During the initial visit, patients demonstrated improvement in inhaler technique for metered dose inhalers (albuterol, budesonide/formoterol), dry powder inhalers (formoterol, mometasone, tiotropium), and soft mist inhalers (ipratropium/albuterol) (p < 0.01 for all). Improved inhaler technique was sustained at 2 months (p < 0.01). Ninety-four percent of participants were satisfied with the program. Although technical issues were common, occurring among 63% of attempted visits, most of these visits (87%) could be completed. There was no significant difference in emergency department visits and hospitalizations pre- and post-training.

DISCUSSION

This study demonstrated high patient acceptance of video telehealth training and objective improvement in inhaler technique.

CONCLUSIONS

Video telehealth inhaler training using the TTG methodology is a promising program that improved inhaler technique and access to inhaler teaching for rural patients with COPD or asthma.

Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes

Objective To determine whether the presence of an informal caregiver and the patient's level of social support are associated with better diabetes self-care among adults with poorly controlled diabetes. Methods Cross-sectional study using baseline data from 253 adults of age 30-70 with poorly controlled diabetes. Participants who reported receiving assistance with their diabetes from a friend or family member in the past month were classified as having a caregiver. We used multivariate linear and logistic regression models to evaluate the associations between having a caregiver and level of social support with five self-reported diabetes self-care behaviors: diet, foot checks, blood glucose monitoring, medications, and physical activity. Results Compared to participants with no informal caregiver, those with an informal caregiver were significantly more likely to report moderate or high medication adherence (OR = 1.93, 95% CI: 1.07-3.49, p = 0.028). When we included social support in the model, having a caregiver was no longer significantly associated with medication adherence (OR = 1.50, 95% CI: 0.80-2.82), but social support score was (OR = 1.22, 95% CI: 1.03-1.45, p = 0.023). Discussion Among low-income adults with poorly controlled diabetes, having both an informal caregiver and high social support for diabetes may have a beneficial effect on medication adherence, a key self-care target to improve diabetes control.

Inhaler Training Delivered by Internet-Based Home Videoconferencing Improves Technique and Quality of Life

BACKGROUND

COPD is common, and inhaled medications can reduce the risk of exacerbations. Incorrect inhaler use is also common and may lead to worse symptoms and increased exacerbations. We examined whether inhaler training could be delivered using Internet-based home videoconferencing and its effect on inhaler technique, self-efficacy, quality of life, and adherence.

METHODS

In this pre-post pilot study, participants with COPD had 3 monthly Internet-based home videoconference visits with a pharmacist who provided inhaler training using teach-to-goal methodology. Participants completed mailed questionnaires to ascertain COPD severity, self-efficacy, health literacy, quality of life, adherence, and satisfaction with the intervention.

RESULTS

A total of 41 participants completed at least one, and 38 completed all 3 home videoconference visits. During each visit, technique improved for all inhalers, with significant improvements for the albuterol metered-dose inhaler, budesonide/formoterol metered-dose inhaler, and tiotropium dry powder inhaler. Improved technique was sustained for nearly all inhalers at 1 and 2 months. Quality of life measured with the Chronic Respiratory Questionnaire improved following the training: dyspnea (+0.3 points, P = .01), fatigue (+0.6 points, P < .001), emotional function (+0.5 points, P = .001), and mastery (+0.7 points, P < .001). Coping skills measured with the Seattle Obstructive Lung Disease Questionnaire improved (+9.9 points, P = .003). Participants reported increased confidence in inhaler use; for example, mean self-efficacy for using albuterol increased 3 points (P < .001). Inhaler adherence improved significantly after the intervention from 1.6 at the initial visit to 1.1 at month 2 (P = .045). The pharmacist reported technical issues in 64% of visits.

CONCLUSIONS

Inhaler training using teach-to-goal methodology delivered by home videoconference is a promising means to provide training to patients with COPD that can improve technique, quality of life, self-efficacy, and adherence.

Diet quality is associated with mental health, social support, and neighborhood factors among Veterans

United States Veterans have a higher prevalence of overweight and related chronic conditions compared to the general population. Although diet is a primary and modifiable contributor to these conditions, little is known about factors influencing diet quality among Veterans. The goal of this study is to examine individual, social environment, and physical environment correlates of general diet quality among Veterans. Study participants (N=653) received care at an urban VA Medical Center in Seattle, WA and completed a mailed survey in 2012 and 2013. Diet quality was assessed with Starting the Conversation, an instrument that measures consumption of unhealthy snacks, fast food, desserts, sugar-sweetened beverages, and fats; fruits and vegetables; and healthy proteins. Variables significantly (p<0.05) associated with diet quality in bivariate analyses were included in a multivariate regression. In the multivariate model, higher level of depressive symptom severity (Diff=0.05; CI=0.01, 0.09; p=0.017); not having others eat healthy meals with the Veteran (Diff=-0.81; CI=-1.5, -0.1; p=0.022); and reduced availability of low-fat foods in neighborhood stores where the Veteran shops (Diff=-0.37; CI=-0.6, -0.2; p<0.001) were associated with poorer diet quality. Consistent with prior research in the general population, this study identified multiple domains associated with Veterans' diet quality, including psychological comorbidity, the social environment, and the physical environment. Findings from this study suggest that interventions aimed at mental health, social support, and neighborhood access to healthy foods are needed to improve Veteran diet quality.

Medicare-VHA dual use is associated with poorer chronic wound healing

Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non-VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare-enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow-up. We used a proportional hazards model to compare wound healing among VHA-exclusive and dual wound care users, using a time-varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow-up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use (HR = 0.63, 95%CI: 0.39-0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61-11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11-8.56, p = 0.031), were significantly higher for dual users compared to VHA-exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA-exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic wound care.

Association Between Chronic Conditions and Physical Function Among Veteran and Non-Veteran Women With Diabetes

PURPOSE OF THE STUDY

To compare the number of chronic conditions among a list of 12 and their association with physical function among postmenopausal non-Veteran and Veteran women with diabetes.

DESIGN AND METHODS

Among women with diabetes from the Women's Health Initiative, we compared the average number of chronic conditions between non-Veterans and Veterans and the association between total number of chronic conditions on subsequent RAND-36 physical function. To examine associations between each condition and subsequent physical function, we compared women with diabetes plus one chronic condition to women with diabetes alone using linear regression in separate models for each condition and for non-Veterans and Veterans.

RESULTS

Both non-Veterans (N = 23,542) and Veterans (N = 618) with diabetes had a median of 3 chronic conditions. Decreases in physical function for each additional condition were larger among Veterans than non-Veterans (-6.3 vs. -4.1 points). Decreases in physical function among women with diabetes plus one chronic condition were greater than that reported for diabetes alone for all combinations and were more pronounced among Veterans (non-Veterans: -11.1 to -24.2, Veterans: -16.6 to -40.4 points). Hip fracture, peripheral artery disease, cerebrovascular disease, and coronary disease in combination with diabetes were associated with the greatest decreases in physical function.

IMPLICATIONS

Chronic conditions were common among postmenopausal women with diabetes and were associated with large declines in physical function, particularly among Veterans. Interventions to prevent and reduce the impact of these conditions and facilitate coordination of care among women with diabetes may help them maintain physical function.

Adverse Childhood Experiences, Military Service, and Adult Health

INTRODUCTION

Prevalence of adverse childhood experiences (ACE) and associations with adult health may vary by gender and military service. This study compares the gender-specific prevalence of ACE by military service and determines the associations of ACE with adult health risk factors and health-related quality of life (HRQOL).

METHODS

This 2014 analysis used data from the 2011 and 2012 CDC Behavioral Risk Factor Surveillance System. Total ACE was operationalized as the number of reported ACE. Associations of total ACE with adult health risk factors were estimated using general linear models; associations with HRQOL were estimated using negative binomial regression. All analyses adjusted for age and race/ethnicity.

RESULTS

Those with military service had more total ACE than civilians. Higher ACE was associated with poorer HRQOL among women (physical health, military service, relative risk [RR]=1.20, 95% CI=1.09, 1.33; civilians, RR=1.18, 95% CI=1.17, 1.20; mental health, military service, RR=1.21, 95% CI=1.12, 1.32; civilians, RR=1.25, 95% CI=1.23, 1.26). Among men, these associations were somewhat attenuated in those with military service relative to civilians (physical health, military service, RR=1.13, 95% CI=1.09, 1.18; civilians, RR=1.20, 95% CI=1.17, 1.24; mental health, military service, RR=1.21, 95% CI=1.16, 1.27; civilians, RR=1.30, 95% CI=1.27, 1.34).

CONCLUSIONS

Relative to civilians, men and women with military service report more ACE, but associations of ACE with adult HRQOL are weaker among men with military service relative to civilians. There is a need to implement and disseminate evidence-based programs to prevent ACE and for research on the long-term health consequences of ACE in military populations.

Evidence-based chronic ulcer care and lower limb outcomes among Pacific Northwest veterans

Evidence-based ulcer care guidelines detail optimal components of care for treatment of ulcers of different etiologies. We investigated the impact of providing specific evidence-based ulcer treatment components on healing outcomes for lower limb ulcers (LLU) among veterans in the Pacific Northwest. Components of evidence-based ulcer care for venous, arterial, diabetic foot ulcers/neuropathic ulcers were abstracted from medical records. The outcome was ulcer healing. Our analysis assessed the relationship between evidence-based ulcer care by etiology, components of care provided, and healing, while accounting for veteran characteristics. A minority of veterans in all three ulcer-etiology groups received the recommended components of evidence-based care in at least 80% of visits. The likelihood of healing improved when assessment for edema and infection were performed on at least 80% of visits (hazard ratio [HR] = 3.20, p = 0.009 and HR = 3.54, p = 0.006, respectively) in patients with venous ulcers. There was no significant association between frequency of care components provided and healing among patients with arterial ulcers. Among patients with diabetic/neuropathic ulcers, the chance of healing increased 2.5-fold when debridement was performed at 80% of visits (p = 0.03), and doubled when ischemia was assessed at the first visit (p = 0.045). Veterans in the Pacific Northwest did not uniformly receive evidence-based ulcer care. Not all evidence-based ulcer care components were significantly associated with healing. At a minimum, clinicians need to address components of ulcer care associated with improved ulcer healing.

Prenatal Care for Women Veterans Who Use Department of Veterans Affairs Health Care

OBJECTIVE

The number of women Veterans of childbearing age enrolling in Department of Veterans Affairs (VA) health care is increasing. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits.

STUDY DESIGN

We used data from the National Survey of Women Veterans, a population-based survey. VA-eligible women veterans with at least one live birth who had ever used VA and were younger than 45 years when VA prenatal benefits became available were categorized based on self-reported receipt of VA prenatal benefits. Characteristics of by use of VA prenatal benefits were compared using χ2 tests with Rao-Scott adjustment. All analyses used sampling weights.

RESULTS

In our analytic sample, of those who potentially had the opportunity to use VA prenatal benefits, 25% used these benefits and 75% did not. Compared with women veterans not using VA prenatal benefits, those who did were more likely to be 18 to 24 years old (39.9% vs. 3.7%; p=.03), and more likely to have self-reported diagnosed depression (62.5% vs. 24.5%; p=.02) and current depression or posttraumatic stress disorder (PTSD) symptoms (depression, 46.1% vs. 8% [p=.02]; PTSD, 52.5% vs. 14.8% [p=.02]). Compared with women veterans not using VA prenatal benefits, those who did were more likely to resume VA use after delivery (p<.001).

CONCLUSION

Pregnant women veterans who use VA prenatal benefits are a high-risk group. Among those who opt not to use these benefits, pregnancy is an important point of attrition from VA health care, raising concerns regarding retention of women veterans within VA and continuity of care.

Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression

OBJECTIVES

To assess whether the relationship between antidepressant adherence and coronary artery disease (CAD) hospitalizations varied between older and younger adults with depression.

DESIGN

Retrospective cohort study.

SETTING

Department of Veterans Affairs outpatient clinics nationwide.

PARTICIPANTS

Chronically depressed individuals (n = 50,261; aged 20-97) who had been prescribed an antidepressant were identified from records indicating an outpatient clinic visit for depression (index depression visit) during fiscal years 2009 and 2010. Individuals were considered chronically depressed if they had had prior depression visits and treatment for depression within the previous 4 months. The sample was age-stratified into younger (<65) and older (≥ 65) groups.

MEASUREMENTS

After the index depression visit, medication possession ratios were calculated from pharmacy refill data to determine whether participants had 80% or greater adherence to antidepressant refills during a 6-month treatment observation period. International Classification of Diseases, Ninth Revision, codes were used to derive CAD-related hospitalizations during the follow-up period. Mean follow-up was 24 months. Data were analyzed using Cox proportional hazard models.

RESULTS

Older participants with 80% or greater antidepressant adherence had 26% lower risk of CAD hospitalizations (hazard ratio = 0.74, 95% confidence interval = 0.60-0.93). Antidepressant adherence was not significantly related to CAD hospitalizations in younger adults.

CONCLUSION

Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD hospitalizations at follow-up than those with less than 80% adherence. These preliminary results suggest that older adults with depression may derive cardiovascular benefits from clinical efforts to increase antidepressant adherence.

Teledermatology in the diagnosis of melanoma

Summary

We conducted a retrospective chart review of US Veterans in the Pacific Northwest area to compute melanoma incidence and Breslow depth at diagnosis. We compared Veterans with access to teledermatology (TD) and those without (non-TD). We identified pathology-confirmed primary melanomas in Veterans who had had at least one encounter at a VA facility during a 3-year study period. The age-adjusted melanoma incidence for all, TD and non-TD Veterans was 36, 15 and 57 per 100,000, respectively. The mean Breslow depth was significantly greater in the TD group ( P = 0.03). Although a higher proportion of thin (Breslow depth ≤1 mm) TD melanomas were mitotically active, this difference was not significant. We also found that 180 (40%) of the non-TD (face-to-face) diagnosed melanomas were from Veterans living in areas where TD was available. This suggests that the higher melanoma incidence in the non-TD group was mainly due to under-utilization of TD services. The study demonstrated that the TD service was not fully utilized in the VISN20 region, although the reasons for this are not clear. Where TD was utilized it tended to diagnose more advanced melanomas with worse initial prognosis.

Sexual behaviors and sexually transmitted infections in a nationally representative sample of women veterans and nonveterans

BACKGROUND

Women veterans are a growing population with unique characteristics and documented health disparities. Few studies have examined their sexual behaviors and rates of sexually transmitted infections (STIs), and none have compared women veterans to nonveterans to identify potential sexual health disparities.

METHODS

We used data from the 1999-2010 National Health and Nutrition Examination Survey, a nationally representative U.S. survey. We compared lifetime sexual history (age at first intercourse, number of partners), sexual activity in the last year, and STIs between women veterans (n=151) and nonveterans (n=8738), adjusting for age, race/ethnicity, education, marital status, binge drinking, and survey year.

RESULTS

Compared to nonveterans, women veterans reported a younger age at first intercourse and a greater number of female and male lifetime sexual partners, and they were more likely to have ever had sex with a woman. They were also more likely than nonveterans to have genital herpes and genital warts.

CONCLUSIONS

Women veterans reported higher rates of sexual activity and STIs than nonveterans. Future research is needed to assess high-risk behaviors and determine what factors may underlie these associations. Providers should ensure thorough screening and intervention services are provided for this growing population.

Sex Differences in Associations of Depressive Symptoms with Cardiovascular Risk Factors and Metabolic Syndrome among African Americans

Young to middle-aged women usually have notably lower rates of cardiovascular disease (CVD) than their male counterparts, but African American women lack this advantage. Their elevated CVD may be influenced by sex differences in associations between depressed mood and CVD risk factors. This cross-sectional study examined whether relations between scores on the Center for Epidemiologic Studies-Depression (CES-D) scale and a spectrum of CVD risk factors varied by sex among African Americans (n = 1076; ages 30-64) from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. Sex-stratified multiple regressions and logistic regressions were conducted. Among women, CES-D scores correlated positively with systolic blood pressure and waist-to-hip ratio (P's < .05), but inversely with high-density lipoprotein cholesterol (HDL-C) (P < .01). Women had twice the odds for metabolic syndrome if CES-D scores ≥16 and had a ≥14% increase in odds of hypertension, abdominal obesity, and low HDL-C with each 5-unit increase in CES-D scores. Among men, CES-D scores correlated positively with high-sensitivity C-reactive protein (P < .05), and odds of hypertension increased by 21% with each 5-unit increase in CES-D scores. Depressive symptoms may promote premature CVD risk in African Americans, at least in part, via CVD risk factors and prevalent metabolic syndrome, particularly in African American women.

Peripheral neuropathy defined by monofilament insensitivity and diabetes status: NHANES 1999-2004

OBJECTIVE

To determine whether diabetes status, including prediabetes, is associated with increased risk of peripheral neuropathy as defined by monofilament insensitivity.

RESEARCH DESIGN AND METHODS

This study used data from the 1999-2004 National Health and Nutrition Examination Survey (n = 7,818). Peripheral neuropathy was defined as one or more insensate sites detected by a Semmes-Weinstein 10-g monofilament. Generalized linear models were used to directly estimate relative risks (RRs) for the association of diabetes status and peripheral neuropathy.

RESULTS

After adjustment compared with no diabetes, prediabetes [RR 1.11 (95% CI 0.92-1.34)] and undiagnosed diabetes [1.08 (0.73-1.61)] were associated with modest increases in risk of peripheral neuropathy, and diabetes was associated with a 74% higher risk of peripheral neuropathy [1.74 (1.50-2.01)].

CONCLUSIONS

Diabetes is associated with increased risk of peripheral neuropathy defined by monofilament insensitivity, but prediabetes and undiagnosed diabetes may be associated with only a modest increase in risk.

A teledermatology care management protocol for tracking completion of teledermatology recommendations

In July 2009 we implemented a 3-year store-and-forward teledermatology project to provide dermatology care to veterans living in rural and underserved areas of the US Pacific Northwest. We also developed a follow-up protocol and tracking system. Information about all completed teledermatology consultations was entered into a database, and major procedures and select medications were tracked. In the first 21 months, 8202 dermatology conditions in 5232 veterans were treated and 3370 major procedures carried out. Ninety-five percent of conditions were associated with no more than two teledermatology consultations, and no condition required more than ten consultations. In total, 1454 conditions were reviewed for clinical pathological correlation, and in 310 (21%) there was a subsequent clinical pathological correlation conference, resulting in a change in final diagnosis for 93 conditions. The follow-up was important in ensuring high quality patient care.

Implementation of an education and skills programme in a teledermatology project for rural veterans

In July 2009 we implemented a store-and-forward teledermatology project to provide dermatology care to veterans living in underserved rural areas of the Pacific Northwest region of the US. We also developed an educational programme for rural primary care providers and imaging technicians. Participants were tested and their competencies were assessed at baseline and during a two-year project. Participation in a comprehensive education programme improved the knowledge of dermatology diagnosis and treatment care plans. All of the providers were performing dermatology procedures (e.g. biopsies, excisions, cauteries) after two years and more patients were being seen at their rural clinics than when the teledermatology project began (85% vs 39%). After two years, 71% of the providers and 56% of the imaging technicians had completed surgical training sessions and all passed their competency assessments. The educational component of the teledermatology project created teams of primary care health-care providers and imaging technicians with improved dermatology educational levels and new dermatology skills.

Depression and incident lower limb amputations in veterans with diabetes

PROBLEM

Depression is associated with a higher risk of macrovascular and microvascular complications and mortality in diabetes, but whether depression is linked to an increased risk of incident amputations is unknown. We examined the association between diagnosed depression and incident non-traumatic lower limb amputations in veterans with diabetes.

METHODS

This was a retrospective cohort study from 2000-2004 that included 531,973 veterans from the Diabetes Epidemiology Cohorts, a national Veterans Affairs (VA) registry with VA and Medicare data. Depression was defined by diagnostic codes or antidepressant prescriptions. Amputations were defined by diagnostic and procedural codes. We determined the HR and 95% CI for incident non-traumatic lower limb amputation by major (transtibial and above) and minor (ankle and below) subtypes, comparing veterans with and without diagnosed depression and adjusting for demographics, health care utilization, diabetes severity and comorbid medical and mental health conditions.

RESULTS

Over a mean 4.1 years of follow-up, there were 1289 major and 2541 minor amputations. Diagnosed depression was associated with an adjusted HR of 1.33 (95% CI: 1.15-1.55) for major amputations. There was no statistically significant association between depression and minor amputations (adjusted HR 1.01, 95% CI: 0.90-1.13).

CONCLUSIONS

Diagnosed depression is associated with a 33% higher risk of incident major lower limb amputation in veterans with diabetes. Further study is needed to understand this relationship and to determine whether depression screening and treatment in patients with diabetes could decrease amputation rates.

Department of Veterans Affairs compensation and medical care benefits accorded to veterans with major limb loss

Veterans injured in theaters of combat operations are eligible for benefits, including medical care and compensation. This article describes veterans with service-connected disability for major lower- and/or upper-limb loss resulting from combat-field-associated injuries sustained in the Vietnam war, Operation Desert Shield/Operation Desert Storm, and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). Using the Department of Veterans Affairs (VA) Compensation and Pension Mini-Master file, we identified 2,690 veterans who in August 2007 received compensation for loss of one or more limbs. More than 97% sustained their injuries in Vietnam; most were young men who served in the U.S. Army or Marine Corps. All but 5% had at least 50% combined service-connected disability and nearly half had a 100% rating. In addition to limb loss, one of the most prevalent compensable conditions was posttraumatic stress disorder, present in 46% of OIF/OEF and 20% of Vietnam veterans. Of these veterans, 82% visited VA outpatient clinics in 2007, although only 4% were hospitalized. A special obligation exists to those who have sustained serious injuries related to combat; this responsibility extends for the life of the servicemember and beyond to his or her spouse and dependents.

Prosthetic cost projections for servicemembers with major limb loss from Vietnam and OIF/OEF

This study projects prosthetic- and assistive-device costs for veterans with limb loss from Vietnam and injured servicemembers returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) to inform the Department of Veterans Affairs (VA) for these veterans' future care. The 2005 Medicare prosthetic device component prices were applied to current prosthetic and assistive-device use obtained from a national survey of 581 veterans and servicemembers with major traumatic amputations. Projections were made for 5-year, 10-year, 20-year, and lifetime costs based on eight Markov models. Average 5-year projected costs for prosthetic and assistive-device replacement for the Vietnam group are lower than for the OIF/OEF cohort due in part to use of fewer and less technologically advanced prosthetic devices and higher frequency of prosthetic abandonment. By limb-loss level, for the Vietnam group and OIF/OEF cohort, 5-year projected unilateral upper limb average costs are $31,129 and $117,440, unilateral lower limb costs are $82,251 and $228,665, and multiple limb costs are $130,890 and $453,696, respectively. These figures provide the VA with a funding estimate for technologically advanced prosthetic and assistive devices within the framework of ongoing rehabilitation for veterans with traumatic limb loss from the Vietnam and OIF/OEF conflicts.

Multiple traumatic limb loss: a comparison of Vietnam veterans to OIF/OEF servicemembers

Multiple-limb loss due to war-theater injuries results in a unique group of servicemembers requiring intensive rehabilitation and diverse prosthetic devices. This article compares the Vietnam and the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) groups with war-theater-associated multiple-limb loss to document significant changes in health status, prosthetic-device use, and long-term prognosis. During 2007 and 2008, a national survey queried 73 Vietnam veterans and 61 OIF/OEF servicemembers sustaining multiple-limb loss. Average years since limb loss are 39 for Vietnam veterans and 3 for OIF/OEF servicemembers. Self-rated health status was excellent or very good in 38.9% of the Vietnam group and 60.7% of the OIF/OEF group (p = 0.01). More of the OIF/OEF group than the Vietnam group reported performing high-impact aerobic activities, 18% versus 3% (p = 0.005). The OIF/OEF group currently uses more diverse prosthetic-device types than the Vietnam group. Based on Vietnam veterans' 39-year experience, the long-term prognosis for OIF/OEF servicemembers with multiple-limb loss is an active, fulfilling life. The healthcare team caring for these patients should carefully address proper prosthesis fit and maintenance of good health and function.

Depression and incident diabetic foot ulcers: a prospective cohort study

OBJECTIVE

To test whether depression is associated with an increased risk of incident diabetic foot ulcers.

METHODS

The Pathways Epidemiologic Study is a population-based prospective cohort study of 4839 patients with diabetes in 2000-2007. The present analysis included 3474 adults with type 2 diabetes and no prior diabetic foot ulcers or amputations. Mean follow-up was 4.1 years. Major and minor depression assessed by the Patient Health Questionnaire-9 were the exposures of interest. The outcome of interest was incident diabetic foot ulcers. We computed the hazard ratio and 95% confidence interval (CI) for incident diabetic foot ulcers, comparing patients with major and minor depression with those without depression and adjusting for sociodemographic characteristics, medical comorbidity, glycosylated hemoglobin, diabetes duration, insulin use, number of diabetes complications, body mass index, smoking status, and foot self-care. Sensitivity analyses also adjusted for peripheral neuropathy and peripheral arterial disease as defined by diagnosis codes.

RESULTS

Compared with patients without depression, patients with major depression by Patient Health Questionnaire-9 had a 2-fold increase in the risk of incident diabetic foot ulcers (adjusted hazard ratio 2.00; 95% CI, 1.24-3.25). There was no statistically significant association between minor depression by Patient Health Questionnaire-9 and incident diabetic foot ulcers (adjusted hazard ratio 1.37; 95% CI, 0.77-2.44).

CONCLUSION

Major depression by Patient Health Questionnaire-9 is associated with a 2-fold higher risk of incident diabetic foot ulcers. Future studies of this association should include better measures of peripheral neuropathy and peripheral arterial disease, which are possible confounders or mediators.

Influenza vaccination rates of children in households with high-risk adults

OBJECTIVES

Household contacts of people at high risk for influenza complications should receive yearly influenza vaccination to reduce potential viral transmission. We evaluated influenza vaccine coverage among children to determine whether or not living with a high-risk adult predicts the likelihood of being vaccinated.

METHODS

Using the 2006 National Health Interview Survey, we examined influenza vaccination rates among children (aged 1-17 years) who did and did not reside in a household with an adult at high risk for influenza-related complications.

RESULTS

Among 24,195 sampled families, there were 8,976 high-risk adults, 18.9% of whom reported living with a person 17 years of age of younger. Influenza vaccination rates by age group among children living with high-risk adults were 41.7% (1 year), 30.3% (2-4 years), and 20.0% (5-17 years). Unadjusted influenza vaccination rates were significantly higher for school-aged children who lived with a high-risk adult compared with those who did not (20.0% vs. 15.0%, p < 0.001). Among children younger than 5 years of age, for whom vaccination was universally recommended at the time of the survey, the rates did not differ. After adjusting for the child's age, gender, race, insurance coverage, medical visits, and chronic conditions, children who lived with a high-risk adult were not statistically more likely than those who did not live with a high-risk adult to receive influenza vaccination (odds ratio = 1.16, 95% confidence interval 0.99, 1.36).

CONCLUSIONS

Children had low rates of influenza vaccination, and those who lived with high-risk adults were not significantly more likely to be vaccinated. Clinicians caring for high-risk adults should remind eligible household contacts to receive influenza vaccine.

Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings

Care of veterans and servicemembers with major traumatic limb loss from combat theaters is one of the highest priorities of the Department of Veteran Affairs. We achieved a 62% response rate in our Survey for Prosthetic Use from 298 Vietnam war veterans and 283 servicemembers/veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) who sustained major traumatic limb loss. Participants reported their combat injuries; health status; quality of life; and prosthetic device use, function, rejection, and satisfaction. Despite the serious injuries experienced, health status was rated excellent, very good, or good by 70.7% of Vietnam war and 85.5% of OIF/OEF survey participants. However, many health issues persist for Vietnam war and OIF/OEF survey participants (respectively): phantom limb pain (72.2%/76.0%), chronic back pain (36.2%/42.1%), residual-limb pain (48.3%/62.9%), prosthesis-related skin problems (51.0%/58.0%), hearing loss (47.0%/47.0%), traumatic brain injury (3.4%/33.9%), depression (24.5%/24.0%), and posttraumatic stress disorder (37.6%/58.7%). Prosthetic devices are currently used by 78.2% of Vietnam war and 90.5% of OIF/OEF survey participants to improve function and mobility. On average, the annual rate for prosthetic device receipt is 10.7-fold higher for OIF/OEF than for Vietnam war survey participants. Findings from this cross-conflict survey identify many strengths in prosthetic rehabilitation for those with limb loss and several areas for future attention.

Foot care education and self management behaviors in diverse veterans with diabetes

The objective of this study was to examine differences in self-reported diabetes foot care education, self management behaviors, and barriers to good foot care among veterans with diabetes by race and ethnicity. Data was collected using the Veterans Health Administration Footcare Survey, a validated tool that assessed demographic, general health, diabetes and foot self-care information, barriers to foot self-care, receipt of professional foot care, and satisfaction with current care. We mailed surveys to a random sample of patients with diabetes from eight VA medical centers. Study participants were 81% White; 13% African American; 4% Asian, and 2% American Indian and Pacific Islanders. The majority of respondents felt that they did not know enough about foot self-care. There were large gaps between self-reported knowledge and actual foot care practices, even among those who reported "knowing enough" on a given topic. There were significant differences in self-reported foot care behaviors and education by race and ethnicity. These findings document the need for culturally-specific self-management education to address unique cultural preferences and barriers to care.

Challenges in merging Medicaid and Medicare databases to obtain healthcare costs for dual-eligible beneficiaries: using diabetes as an example

Dual-eligible Medicaid-Medicare beneficiaries represent a group of people who are in the lowest income bracket in the US, have numerous co-morbidities and place a heavy financial burden on the US healthcare system. As cost-effectiveness analyses are used to inform national policy decisions and to determine the value of implemented chronic disease control programmes, it is imperative that complete and valid determination of healthcare utilization and costs can be obtained from existing state and federal databases. Differences and inconsistencies between the Medicaid and Medicare databases have presented significant challenges when extracting accurate data for dual-eligible beneficiaries. To describe the challenges inherent in merging Medicaid and Medicare claims databases and to present a protocol that would allow successful linkage between these two disparate databases. Healthcare claims and costs were extracted from both Medicaid and Medicare databases for King County, Seattle, WA, USA. Three Medicaid files were linked to eight Medicare files for unique dual-eligible beneficiaries with type 2 diabetes mellitus. Although major differences were identified in how variables and claims were defined in each database, our method enabled us to link these two different databases to compile a complete and accurate assessment of healthcare use and costs for dual-eligible beneficiaries with a costly chronic condition. For example, of the 1759 dual-eligible beneficiaries with diabetes, the average cost of healthcare was USD 15,981 per capita, with an average of 76 claims per person per year. The resulting merged database provides a virtually complete documentation of both utilization and costs of medical care for a population who receives coverage from two different programmes. By identifying differences and implementing our linkage protocol, the merged database serves as a foundation for a broad array of analyses on healthcare use and costs for effectiveness research.

Relationship between foot type, foot deformity, and ulcer occurrence in the high-risk diabetic foot

We hypothesized an association between foot type, foot deformity, and foot ulceration and conducted an analysis of a well-characterized, high-risk diabetic population of 398 subjects. The average age was 62 years of age and 74% of the study population were males. Foot-type distributions were 19.5% pes cavus (high arch), 51.5% neutrally aligned (normal arch), and 29.0% pes planus (low arch). We quantified the presence of hallux valgus (23.9%), hammer/claw toes (46.7%), and hallux limitus (24.4%). A significant association was found between foot type and hallux valgus (p = 0.003); pes planus feet had the highest prevalence as compared with neutrally aligned feet (odds ratio [OR] = 2.43, p = 0.0006). Foot type was also significantly associated with fixed hammer/claw toes (p = 0.01); pes cavus feet had the highest prevalence as compared with neutrally aligned feet (OR = 3.89, p = 0.001). Foot type was also significantly associated with hallux limitus (p = 0.006) with pes planus feet having the highest prevalence as compared with neutrally aligned feet (OR = 2.19, p = 0.003). However, foot type was not significantly related to any ulcer outcome (p = 0.7). Fixed hammer/claw toes (OR = 3.91, p = 0.003) and hallux limitus (OR = 3.02, p = 0.006) were associated with increased risk of any ulcer occurrence. This study affirms that foot type and foot deformity are related and that foot deformities are associated with ulcer occurrence.

The process of implementing a rural VA wound care program for diabetic foot ulcer patients

Delivering and documenting evidence-based treatment to all Department of Veterans Affairs (VA) foot ulcer patients has wide appeal. However, primary and secondary care medical centers where 52% of these patients receive care are at a disadvantage given the frequent absence of trained specialists to manage diabetic foot ulcers. A retrospective review of diabetic foot ulcer patient records and a provider survey were conducted to document the foot ulcer problem and to assess practitioner needs. Results showed of the 125 persons with foot ulcers identified through administrative data, only, 21% of diabetic foot patients were correctly coded. Chronic Care and Microsystem models were used to prepare a tailored intervention in a VA primary care medical center. The site Principal Investigators, a multidisciplinary site wound care team, and study investigators jointly implemented a diabetic foot ulcer program. Intervention components include wound care team education and training, standardized good wound care practices based on strong scientific evidence, and a wound care template embedded in the electronic medical record to facilitate data collection, clinical decision making, patient ordering, and coding. A strategy for delivering offloading pressure devices, regular case management support, and 24/7 emergency assistance also was developed. It took 9 months to implement the model. Patients were enrolled and followed for 1 year. Process and outcome evaluations are on-going.

Veterans using and uninsured veterans not using Veterans Affairs (VA) health care

OBJECTIVES

The objectives of this study were to: (1) examine veteran reliance on health services provided by the Veterans Health Administration (VA), (2) describe the characteristics of veterans who receive VA care, and (3) report rates of uninsurance among veterans and characteristics of uninsured veterans.

METHODS

The authors analyzed data from the 2000 Behavioral Risk Factor Surveillance System. Using bivariate and multivariate analyses, the association of veteran's demographic characteristics, health insurance coverage, and use of VA services were examined. Veterans not reporting VA coverage and having no other source of health insurance were considered uninsured.

RESULTS

Among veteran respondents, 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. Poor, less-educated, and minority veterans were more likely to receive all of their health care at the VA. Veterans younger than age 65 who utilized the VA for all of their health care also reported coverage with either private insurance (42.6%) or Medicare (36.3%). Of the veterans younger than age 65, 8.6% (population estimate: 1.3 million individuals) were uninsured. Uninsured veterans were less likely to be able to afford a doctor or see a doctor within the last year.

CONCLUSIONS

Veterans who utilized the VA for all of their health care were more likely to be from disadvantaged groups. A large number of veterans who could use VA services were uninsured. They should be targeted for VA enrollment given the detrimental clinical effects of being uninsured.

Diabetes-related foot care at 10 Veterans Affairs medical centers: must do's associated with successful microsystems

BACKGROUND

Well-coordinated interdisciplinary preventive foot care has been reported to significantly reduce diabetes-related foot ulcers, amputations, and hospitalization. However, the contribution of the specific components leading to these "successes" is not fully characterized. The microsystem conceptual framework was adapted to foot care to determine which of the microsystem success characteristics were associated with decreased major lower-limb amputation rates at 10 Veterans Affairs (VA) medical centers.

METHODS

Two-day site visits were conducted using standardized interviews at the 10 VA medical centers.

RESULTS

Six "must do's" for foot care in microsystems were correlated at > or = (-.30) with amputation rates: (1) addressing all foot care needs, (2) appropriate referrals, (3) ease in recruiting staff, (4) confidence in staff, (5) available stand alone specialized diabetic foot care services, and (6) providers attending diabetic foot care education in the past three years. Using multiple linear regression, the sum of these items described 59% of the variance (p = 0.006).

DISCUSSION

Clinicians and managers may want to include the must-do's in system modifications to improve foot care for people with diabetes. Many of the sites displayed exemplary features in foot care, such as providing a formal orientation to the foot care clinics.

Influenza and pneumococcal vaccination in older veterans: results from the behavioral risk factor surveillance system

OBJECTIVES

To compare influenza and pneumococcal vaccination rates of older veterans with those of nonveterans and to compare vaccination rates of veterans who receive care at U.S. Department of Veterans Affairs (VA) medical centers with those of veterans who do not.

DESIGN

Cross-sectional population-based study.

SETTING

United States and territories.

PARTICIPANTS

Persons aged 65 and older who participated in the 2003 Behavioral Risk Factor Surveillance System.

MEASUREMENTS

Telephone survey of sociodemographics factors, including veteran status and VA care, health and behavioral characteristics, and influenza and pneumococcal vaccine use.

RESULTS

Thirty percent of adults aged 65 and older were veterans, and 21% of veterans reported receiving care at VA health facilities. Veterans, especially VA users, were older and described poorer self-perceived health than nonveterans. Influenza and pneumococcal vaccination rates were higher for veterans than for nonveterans (74% vs 68% and 68% vs 63%, respectively, P < .001 for both) and for VA users than non-VA users (80% vs 72% and 81% vs 64%, respectively, P < .001 for both). For veterans, VA care was independently associated with influenza (odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.5-2.2) and pneumococcal (OR = 2.4, 95% CI = 2.0-2.9) vaccine use after adjusting for sociodemographics factors, perceived health status, diabetes mellitus, asthma, and smoking. Current smoking and black race were independent predictors of low influenza vaccine uptake.

CONCLUSION

VA care was associated with improved influenza and pneumococcal vaccine coverage, although vaccination rates for all elderly veterans fell short of Healthy People 2010 goals. Increased efforts to reach undervaccinated groups, particularly blacks and smokers, are warranted.

Recruitment of Medicaid and dual-enrolled Medicare beneficiaries with diabetes mellitus into a randomized controlled trial

OBJECTIVE

To document the recruitment of Medicaid and dual-enrolled Medicare beneficiaries with diabetes mellitus into a randomized clinical trial.

STUDY DESIGN

Randomized controlled trial with 1-year follow-up.

METHODS

A total of 2242 Medicaid or dual-enrolled Medicare beneficiaries with diabetes residing in King County, Washington, were recruited by direct mail for a clinical trial of diabetes self-care management. Washington State Medicaid program databases were used to identify the target population who received recruitment packets from the program director. Individuals who did not return a participation refusal letter were telephoned to determine study eligibility. Subjects were screened during a study visit, and written informed consent was obtained. Enrolled subjects were randomized to a self-care intervention group or a usual care group.

RESULTS

Of 2242 recruitment packets sent, we were unable to contact 40% of the target population, despite the fact that packets were sent to the same mailing addresses used for monthly Medicaid check distributions. The primary recruitment challenges were missing telephone contact information and a lack of interpreters speaking needed dialects. Of the 146 subjects enrolled, 71% were nonwhite, 28% were non-English speaking, 69% were women, and the mean age was 59.8 years.

CONCLUSIONS

Research in Medicaid and Medicare populations is possible but requires additional time, energy, and resources. The finding that 40% of the Medicaid population could not be contacted suggests that Medicaid may want to revisit their contact information procedures to facilitate case management and other programs.