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Kimpel CC, Myer EA, Cupples A, Roman Jones J, Seidler KJ, Rick CK, Brown R, Rawlins C, Hadler R, Tsivitse E, Lawlor MAC, Ratcliff A, Holt NR, Callaway-Lane C, Godwin K, Ecker AH. Identifying Barriers and Facilitators to Veterans Affairs Whole Health Integration Using the Updated Consolidated Framework for Implementation Research. J Healthc Qual 2024; 46:137-149. [PMID: 38147581 PMCID: PMC11065588 DOI: 10.1097/jhq.0000000000000419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND Veterans Affairs (VA) implemented the Veteran-centered Whole Health System initiative across VA sites with approaches to implementation varying by site. PURPOSE Using the Consolidated Framework for Implementation Research (CFIR), we aimed to synthesize systemic barriers and facilitators to Veteran use with the initiative. Relevance to healthcare quality, systematic comparison of implementation procedures across a national healthcare system provides a comprehensive portrait of strengths and opportunities for improvement. METHODS Advanced fellows from 11 VA Quality Scholars sites performed the initial data collection, and the final report includes CFIR-organized results from six sites. RESULTS Key innovation findings included cost, complexity, offerings, and accessibility. Inner setting barriers and facilitators included relational connections and communication, compatibility, structure and resources, learning centeredness, and information and knowledge access. Finally, results regarding individuals included innovation deliverers, implementation leaders and team, and individual capability, opportunity, and motivation to implement and deliver whole health care. DISCUSSION AND IMPLICATIONS Examination of barriers and facilitators suggest that Whole Health coaches are key components of implementation and help to facilitate communication, relationship building, and knowledge access for Veterans and VA employees. Continuous evaluation and improvement of implementation procedures at each site is also recommended.
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Johnson WV, Phung QH, Patel VR, Tsai AK, Arora N, Klein MA, Westanmo AD, Blaes AH, Gupta A. Trajectory of Healthcare Contact Days for Veterans With Advanced Gastrointestinal Malignancy. Oncologist 2024; 29:e290-e293. [PMID: 38016182 PMCID: PMC10836304 DOI: 10.1093/oncolo/oyad313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/03/2023] [Indexed: 11/30/2023] Open
Abstract
How and where patients with advanced cancer facing limited survival spend their time is critical. Healthcare contact days (days with healthcare contact outside the home) offer a patient-centered and practical measure of how much of a person's life is consumed by healthcare. We retrospectively analyzed contact days among decedent veterans with stage IV gastrointestinal cancer at the Minneapolis Veterans Affairs Healthcare System from 2010 to 2021. Among 468 decedents, the median overall survival was 4 months. Patients spent 1 in 3 days with healthcare contact. Over the course of illness, the percentage of contact days followed a "U-shaped" pattern, with an initial post-diagnosis peak, a lower middle trough, and an eventual rise as patients neared the end-of-life. Contact days varied by clinical factors and by sociodemographics. These data have important implications for improving care delivery, such as through care coordination and communicating expected burdens to and supporting patients and care partners.
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Affiliation(s)
- Whitney V Johnson
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Quan H Phung
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Vishal R Patel
- Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Alexander K Tsai
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nivedita Arora
- Hematology/Oncology Section, Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN, US
| | - Mark A Klein
- Hematology/Oncology Section, Minneapolis Veterans Affairs Healthcare System, Minneapolis, MN, US
| | - Anders D Westanmo
- Department of Pharmacy, Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | - Anne H Blaes
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Arjun Gupta
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Kalva P, Kakkilaya A, Hasan T, Hession R, Kooner K. Residency Program Characteristics Associated with Higher Cataract Surgery Volume. Semin Ophthalmol 2023; 38:773-776. [PMID: 37306262 PMCID: PMC10538430 DOI: 10.1080/08820538.2023.2223295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE Prior research has shown that ophthalmology residents improve their cataract surgery competency as they perform additional surgeries beyond the 86 minimum cases mandated by the Accreditation Council for Graduate Medical Education (ACGME). Therefore, cataract surgery volume is an important benchmark for ophthalmology programs. Understanding the possible influence of residency program characteristics on resident cataract surgery volume may help educators in identifying areas for improvement and aid applicants in choosing between programs. The aim of this study was to assess residency program characteristics associated with higher mean cataract surgery volume for ophthalmology residents. METHODS We conducted a retrospective, cross-sectional analysis of the San Francisco Match Program Profile Database to assess various program characteristics from the 113 listed ophthalmology residency programs. The associations between program characteristics and the mean cataract surgery volume per graduating resident (CSV/GR) over years 2018-2021 were analyzed using multiple linear regression. RESULTS Out of 113 listed residency programs, 109 (96.5%) were included in our study. Across all programs, the mean (SD) CSV/GR was 195.9 (56.9) cases with a range of 86 to 365 cases. In multiple linear regression analysis, the presence of a Veteran Affairs (VA) training site (β = 38.8, P = .005) and the number of approved fellows per year (β = 2.9, P = .026) were positively correlated with higher mean CSV/GR. The 85 (78.0%) programs with VA training sites had a higher mean (SD) CSV/GR of 204.1 (55.7) cases compared to 166.7 (52.7) cases in the 24 (22.0%) programs without VA sites (P = .004). The mean CSV/GR increased by 2.9 cases for each additional fellow slot after adjusting for other factors. The number of approved residents per year, affiliation with a medical school, and the number of faculty were not significantly associated with CSV/GR. CONCLUSION All ophthalmology residency programs included in this study currently meet or exceed the ACGME requirements for cataract surgery case numbers. The presence of a VA training site and a higher number of fellowship positions were associated with higher mean resident cataract surgery volumes. Residency programs may consider further investing in these areas when seeking to improve resident surgical education. Additionally, residency applicants prioritizing cataract surgery volume may consider these factors when evaluating programs.
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Affiliation(s)
- Praneeth Kalva
- Department of Ophthalmology, University of Texas at Southwestern Medical Center, Dallas, TX, US
| | | | - Taimur Hasan
- Texas A&M University School of Medicine, Bryan, TX, US
| | - Richard Hession
- Department of Ophthalmology, University of Texas at Southwestern Medical Center, Dallas, TX, US
| | - Karanjit Kooner
- Department of Ophthalmology, University of Texas at Southwestern Medical Center, Dallas, TX, US
- Department of Ophthalmology, Veteran Affairs North Texas Health Care Medical Center, Dallas, TX US
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Wilhite K, Reid JM, Lane M. Risk of Pancreatitis With Incretin Therapies Versus Thiazolidinediones in the Veterans Health Administration. Ann Pharmacother 2023:10600280231205490. [PMID: 37881914 DOI: 10.1177/10600280231205490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Incretin therapies, comprised of the dipeptidyl peptidase-4 inhibitors (DPP-4i) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), have been increasingly utilized for the treatment of type 2 diabetes (T2DM). Previous studies have conflicting results regarding risk of pancreatitis associated with these agents-some suggest an increased risk and others find no correlation. Adverse event reporting systems indicate that incretin therapies are some of the most common drugs associated with reports of pancreatitis. OBJECTIVES This study aimed to compare the odds of developing pancreatitis in veterans with T2DM prescribed an incretin therapy versus thiazolidinediones (TZDs: pioglitazone and rosiglitazone) within the Veterans Health Administration (VHA). METHODS This was a retrospective cohort study analyzing veterans with T2DM first prescribed an incretin therapy or a TZD between January 1, 2011, and December 31, 2021. A diagnosis of pancreatitis within 365 days of being prescribed either therapy was counted as a positive case. Data was collected and analyzed utilizing VA's Informatics and Computing Infrastructure (VINCI) and an adjusted odds ratio was calculated. RESULTS The TZD cohort consisted of 42 912 patients compared with the incretin cohort of 304 811 patients. The TZD cohort had a pancreatitis incidence rate of 1.94 cases per 1000 patients. The incretin cohort had a incidence rate of 2.06 cases per 1000 patients. An adjusted odds ratio found no statistical difference of pancreatitis cases between the TZD and incretin cohorts (adjusted odds ratio [AOR] = 0.94, 95% CI [0.75, 1.18]). CONCLUSION AND RELEVANCE This retrospective cohort study of national VHA data found a relatively low incidence of pancreatitis in both cohorts, and an adjusted odds ratio found no statistical difference of pancreatitis in patients prescribed an incretin therapy compared with a control group. This data adds to growing evidence that incretin therapies do not seem to be associated with an increased risk of developing pancreatitis.
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Affiliation(s)
- Kristen Wilhite
- Department of Pharmacy, Veterans Affairs Medical Center, Louisville, KY, USA
| | - Jennifer Meyer Reid
- Department of Pharmacy, Veterans Affairs Health Care System, Lexington, KY, USA
| | - Matthew Lane
- Department of Pharmacy, Veterans Affairs Health Care System, Lexington, KY, USA
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Hemrajani A, Lo S, Vahlkamp A, Silva A, Limaye S. Concurrent Hospice Healthcare Utilization in the Hematology/Oncology Veteran's Affairs Patient Population. Am J Hosp Palliat Care 2023:10499091231206561. [PMID: 37846638 DOI: 10.1177/10499091231206561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
Objectives: Concurrent care is a unique care delivery system that allows patients to receive disease modifying treatments and other supportive interventions while also receiving the traditional benefits of hospice care. The objectives of our observational study were to examine health care utilization, use of cancer-directed therapies and palliative interventions, and location of death in patients enrolled in concurrent care. Methods: 72 hematology-oncology patients at the Hines Veteran's Affairs Medical Center (VAMC) who enrolled in concurrent care from 12/2018-4/2021 were reviewed. Data were summarized with descriptive statistics including medians and percentages. Results: A minority of patients received cytotoxic chemotherapy (27.8%), immunotherapy (20.8%), palliative radiation (20.9%), blood products (11.1%), or invasive pain procedures (4.2%). Patients also used fewer cancer-directed treatments as they approached end of life (24.4% within 30 days of death compared to 13.3% within 14 days of death). Most patients died at home (62.9%) or in inpatient hospice (12.9%) as opposed to the hospital (2.9%). Conclusions: A minority of concurrent care patients received cancer-directed therapies or additional types of health care interventions despite the option to do so. Cancer-directed treatment utilization also decreased as patients approached end of life. Patients enrolled in concurrent care were able to appreciate its benefits for longer, as the average length of stay on concurrent care was nearly 3 months.
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Affiliation(s)
- Anshu Hemrajani
- Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
| | - Shelly Lo
- Loyola University Medical Center, Maywood, IL, USA
| | | | - Abigail Silva
- Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL. USA
| | - Seema Limaye
- Edward Hines, Jr. VA Hospital, Hines, IL, USA
- Loyola University Medical Center, Maywood, IL, USA
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Chapman AB, Cordasco K, Chassman S, Panadero T, Agans D, Jackson N, Clair K, Nelson R, Montgomery AE, Tsai J, Finley E, Gabrielian S. Assessing longitudinal housing status using Electronic Health Record data: a comparison of natural language processing, structured data, and patient-reported history. Front Artif Intell 2023; 6:1187501. [PMID: 37293237 PMCID: PMC10244644 DOI: 10.3389/frai.2023.1187501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/05/2023] [Indexed: 06/10/2023] Open
Abstract
Introduction Measuring long-term housing outcomes is important for evaluating the impacts of services for individuals with homeless experience. However, assessing long-term housing status using traditional methods is challenging. The Veterans Affairs (VA) Electronic Health Record (EHR) provides detailed data for a large population of patients with homeless experiences and contains several indicators of housing instability, including structured data elements (e.g., diagnosis codes) and free-text clinical narratives. However, the validity of each of these data elements for measuring housing stability over time is not well-studied. Methods We compared VA EHR indicators of housing instability, including information extracted from clinical notes using natural language processing (NLP), with patient-reported housing outcomes in a cohort of homeless-experienced Veterans. Results NLP achieved higher sensitivity and specificity than standard diagnosis codes for detecting episodes of unstable housing. Other structured data elements in the VA EHR showed promising performance, particularly when combined with NLP. Discussion Evaluation efforts and research studies assessing longitudinal housing outcomes should incorporate multiple data sources of documentation to achieve optimal performance.
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Affiliation(s)
- Alec B. Chapman
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Salt Lake City Veterans Affairs Healthcare System, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah, School of Medicine, Salt Lake City, UT, United States
| | - Kristina Cordasco
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, United States
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Stephanie Chassman
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, United States
- Desert Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), Veterans Affairs Greater Los Angeles, Los Angeles, CA, United States
| | - Talia Panadero
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, United States
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States
| | - Dylan Agans
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, United States
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States
| | - Nicholas Jackson
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, United States
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Kimberly Clair
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, United States
| | - Richard Nelson
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, Salt Lake City Veterans Affairs Healthcare System, Salt Lake City, UT, United States
- Division of Epidemiology, University of Utah, School of Medicine, Salt Lake City, UT, United States
| | - Ann Elizabeth Montgomery
- United States Department of Veteran Affairs, Birmingham Veterans Affairs Health Care System, Birmingham, AL, United States
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jack Tsai
- National Homeless Programs Office, United States Department of Veterans Affairs, Washington, DC, United States
| | - Erin Finley
- United States Department of Veteran Affairs, Birmingham Veterans Affairs Health Care System, Birmingham, AL, United States
| | - Sonya Gabrielian
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, United States
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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Pereira V, Oyekunle T, Janes J, Amling CJ, Aronson WJ, Cooperberg MR, Kane CJ, Terris MK, Klaassen Z, Freedland SJ, Vidal AC, Csizmadi I. Time from biopsy to radical prostatectomy by race in an equal-access healthcare system: Results from the SEARCH cohort. Prostate 2023. [PMID: 37096737 DOI: 10.1002/pros.24542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 03/31/2023] [Accepted: 04/11/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND We previously showed that within an equal-access health system, race was not associated with the time between prostate cancer (PC) diagnosis and radical prostatectomy (RP). However, in the more recent time-period of the study (2003-2007), Black men had significantly longer times to RP. We sought to revisit the question in a larger study population with more contemporary patients. We hypothesized that time from diagnosis to treatment would not differ by race, even after accounting for active surveillance (AS) and the exclusion of men at very low to low risk of PC progression. METHODS We analyzed data from 5885 men undergoing RP from 1988 to 2017 at eight Veterans Affairs Hospitals from SEARCH. Multiple linear regression was used to compare time from biopsy to RP and to examine the risk of delays (>90 and >180 days) between races. In sensitivity analyses we excluded men deemed to have initially chosen AS based on having >365 days from biopsy to RP and men at very low to low PC risk for progression according to National Comprehensive Cancer Network Clinical Practice Guidelines. RESULTS At biopsy, Black men (n = 1959) were younger, had lower body mass index, and higher prostate specific antigen levels, (all p < 0.02), compared to White men (n = 3926). Time from biopsy to RP was longer in Black men (mean days: 98 vs. 92; adjusted ratio of mean number of days, 1.07 [95% confidence interval: 1.03-1.11], p < 0.001); however, there were no differences in delays >90 or >180 days after adjusting for confounders (all p ≥ 0.286). Results were similar following the exclusion of men potentially under on AS and at very low and low risk. CONCLUSIONS In an equal-access healthcare system, we did not find evidence of clinically relevant differences in time from biopsy to RP in Black versus White men.
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Affiliation(s)
- Victor Pereira
- Urology Section, Durham VA Medical Center, Durham, North Carolina, USA
| | - Taofik Oyekunle
- Urology Section, Durham VA Medical Center, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jessica Janes
- Urology Section, Durham VA Medical Center, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - William J Aronson
- Department of Surgery, Urology Section, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Urology, UCLA School of Medicine, Los Angeles, California, USA
| | - Matthew R Cooperberg
- Department of Urology, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Christopher J Kane
- Urology Department, University of California San Diego Health System, San Diego, California, USA
| | - Martha K Terris
- Section of Urology, Veterans Affairs Health Care System, Augusta, Georgia, USA
- Section of Urology, Medical College of Georgia, Augusta, Georgia, USA
| | - Zachary Klaassen
- Section of Urology, Veterans Affairs Health Care System, Augusta, Georgia, USA
- Section of Urology, Medical College of Georgia, Augusta, Georgia, USA
| | - Stephen J Freedland
- Urology Section, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Adriana C Vidal
- Center for Human Health and the Environment, North Carolina State University, Raleigh, North Carolina, USA
| | - Ilona Csizmadi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Wong RJ, Rupp L, Lu M, Yang Z, Daida YG, Schmidt M, Boscarino JA, Gordon SC, Chitnis AS. Prevalence of hepatitis B virus (HBV) and latent tuberculosis co-infection and risk of drug-induced liver injury across two large HBV cohorts in the United States. J Viral Hepat 2023; 30:512-519. [PMID: 36843435 DOI: 10.1111/jvh.13823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 02/28/2023]
Abstract
The epidemiology of latent tuberculosis and hepatitis B virus (HBV-LTBI) co-infection among U.S. populations is not well studied. We aim to evaluate LTBI testing patterns and LTBI prevalence among two large U.S. cohorts of adults with chronic HBV (CHB). Adults with CHB in the Chronic Hepatitis Cohort Study (CHeCS) and Veterans Affairs national cohort were included in the analyses. Prevalence of HBV-LTBI co-infection was defined as the number of HBV patients with LTBI divided by the number of HBV patients in a cohort. Multivariable logistic regression evaluated odds of HBV-LTBI co-infection among CHB patients who underwent TB testing. Among 6019 CHB patients in the CHeCS cohort (44% female, 47% Asian), 9.1% were tested for TB, among whom 7.7% had HBV-LTBI co-infection. Among HBV-LTBI co-infected patient, only 16.7% (n = 7) received LTBI treatment, among whom 28.6% (n = 2) developed DILI. Among 12,928 CHB patients in the VA cohort (94% male, 42% African American, 39% non-Hispanic white), 14.7% were tested for TB, among whom 14.5% had HBV-LTBI. Among HBV-LTBI co-infected patient, 18.6% (n = 51) received LTBI treatment, among whom 3.9% (n = 3) developed DILI. Presence of cirrhosis, race/ethnicity, and country of birth were observed to be associated with odds of HBV-LTBI co-infection among CHB patients who received TB testing. In summary, among two large distinct U.S. cohorts of adults with CHB, testing for LTBI was infrequent despite relatively high prevalence of HBV-LTBI co-infection. Moreover, low rates of LTBI treatment were observed among those with HBV-LTBI co-infection.
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Affiliation(s)
- Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA.,Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Loralee Rupp
- Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Mei Lu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan, USA
| | - Zeyuan Yang
- Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Yihe G Daida
- Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Portland, Oregon, USA
| | - Mark Schmidt
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | | | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System and Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Amit S Chitnis
- Tuberculosis Section, Alameda County Public Health Department, Oakland, California, USA
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Cheng ZH, Fujii D, Wong SN, Davis DM, Rosner CM, Chen JA, Bates J, Jackson J. What matters to psychology trainees when making decisions about internship and postdoctoral training sites: Differences between racial/ethnic minority and White VA trainees. Psychol Serv 2023; 20:178-187. [PMID: 34793188 PMCID: PMC9170130 DOI: 10.1037/ser0000587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
It is projected that by 2045, racial/ethnic minorities in the U.S. will become the majority. Unfortunately, the numbers of racial/ethnic minority psychologists have not kept up with population trends. This discrepancy poses challenges for many psychology training sites, including the Department of Veterans Affairs (VA). There is a lack of data on what factors are important for psychology applicants, including racial/ethnic minority trainees when they are considering internship and postdoctoral training sites. This quality improvement project surveyed 237 VA psychology trainees (59% psychology interns, 32.5% psychology postdoctoral fellows, 69.6% White, 9.3% multiracial, 6.8% Asian American or Pacific Islander, 5.1% Black/African American, 4.2% Latinx American, 0.8% Native American, 0.8% Middle Eastern) to study what factors are important when considering training sites. Results indicated that overall, racial/ethnic minority and White trainees endorsed similar primary factors when considering training programs. Site related factors (e.g., perceived workload, training opportunities) and future work related factors (e.g., ease of licensure, obtaining a first job) were top considerations regardless of race/ethnicity. The groups diverged in secondary factors with racial/ethnic minorities desiring infusion of diversity in training more than White applicants and White applicants considering quality of life factors such as extracurricular opportunities and convenience of daily living more important than racial/ethnic minority applicants. Qualitative data indicated applicants perceived VA training sites to be more welcoming and offer more opportunities for learning about diversity than non-VA sites. Recommendations for recruiting psychology trainees in general, and then specifically for racial/ethnic minority applicants are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | - Daryl Fujii
- VA Pacific Islands Health Care Services Community Living Center, Honolulu, Hawaii, United States
| | - Stephanie N. Wong
- VA Palo Alto Healthcare System, Menlo Park, California, United States
| | - Darlene M. Davis
- Aidan Behavioral Health & Consulting, Frankfort, Kentucky, United States
| | - Christine M. Rosner
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, United States
| | - Jessica A. Chen
- VA Puget Sound Health Care System, Seattle, Washington, United States
- Department of Psychiatry, University of Washington
| | - Jeffrey Bates
- U.S. Department of Veterans Affairs, Office of Academic Affiliations, Washington, DC, United States
| | - Jamylah Jackson
- Veterans Affairs North Texas Health Care System, Dallas, Texas, United States
- University of Texas Southwestern Medical Center
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10
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Boska RL, Dunlap S, Bishop TM, Goldstrom D, Tomberlin D, Baxter S, Kopacz M, Quigley KS, Harris JI. Chaplains' perspectives on standardizing spiritual assessments. Psychol Serv 2023; 20:30-39. [PMID: 36469435 PMCID: PMC10165507 DOI: 10.1037/ser0000726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Chaplains are an integral part of mental health treatment within the Veterans Health Administration (VHA) and over the past decade, efforts have been made to integrate chaplain services into behavioral health treatment. One unique duty of chaplains is to conduct spiritual assessments, which are characterized as collaborative discussions with veterans to understand their overall religious and belief system, identify spiritual injuries, and how to integrate one's spiritual values into medical care. Although spiritual assessments in Veterans Affairs Medical Centers have evolved throughout the years to adopt a more structured approach, spiritual assessments can vary depending on site, clinical setting, and medical center. The present study sought to examine chaplains' perspectives on standardizing spiritual assessments and incorporating empirically validated measures into the assessments. Thematic analysis was conducted on two focus groups of chaplains from a large VHA medical center. Overall, chaplains appeared interested in standardizing spiritual assessments, with an expressed desire to maintain their current conversational format. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Rachel L. Boska
- VA Center of Excellence for Suicide Prevention; Department of Psychiatry, University of Rochester Medical Center
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Health Care System
| | - Todd M. Bishop
- VA Center of Excellence for Suicide Prevention; Department of Psychiatry, University of Rochester Medical Center
| | | | | | | | - Marek Kopacz
- Fors Marsh Group, Military Health & Wellbeing Research, Arlington, VA
| | - Karen S. Quigley
- Department of Psychology, Northeastern University & VA Bedford Health Care System
| | - J. Irene Harris
- University of Minnesota Medical School, VA Bedford Health Care System
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11
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Yu Y, Kunac A, Oliver JB, Sehat AJ, Anjaria DJ. General Surgery Resident Complement and Operative Autonomy - Size Matters. J Surg Educ 2022; 79:e76-e84. [PMID: 36253329 DOI: 10.1016/j.jsurg.2022.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/21/2022] [Accepted: 09/11/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Operative autonomy has progressively decreased for surgery residents. This study investigates the effect of general surgery resident complement size at Veterans Affairs (VA) hospitals on operative autonomy for the residents. We hypothesize that smaller complements of residents would result in fewer opportunities for operative autonomy. DESIGN Retrospective analysis of the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. SETTING Operative cases within the VASQIP database from July 1, 2004 to September 30, 2019 were analyzed. PARTICIPANTS All general surgery procedures performed at teaching VA hospitals from January 2004 to September 2019 were included. The level of resident operative autonomy is defined as follows: attending primary surgeon with or without a resident (AP), resident primary surgeon with attending scrubbed (AR), and resident primary without attending scrubbed (RP). Resident complement is based on funded resident positions at each VA hospital during the academic year 2017-2018 and stratified into 3 groups: small (≤4), medium (>4-<7), and large (≥7). The primary outcome was the proportion of operative autonomy for each resident complement group. Secondary outcomes were level of autonomy over time, and mortality and morbidity for RP procedures. Categorical data were compared with Chi-squared test. RESULTS Four hundred sixty-one thousand seven hundred thirty-four procedures across 92 VA hospitals with general surgery residents were included in the analysis. There were 126,062 cases performed at 29 small resident complement hospitals, 135,539 at 28 medium resident complement hospitals, and 200,133 at 35 large resident complement hospitals. The percentage of RP procedures was higher with increasing resident complement (2.1% vs 6.8% vs 9.9%, p < 0.001). RP procedures have decreased over time in all groups, but the relative decrease was less pronounced as resident complement increased (79.5% vs 73.3% vs 64.7%, p < 0.001). There was no significant difference in adjusted 30-day all-cause mortality between groups. CONCLUSIONS Increased resident complement at VA hospitals is associated with increased resident autonomy in resident primary procedures. Resident autonomy has decreased over time regardless of complement size, but it is less dramatic at sites with more residents. Increasing resident complement at a site may improve operative autonomy, leading to an improved educational experience for surgical residents.
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Affiliation(s)
- Yasong Yu
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Joseph B Oliver
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Alvand J Sehat
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Devashish J Anjaria
- Department of Surgery, VA New Jersey Healthcare System, East Orange, New Jersey; Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
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12
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Giannitrapani KF, Yefimova M, McCaa MD, Goebel JR, Kutney-Lee A, Gray C, Shreve ST, Lorenz KA. Using Family Narrative Reports to Identify Practices for Improving End-of-Life Care Quality. J Pain Symptom Manage 2022; 64:349-358. [PMID: 35803554 DOI: 10.1016/j.jpainsymman.2022.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 06/07/2022] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
CONTEXT Patient experiences should be considered by healthcare systems when implementing care practices to improve quality of end-of-life care. Families and caregivers of recent in-patient decedents may be best positioned to recommend practices for quality improvement. OBJECTIVES To identify actionable practices that bereaved families highlight as contributing to high quality end-of-life care. METHODS We conducted qualitative content analysis of narrative responses to the Bereaved Family Surveys Veterans Health Administration inpatient decedents. Out of 5964 completed surveys in 2017, 4604 (77%) contained at least one word in response to the open-ended questions. For feasibility, 1500/4604 responses were randomly selected for analysis. An additional 300 randomly selected responses were analyzed to confirm saturation. RESULTS Over 23% percent (355/1500) of the initially analyzed narrative responses contained actionable practices. By synthesizing narrative responses to the BFS in a national healthcare system, we identified 98 actionable practices reported by the bereaved families that have potential for implementation in QI efforts. Specifically, we identified 67 end-of-life practices and 31 practices in patient-centered care domains of physical environment, food, staffing, coordination, technology and transportation. The 67 cluster into domains including respectful care and communication, emotional and spiritual support, death benefits, symptom management. Sorting these practices by target levels for organizational change illuminated opportunities for implementation. CONCLUSION Narrative responses from bereaved family members can yield approaches for systematic quality improvement. These approaches can serve as a menu in diverse contexts looking for approaches to improve patient quality of death in in-patient settings.
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Affiliation(s)
- Karleen F Giannitrapani
- Center for Innovation to Implementation (K.F.G., M.Y., M.D.M., J.R.G., C.G., K.A.L.), VA Palo Alto Health Care System, Menlo Park, CA, USA; Division of Primary Care and Population Health (K.F.G., K.A.L.), Stanford University School of Medicine, Stanford, CA, USA.
| | - Maria Yefimova
- Center for Innovation to Implementation (K.F.G., M.Y., M.D.M., J.R.G., C.G., K.A.L.), VA Palo Alto Health Care System, Menlo Park, CA, USA; Office of Research (M.Y.), Patient Care Services, Stanford Healthcare, Stanford, CA, USA
| | - Matthew D McCaa
- Center for Innovation to Implementation (K.F.G., M.Y., M.D.M., J.R.G., C.G., K.A.L.), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Joy R Goebel
- Center for Innovation to Implementation (K.F.G., M.Y., M.D.M., J.R.G., C.G., K.A.L.), VA Palo Alto Health Care System, Menlo Park, CA, USA; School of Nursing California State University Long Beach (J.R.G.), Long Beach CA, USA
| | - Ann Kutney-Lee
- Veteran Experience Center (A.K.L.), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; University of Pennsylvania School of Nursing (A.K.L.), Philadelphia, PA, USA
| | - Caroline Gray
- Center for Innovation to Implementation (K.F.G., M.Y., M.D.M., J.R.G., C.G., K.A.L.), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Scott T Shreve
- Hospice and Palliative Care Program (S.T.S.), US Department of Veteran Affairs, Hospice and Palliative Care Unit, Lebanon VA Medical Center, Lebanon, PA, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation (K.F.G., M.Y., M.D.M., J.R.G., C.G., K.A.L.), VA Palo Alto Health Care System, Menlo Park, CA, USA; Division of Primary Care and Population Health (K.F.G., K.A.L.), Stanford University School of Medicine, Stanford, CA, USA
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13
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Lee KM, Bryant AK, Alba P, Anglin T, Robison B, Rose BS, Lynch JA. Impact of COVID-19 on the incidence of localized and metastatic prostate cancer among White and Black Veterans. Cancer Med 2022; 12:3727-3730. [PMID: 35984395 PMCID: PMC9538539 DOI: 10.1002/cam4.5151] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/08/2022] [Accepted: 08/08/2022] [Indexed: 12/04/2022] Open
Abstract
The COVID-19 pandemic disrupted prostate-specific antigen (PSA) screening and prostate biopsy procedures. We sought to determine whether delayed screening and diagnostic workup of prostate cancer (PCa) was associated with increased subsequent rates of incident PCa and advanced PCa and whether the rates differed by race. We analyzed data from the Veterans Health Administration to assess the changes in the rates of PSA screening, prostate biopsy procedure, incident PCa, PCa with high-grade Gleason score, and incident metastatic prostate cancer (mPCa) before and after January 2020. While the late pandemic mPCa rate among White Veterans was comparable to the pre-pandemic rate (5.4 pre-pandemic vs 5.2 late-pandemic, p = 0.67), we observed a significant increase in incident mPCa cases among Black Veterans in the late pandemic period (8.1 pre-pandemic vs 11.3 late-pandemic, p < 0.001). Further investigation is warranted to fully understand the impact of the COVID-19 pandemic on the diagnosis of advanced prostate cancer.
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Affiliation(s)
- Kyung Min Lee
- VA Informatics and Computing InfrastructureVA Salt Lake City Health Care SystemSalt Lake CityUtahUSA
| | - Alex K. Bryant
- Department of Radiation OncologyVeterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA,Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Patrick Alba
- VA Informatics and Computing InfrastructureVA Salt Lake City Health Care SystemSalt Lake CityUtahUSA
| | - Tori Anglin
- VA Informatics and Computing InfrastructureVA Salt Lake City Health Care SystemSalt Lake CityUtahUSA
| | - Brian Robison
- VA Informatics and Computing InfrastructureVA Salt Lake City Health Care SystemSalt Lake CityUtahUSA
| | - Brent S. Rose
- VA San Diego Healthcare SystemSan DiegoCaliforniaUSA,Department of Radiation Medicine and Applied SciencesUniversity of California, San DiegoLa JollaCaliforniaUSA,Department of UrologyUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Julie A. Lynch
- VA Informatics and Computing InfrastructureVA Salt Lake City Health Care SystemSalt Lake CityUtahUSA
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14
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Barnes RFW, Pandey B, Sun HL, Jackson S, Kruse-Jarres R, Quon DV, von Drygalski A. Diabetes, hepatitis C and human immunodeficiency virus influence hypertension risk differently in cohorts of haemophilia patients, veterans and the general population. Haemophilia 2022; 28:e228-e236. [PMID: 35877992 DOI: 10.1111/hae.14637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/16/2022] [Accepted: 07/09/2022] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The reasons for the high prevalence of hypertension in persons with haemophilia (PWH) are poorly understood. AIM To examine the roles of diabetes, Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) in the etiology of hypertension for PWH. METHODS Retrospective cross-sectional design. Adult PWH (n = 691) were divided into two groups: (A) free of diabetes, HCV and HIV; (B) with diabetes and/or HCV positivity and/or HIV positivity. Each group was matched by race and age with random samples from the general population of the US (National Health and Nutrition Examination Surveys, NHANES) and outpatients at the Veterans Affairs Medical Center (VAMC) in San Diego. Generalized additive models (GAMs) were fitted for graphical analysis of hypertension risk over the lifespan. RESULTS In Group A, PWH had the highest prevalence of hypertension compared to NHANES and VAMC, especially in young adults. In Group B, diabetes increased the risk of hypertension for all three cohorts (PWH, NHANES and VAMC), especially for PWH. In PWH, hypertension risk was also increased by HIV, in NHANES by HCV, and in VAMC by HCV and HIV. CONCLUSION Diabetes conferred the greatest risk of hypertension for all three cohorts. However, curves of hypertension in relation to age revealed that diabetes, HCV and HIV modulated hypertension risk differently in PWH. PWH experienced a disproportionally high risk increase with diabetes. Therefore, haemophilia care should include screening for hypertension and diabetes at a young age.
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Affiliation(s)
- Richard F W Barnes
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Braj Pandey
- Department of Medicine, University of California San Diego, San Diego, California, USA.,Department of Primary Care, Veterans Affairs Medical Center, San Diego, California, USA
| | | | | | - Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders at Bloodworks Northwest, Seattle, Washington, USA
| | - Doris V Quon
- Orthopaedic Institute for Children, Los Angeles, California, USA
| | - Annette von Drygalski
- Department of Medicine, University of California San Diego, San Diego, California, USA
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15
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Wang Z, Zuschlag ZD, Myers US, Hamner M. Atomoxetine in comorbid ADHD/PTSD: A randomized, placebo controlled, pilot, and feasibility study. Depress Anxiety 2022; 39:286-295. [PMID: 35312136 DOI: 10.1002/da.23248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/24/2022] [Accepted: 02/26/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND PTSD and ADHD often occur comorbidly. Research indicates that the cognitive deficits in PTSD may be related to the same disturbance of fronto-temporal systems as observed in ADHD, and ADHD has been shown to impact PTSD treatment outcomes. The presented study evaluated the safety and efficacy of atomoxetine in Veterans with comorbid ADHD/PTSD. METHODS A double blind, randomized, placebo controlled, cross-over pilot and feasibility study was conducted. Atomoxetine was examined as an adjunctive treatment over this 10 weeks, two phase, crossover study which compared treatment with atomoxetine 80 mg daily to placebo daily. The primary outcome was improvement in ADHD symptoms as measured by the Conners' Adult ADHD Rating Scales-Self-Report: Short Version (CAARS-S:S), the Barkley Adult ADHD Rating Scale-IV (BAARS-IV), and the Adult ADHD Quality of Life-29 (AAQoL-29). Secondary outcomes included the Clinician Administered PTSD Scale (CAPS), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and the response inhibition task Go/NoGo (GNG). RESULTS Atomoxetine treated patients had greater reductions in ADHD symptoms as defined by total scores on the CAARS-S:S (F(1, 29) = 6.37, p = .017); both the BAARS-IV (F(1, 26) = 3.16, p = .087); and GNG overall errors test (F(1, 29) = 3.88, p = .06), reached a trend level of significance. No significant differences were noted in quality of life assessments, GNG latency periods, or CAPS scores. Atomoxetine was well-tolerated with no serious adverse events observed. CONCLUSIONS In Veterans with ADHD comorbid with PTSD, atomoxetine demonstrated modest efficacy for ADHD symptoms; quality of life measures and PTSD symptoms were not affected.
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Affiliation(s)
- Zhewu Wang
- Mental Health Services, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zachary D Zuschlag
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans' Hospital, Tampa, Florida, USA.,Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, Florida, USA
| | - Ursula S Myers
- Mental Health Services, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA.,Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - Mark Hamner
- Mental Health Services, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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16
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Pandey B, Barnes RFW, Sun HL, Jackson S, Kruse-Jarres R, Quon DV, von Drygalski A. Risk of diabetes in haemophilia patients compared to clinic and non-clinic control cohorts. Haemophilia 2022; 28:445-452. [PMID: 35238443 DOI: 10.1111/hae.14515] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/19/2022] [Accepted: 02/04/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Ageing patients with haemophilia (PWH) develop cardiovascular risk factors impacting care. Little is known about the prevalence of diabetes in PWH and its relation to other comorbidities. AIM To examine the risk of diabetes for adult PWH compared to men from the general United States population (National Health and Nutrition Examination Surveys [NHANES]) and outpatients attending a Veterans Affairs Medical Center (VAMC) clinic. METHODS Retrospective cross-sectional design. PWH from four haemophilia centres (n = 690) were matched with random samples from NHANES and VAMC. Diabetes (yes/no) was the outcome, while age, body mass index (BMI), race and Hepatitis C (HCV; by serology) and human immunodeficiency virus (HIV) positivity were covariates. We fitted semiparametric generalized additive models (GAMs) in order to compare diabetes risk between cohorts. RESULTS Younger PWH were at lower risk of diabetes than NHANES or VAMC subjects irrespective of BMI. However, the risk of diabetes rose in older PWH and was closely associated with HCV. For HCV-negative subjects, the risk of diabetes was considerably lower for PWH than NHANES and VAMC subjects. The difference persisted after controlling for BMI and age, indicating that the low risk of diabetes in PWH cannot be explained by lean body mass alone. CONCLUSION Since many ageing PWH are HCV positive and therefore at heightened risk for diabetes, it is important to incorporate diabetes screening into care algorithms in Haemophilia Treatment Centers, especially since PWH are not always followed in primary care clinics.
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Affiliation(s)
- Braj Pandey
- Department of Primary Care, Veterans Affairs Medical Center, San Diego, California, USA.,Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Richard F W Barnes
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | | | | | | | - Doris V Quon
- Washington Center for Bleeding Disorders at Bloodworks NorthWest, Seattle, Washington, USA
| | - Annette von Drygalski
- Department of Medicine, University of California San Diego, San Diego, California, USA
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17
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Gerlach LB, Van T, Kim HM, Chang MUM, Bohnert KM, Zivin K. Trends in Incident Varenicline Prescribing Among Veterans Following the US Food and Drug Administration Drug Safety Warnings. J Clin Psychiatry 2021; 83:20m13763. [PMID: 34936245 PMCID: PMC8711607 DOI: 10.4088/jcp.20m13763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Objective: To evaluate national trends in incident varenicline and nicotine replacement therapy (NRT) prescribing among Department of Veterans Affairs (VA) beneficiaries before and after US Food and Drug Administration (FDA) warnings regarding neuropsychiatric side effects with varenicline use. Methods: All adult VA patients identified as smokers from 2007 to 2019 (N = 3,600,947) were determined and monthly counts of new varenicline and NRT users were calculated. An interrupted time-series analysis estimated the effect of the FDA warnings on varenicline and NRT prescribing overall and among Veterans with and without mental health disorders. Results: The incident use rate of varenicline decreased from a peak of 6.2 per 1,000 veteran smokers in October 2007 to 1.0 by July 2009 following the first FDA warning (pre-warning monthly slope = -0.27; P = .03). New NRT use increased from 10.7 per 1,000 veteran smokers in October 2007 to a peak of 12.6 per 1,000 in July 2009 (slope change = 0.71; P = .01), suggesting potential substitution. Following removal of the FDA boxed warning in December 2016, varenicline prescribing increased but did not return to pre-warning levels by December 2019. Among veterans with and without mental health disorders, varenicline use decreased 90% and 88%, respectively, following the first FDA warning, and both groups had comparable rates of new NRT use. Conclusions: Following the first FDA warning, incident use of varenicline declined significantly among veterans both with and without mental health disorders. Despite removal of the FDA boxed warning in December 2016, new use of varenicline had not returned to pre-warning levels 3 years following the removal.
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Affiliation(s)
- Lauren B. Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Tony Van
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Hyungjin Myra Kim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Ming-Un Myron Chang
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Kipling M. Bohnert
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
| | - Kara Zivin
- Department of Psychiatry, University of Michigan, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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18
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Yanke E, Moriarty H, Carayon P, Safdar N. "The Invisible Staff": A Qualitative Analysis of Environmental Service Workers' Perceptions of the VA Clostridium difficile Prevention Bundle Using a Human Factors Engineering Approach. J Patient Saf 2021; 17:e806-e814. [PMID: 29894437 PMCID: PMC6800805 DOI: 10.1097/pts.0000000000000500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 12/15/2022]
Abstract
OBJECTIVES Using a novel human factors engineering approach, the Systems Engineering Initiative for Patient Safety model, we evaluated environmental service workers' (ESWs) perceptions of barriers and facilitators influencing adherence to the nationally mandated Department of Veterans Affairs Clostridium difficile infection (CDI) prevention bundle. METHODS A focus group of ESWs was conducted. Qualitative analysis was performed employing a visual matrix display to identify barrier/facilitator themes related to Department of Veterans Affairs CDI bundle adherence using the Systems Engineering Initiative for Patient Safety work system as a framework. RESULTS Environmental service workers reported adequate cleaning supplies/equipment and displayed excellent knowledge of CDI hand hygiene requirements. Environmental service workers described current supervisory practices as providing an acceptable amount of time to clean CDI rooms, although other healthcare workers often pressured ESWs to clean rooms more quickly. Environmental service workers reported significant concern for CDI patients' family members as well as suggesting uncertainty regarding the need for family members to follow infection prevention practices. Small and cluttered patient rooms made cleaning tasks more difficult, and ESW cleaning tasks were often interrupted by other healthcare workers. Environmental service workers did not feel comfortable asking physicians for more time to finish cleaning a room nor did ESWs feel comfortable pointing out lapses in physician hand hygiene. CONCLUSIONS Multiple work system components serve as barriers to and facilitators of ESW adherence to the nationally mandated Department of Veterans Affairs CDI bundle. Environmental service workers may represent an underappreciated resource for hospital infection prevention, and further efforts should be made to engage ESWs as members of the health care team.
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Affiliation(s)
- Eric Yanke
- Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Helene Moriarty
- Villanova University M. Louise Fitzpatrick College of Nursing, Villanova, Pennsylvania and Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Hospital and Division of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School and Infection Control Department, University of Wisconsin-Madison, Madison, Wisconsin
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19
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Stroupe KT, Martinez R, Hogan TP, Gordon EJ, Gonzalez B, Tarlov E, Silva A, Huo Z, Kale I, Ippolito D, Osteen C, Jordan N, French DD, Gordon H, Fischer MJ, Smith BM. Health Insurance Coverage Among Veterans Receiving Care From VA Health Care Facilities. Med Care Res Rev 2021; 79:511-524. [PMID: 34622682 DOI: 10.1177/10775587211048661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Reasons for acquiring insurance outside Department of Veterans Affairs (VA) health care coverage among VA enrollees are incompletely understood. To assess Veterans' decision-making and acquisition of non-VA health care insurance in the Affordable Care Act era, we used mailed questionnaires and semistructured interviews in a stratified random sample of VA enrollees <65 years in the Midwest. Of the 3,666 survey participants, 32.1% reported non-VA insurance. Frequently reported reasons included wanting coverage for emergency situations or family members. Those without non-VA insurance cited unaffordability as the main obstacle. Analysis of the semistructured interview data revealed similar findings. In multivariable logistic regression analyses, characteristics associated with non-VA insurance included higher income (>$50,000 vs. <$10,000, odds ratio [OR] = 5.95, 95% confidence interval [CI]: 3.45-10.3, p < .001). As financial barriers exist for acquisition of non-VA insurance and hence community care, it is critically important that VA enrollees' health care needs are met through VA or community providers financed through VA.
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Affiliation(s)
- Kevin T Stroupe
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA.,Loyola University Chicago, Maywood, IL, USA
| | - Rachael Martinez
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA
| | - Timothy P Hogan
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,The University of Texas Southwestern Medical Center, Dallas, USA
| | | | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA
| | - Elizabeth Tarlov
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA.,University of Illinois at Chicago, USA
| | - Abigail Silva
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA.,Loyola University Chicago, Maywood, IL, USA
| | - Zhiping Huo
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA
| | - Ibuola Kale
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA
| | - Dolores Ippolito
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA
| | - Chad Osteen
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA
| | - Neil Jordan
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA.,Northwestern University, Chicago, IL, USA
| | - Dustin D French
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA.,Northwestern University, Chicago, IL, USA
| | - Howard Gordon
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA.,University of Illinois at Chicago, USA.,Jesse Brown Veterans Affairs Medical Center, Chicago, IL, USA
| | - Michael J Fischer
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA.,University of Illinois at Chicago, USA.,Jesse Brown Veterans Affairs Medical Center, Chicago, IL, USA
| | - Bridget M Smith
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, IL, USA.,Northwestern University, Chicago, IL, USA
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20
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Rabiee A, Taddei T, Aytaman A, Rogal SS, Kaplan DE, Morgan TR. Development and Implementation of Multidisciplinary Liver Tumor Boards in the Veterans Affairs Health Care System: A 10-Year Experience. Cancers (Basel) 2021; 13:4849. [PMID: 34638333 DOI: 10.3390/cancers13194849] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 12/24/2022] Open
Abstract
In this perspective piece, we summarize the development and implementation of multidisciplinary liver tumor boards across the Veterans Affairs health care system dating back to 2010. Referral to multidisciplinary tumor boards (MDLTB) has been demonstrated to decrease the number of unnecessary invasive procedures, reduce health care costs and maximize patient outcomes. Although the VA is the largest single care provider in the US, there is significant heterogeneity in healthcare delivery. We have shown that receiving care at VA centers with MDLTB is associated with higher odds of receiving active therapy and a 13% reduction in mortality. Access to expert hepatology care appears to be one of the critical benefits of MDLTB resulting in 30% reduction in mortality. Integrated health care systems such as the VA have the unique capability of implementing virtual tumor boards that can easily overcome geographic barriers and standardize care across multiple facilities regardless of their access to hepatology or other disciplines. Significant barriers remain requiring implementation plans. This document serves as a roadmap to establish multidisciplinary tumor boards, including standardization of imaging reports, identifying stake holders who need to be present at tumor board, institution buy-in, and specifics for local, regional and integrated service network tumor boards.
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21
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Bramoweth AD, Tighe CA, Berlin GS. Insomnia and Insomnia-Related Care in the Department of Veterans Affairs: An Electronic Health Record Analysis. Int J Environ Res Public Health 2021; 18:8573. [PMID: 34444321 PMCID: PMC8394102 DOI: 10.3390/ijerph18168573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/18/2022]
Abstract
The objective was to examine insomnia and insomnia-related care within a regional network of Department of Veterans Affairs (VA) facilities since the VA roll-out of cognitive behavioral therapy for insomnia (CBT-I) in 2011. A retrospective analysis of VA electronic health records (EHR) data from 2011 to 2019 was conducted. The annual and overall prevalence of four insomnia indicators was measured: diagnoses, medications, consultations for assessment/treatment, and participation in CBT-I. Also examined were sociodemographic and clinical differences among veterans with and without an insomnia indicator, as well as differences among the four individual insomnia indicators. The sample included 439,887 veterans, with 17% identified by one of the four indicators; medications was most common (15%), followed by diagnoses (6%), consults (1.5%), and CBT-I (0.6%). Trends over time included increasing yearly rates for diagnoses, consults, and CBT-I, and decreasing rates for medications. Significant differences were identified between the sociodemographic and clinical variables across indicators. An evaluation of a large sample of veterans identified that prescription sleep medications remain the best way to identify veterans with insomnia. Furthermore, insomnia continues to be under-diagnosed, per VA EHR data, which may have implications for treatment consistent with clinical practice guidelines and may negatively impact veteran health.
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Affiliation(s)
- Adam D. Bramoweth
- VISN 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151RU/MIRECC), University Drive, Pittsburgh, PA 15240, USA;
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151C), University Drive, Pittsburgh, PA 15240, USA
| | - Caitlan A. Tighe
- VISN 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151RU/MIRECC), University Drive, Pittsburgh, PA 15240, USA;
| | - Gregory S. Berlin
- VA Connecticut Healthcare System, 950 Campbell Avenue (116B), West Haven, CT 06516, USA;
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, New Haven, CT 06511, USA
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22
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Vangala C, Shah M, Dave NN, Attar LA, Navaneethan SD, Ramanathan V, Crowley S, Winkelmayer WC. The landscape of renal replacement therapy in Veterans Affairs Medical Center intensive care units. Ren Fail 2021; 43:1146-1154. [PMID: 34261420 PMCID: PMC8280999 DOI: 10.1080/0886022x.2021.1949347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Outpatient dialysis is standardized with several evidence-based measures of adequacy and quality that providers aim to meet while providing treatment. By contrast, in the intensive care unit (ICU) there are different types of prolonged and continuous renal replacement therapies (PIRRT and CRRT, respectively) with varied strategies for addressing patient care and a dearth of nationally accepted quality parameters. To eventually describe appropriate quality measures for ICU-related renal replacement therapy (RRT), we first aimed to capture the variety and prevalence of basic strategies and equipment utilized in the ICUs of Veteran Affairs (VA) medical facilities with inpatient hemodialysis capabilities. Methods Via email to the dialysis directors of all VA facilities that provided inpatient hemodialysis during 2018, we requested survey participation regarding aspects of RRT in VA ICUs. Questions centered around the mode of therapy, equipment, solutions, prescription authority, nursing, anticoagulation, antimicrobial dosing, and access. Results Seventy-six centers completed the questionnaire, achieving a response rate of 87.4%. Fifty-five centers reported using PIRRT or CRRT in addition to intermittent hemodialysis. Of these centers, 42 reported being specifically CRRT-capable. Over half of respondents had the capabilities to perform PIRRT. Twelve centers (21.8%) were equipped to use slow low efficient dialysis (SLED) alone. Therapy was largely prescribed by nephrologists (94.4% of centers). Conclusions Within the VA system, ICU-related RRT practice is quite varied. Variation in processes of care, prescription authority, nursing care coordination, medication management, and safety practices present opportunities for developing cross-cutting measures of quality of intensive care RRT that are agnostic of modality choice.
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Affiliation(s)
- Chandan Vangala
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Houston Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
| | - Maulin Shah
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Natasha N Dave
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | | | - Sankar D Navaneethan
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Venkat Ramanathan
- Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Susan Crowley
- Yale School of Medicine, New Haven, CT, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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23
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Khosla R, Delio J, Glass LN, Khosla SG, Awan O, Bawa A, Vyas K. In-Hospital Cardiac Arrest (IHCA) and Outcomes in Patients Admitted With COVID-19 Infection. Cureus 2021; 13:e15365. [PMID: 34239796 PMCID: PMC8247063 DOI: 10.7759/cureus.15365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 01/08/2023] Open
Abstract
During the COVID-19 pandemic, many patients are hospitalized, and those suffering from in-hospital cardiac arrest (IHCA) have been previously reported to have poor outcomes. This is a single-center, retrospective, observational study conducted at the Veterans Affairs Medical Center, Washington, DC, USA. The inclusion criteria were: patients admitted to the hospital with a diagnosis of COVID-19 who underwent cardiopulmonary resuscitation (CPR) for IHCA. Patients were labeled as COVID-19 positive based on a laboratory-confirmed positive polymerase chain reaction test. Patients with do-not-resuscitate (DNR) orders, those who were made comfort care, or enrolled in hospice were excluded. The study was approved by the hospital’s institutional review board. A total of 155 patients with COVID-19 infection were admitted; 145/155 (93.5%) admitted to the medical floor and 10/155 (6.5%) to the medical intensive care unit (MICU). 36/145 (24.8%) floor patients were upgraded to MICU. Of the 46 patients treated in MICU, 17/46 (36.9%) were excluded for DNR status. From the remaining 29/46 (63.1%) patients, 19/29 (65.5%) patients survived, and 10/29 (34.5%) patients had IHCA. All 10/10 (100%) died after CPR without return of spontaneous circulation (ROSC). The initial rhythm was non-shockable in all patients, with pulseless electrical activity (PEA) in 7/10 (70%) and asystole in 3/10 (30%) patients. Patients with COVID-19 infection who had an IHCA and underwent CPR had a 0% survival at our hospital. Discussions on advanced care options, especially CPR, with COVID-19 patients and their families, are important as the overall prognosis after CPR for IHCA is poor.
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Affiliation(s)
- Rahul Khosla
- Pulmonary and Critical Care Medicine, Veterans Affairs Medical Center, Washington, USA
| | - Joseph Delio
- Pulmonary and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Lisa N Glass
- Pulmonary and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Shikha G Khosla
- Endocrinology, Diabetes and Metabolism, Veterans Affairs Medical Center, Washington, USA
| | - Omar Awan
- Pulmonary and Critical Care Medicine, Veterans Affairs Medical Center, Washington, USA
| | - Amandeep Bawa
- Pulmonary and Critical Care Medicine, Veterans Affairs Medical Center, Washington, USA
| | - Kavita Vyas
- Pulmonary and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, USA.,Pulmonary and Critical Care Medicine, Veterans Affairs Medical Center, Washington, USA
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24
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Tran JE, Fowler CA, Delikat J, Kaplan H, Merzier MM, Schlesinger MR, Litzenberger S, Marszalek JM, Scott S, Winkler SL. Immersive Virtual Reality to Improve Outcomes in Veterans With Stroke: Protocol for a Single-Arm Pilot Study. JMIR Res Protoc 2021; 10:e26133. [PMID: 33970110 PMCID: PMC8145080 DOI: 10.2196/26133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Over the last decade, virtual reality (VR) has emerged as a cutting-edge technology in stroke rehabilitation. VR is defined as a type of computer-user interface that implements real-time simulation of an activity or environment allowing user interaction via multiple sensory modalities. In a stroke population, VR interventions have been shown to enhance motor, cognitive, and psychological recovery when utilized as a rehabilitation adjunct. VR has also demonstrated noninferiority to usual care therapies for stroke rehabilitation. OBJECTIVE The proposed pilot study aims to (1) determine the feasibility and tolerability of using a therapeutic VR platform in an inpatient comprehensive stroke rehabilitation program and (2) estimate the initial clinical efficacy (effect size) associated with the VR platform using apps for pain distraction and upper extremity exercise for poststroke neurologic recovery. METHODS This study will be conducted in the Comprehensive Integrated Inpatient Rehabilitation Program at the James A Haley Veterans' Hospital. Qualitative interviews will be conducted with 10 clinical staff members to assess the feasibility of the VR platform from the clinician perspective. A prospective within-subject pretest-posttest pilot design will be used to examine the tolerability of the VR platform and the clinical outcomes (ie, upper extremity neurologic recovery, hand dexterity, pain severity) in 10 veteran inpatients. A VR platform consisting of commercially available pain distraction and upper extremity apps will be available at the participants' bedside for daily use during their inpatient stay (approximately 4-6 weeks). Clinician interviews will be analyzed using qualitative descriptive analysis. Cohen d effect sizes with corresponding 95% CIs will be calculated for upper extremity neurologic recovery, hand dexterity, and pain. The proportion of participants who achieve minimal clinically important difference after using the VR platform will be calculated for each clinical outcome. RESULTS This study was selected for funding in August 2020. Institutional review board approval was received in October 2020. The project start date was December 2020. The United States Department has issued a moratorium on in-person research activities secondary to COVID-19. Data collection will commence once this moratorium is lifted. CONCLUSIONS Our next step is to conduct a large multi-site clinical trial that will incorporate the lessons learned from this pilot feasibility study to test the efficacy of a VR intervention in inpatient rehabilitation and transition to home environments. When VR is used in patients' rooms, it serves to provide additional therapy and may reduce clinician burden. VR also presents an opportunity similar to home-based practice exercises. VR can be implemented in both clinical settings and people's own homes, where engagement in ongoing self-management approaches is often most challenging. This unique experience offers the potential for seamless transition from inpatient rehabilitation to the home. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/26133.
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Affiliation(s)
- Johanna E Tran
- Physical Medicine and Rehabilitation Service, James A Haley Veterans' Hospital, Tampa, FL, United States.,Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Christopher A Fowler
- Research and Development Service, James A Haley Veterans' Hospital, Tampa, FL, United States.,Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Jemy Delikat
- Research and Development Service, James A Haley Veterans' Hospital, Tampa, FL, United States
| | - Howard Kaplan
- Advanced Visualization Center, Information Technology and Research Computing, University of South Florida, Tampa, FL, United States
| | - Marie M Merzier
- Research and Development Service, James A Haley Veterans' Hospital, Tampa, FL, United States
| | - Michelle R Schlesinger
- Physical Medicine and Rehabilitation Service, James A Haley Veterans' Hospital, Tampa, FL, United States
| | - Stefan Litzenberger
- Physical Medicine and Rehabilitation Service, James A Haley Veterans' Hospital, Tampa, FL, United States.,Department of Physical Medicine and Rehabilitation, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Jacob M Marszalek
- Research and Development Service, James A Haley Veterans' Hospital, Tampa, FL, United States.,Department of Psychology, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Steven Scott
- Polytrauma Rehabilitation Center, James A Haley Veterans' Hospital, Tampa, FL, United States.,Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Sandra L Winkler
- Research and Development Service, James A Haley Veterans' Hospital, Tampa, FL, United States.,Department of Occupational Therapy, Nova Southeastern University, Fort Lauderdale, FL, United States
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25
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Patel PK. One Size Doesn't Fit All-Stewardship Interventions Need To Be Tailored in Large Healthcare Systems. Clin Infect Dis 2021; 71:1177-1178. [PMID: 31673710 DOI: 10.1093/cid/ciz946] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/26/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Payal K Patel
- Division of Infectious Diseases, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor, Michigan, USA
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26
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Keating S, Larsen SE, Collingwood J, Smith HM. The Individualized Addictions Consultation Team Residential Program: A Creative Solution for Integrating Care for Veterans With Substance Use Disorders Too Complex for Other Residential Treatment Programs. J Dual Diagn 2021; 17:172-179. [PMID: 33583351 DOI: 10.1080/15504263.2021.1881685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The Veterans Affairs (VA) healthcare system is one of the main providers of substance use treatment within the United States, and many veterans with a substance use disorder (SUD) present with co-occurring diagnoses or other concerns. Though there has been increasing recognition of the need for integration of treatments for SUD and comorbid mental illness, there have been limited studies of such programs, particularly within the VA healthcare system. To address that gap in the literature, this paper examines treatment outcomes in an integrated model of dual diagnosis residential treatment for veterans: the Individualized Addictions Consultation Team (I-ACT) program. Methods: The current paper draws from clinical outcome evaluation data within a residential treatment program at a large Midwestern VA Medical Center (VAMC). The I-ACT program provides residential substance abuse treatment to individuals with a primary SUD and other factors that interfere with the successful completion of a traditional residential rehabilitation program. Between 2017 and 2018, 130 individuals (97.7% men, average age = 60.62 years) entered the I-ACT program. As part of standard measurement-based care, veterans were administered the Brief Addiction Monitor and the Patient Health Questionnaire-9 at admission and discharge. Results: Most individuals (74.6%) who entered I-ACT completed the residential program (average length of stay 34.2 days). Scores on both measures significantly decreased from intake to discharge (p < .001), with the change in depression scores indicating clinically significant improvement. Those with an additional mental health diagnosis achieved similar decreases in substance use symptoms and had lower depression scores at discharge than those with a SUD alone. Conclusions: Our results indicate that even for veterans who may not benefit from traditional SUD treatment programs, a more integrated and personalized residential program can be effective.
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Affiliation(s)
- Sarah Keating
- Mental Health, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA.,Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sadie E Larsen
- Mental Health, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA.,Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jane Collingwood
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Heather M Smith
- Mental Health, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA.,Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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27
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Shapiro CBH, Cheung RC, Giori NJ. Prevalence of Hepatitis C Virus Infection in the Veteran Population Undergoing Total Joint Arthroplasty: An Update. J Arthroplasty 2021; 36:467-70. [PMID: 32900563 DOI: 10.1016/j.arth.2020.08.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In 2012, we reported on the prevalence of hepatitis C virus (HCV) infection in Veterans Affairs (VA) patients undergoing total joint arthroplasty (TJA) at our center. In this patient population, 8.4% were antibody positive and 4.5% were viremic with HCV. In 2014, the first all-oral direct-acting antiviral treatment for hepatitis C became available. The Department of Veterans Affairs then underwent an aggressive program to eradicate hepatitis C from the veteran population. The purpose of this report is to provide updated information on the prevalence of HCV viremia among patients undergoing primary TJA at the same center. METHODS A retrospective review was performed of all patients undergoing primary TJA at a single VA medical center in 2019. Anti-HCV antibody and HCV viremia prevalence were calculated. Comparisons were made to data from a previously reported cohort of patients who had undergone TJA at the same center from 2007 to 2009. RESULTS Thirty-three (11.6%) of 285 patients screened preoperatively were positive for the hepatitis C antibody. Only one of the 33 anti-HCV-positive patients was viremic at the time of screening for an overall viremic prevalence of 0.4%. We found no statistically significant difference in the birth year, or anti-HCV antibody-positive rate from the prior cohort, but the prevalence of HCV viremia decreased significantly. CONCLUSION Because direct-acting antiviral HCV treatment has become available, HCV viremia among VA patients undergoing TJA has been reduced from 4.5% to 0.4%. Surgeons are still advised to minimize the risk of sharps injury.
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28
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Friedes C, Klingensmith J, Nimo N, Gregor J, Burri R. Late Feeding Tube Dependency in Head and Neck Cancer Patients Treated with Definitive Radiation Therapy and Concurrent Systemic Therapy. Cureus 2020; 12:e7683. [PMID: 32426195 PMCID: PMC7228799 DOI: 10.7759/cureus.7683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective The study aimed to evaluate the impact of late swallowing dysfunction leading to percutaneous endoscopic gastrostomy (PEG) tube dependence on the overall survival (OS) in a cohort of locally advanced head and neck cancer patients treated and cured with definitive radiotherapy (RT) and concurrent systemic therapy (CST). Materials and methods A total of 62 patients with locally advanced head and neck cancer were included in the analysis based on the following selection criteria: stage III, IVA, or IVB disease, treated with definitive RT and CST, no major head and neck surgery, no evidence of local or distant recurrent disease, and at least one post-RT modified barium swallow study. Patients were classified as PEG dependent or PEG independent at the time of the last follow-up. Estimates of OS were calculated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to evaluate the impact of various clinical factors on OS. Results The median follow-up was 48 months (range: 7.6-235 months). The five-year OS was 64.3% in the PEG-dependent group and 86.1% in the PEG-independent group (p=0.022). Age over 70 at diagnosis was also associated with poorer OS (p=0.044). On univariate analysis, PEG dependency maintained a significantly worse OS (hazard ratio [HR]: 2.59; 95% confidence interval [CI]: 1.11-5.99, p=0.028). On multivariate analysis, PEG dependency (HR: 4.25; 95% CI: 1.33-13.62; p=0.015), advanced N stage (HR: 4.74; 95% CI: 1.17-19.26, p=0.035), and older age at diagnosis (HR: 4.37; 95% CI: 1.21-15.84; p=0.025) were significantly associated with worse OS. Conclusions Late PEG dependency is associated with poor OS in head and neck cancer patients cured with definitive RT and CST. Interventions designed to help head and neck cancer patients maintain swallowing function may result in improved outcomes.
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Affiliation(s)
- Cole Friedes
- Medicine, University of Central Florida College of Medicine, Orlando, USA
| | | | - Nana Nimo
- Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | | | - Ryan Burri
- Radiation Oncology, C.W. Bill Young Veterans Affairs Medical Center, Bay Pines, USA
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29
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Scott GD, Osborne TF, Gross SP, Fong D. Value-Based Intervention with Hospital and Pathology Laboratory Informatics: A Case of Analytics and Outreach at the Veterans Affairs. J Pathol Inform 2020; 11:8. [PMID: 32318316 PMCID: PMC7161590 DOI: 10.4103/jpi.jpi_67_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/24/2020] [Accepted: 02/05/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Laboratory tests are among the most ordered tests and account for a large portion of wasted health-care spending. Meta-analyses suggest that the most promising interventions at improving health-care value and reducing cost are low investment strategies involving simple changes to ordering systems. The veterans affairs (VA) has a 2018–2024 strategic objective to reduce wasted spending through data- and performance-focused decision-making. Methods: VA Palo Alto Healthcare System laboratory utilization data were obtained from multiple sources, including the VA Corporate Data Warehouse and utilization reports from reference laboratory. Ordering volume, test results, and follow-up clinical impact data were collected and evaluated in partnership with the treating physicians and hospital informatics in order to optimize ordering sets. Results: Dextromethorphan (Dext) and synthetic cannabinoid testing were identified as the lowest value tests based on a three-tier score of negativity rate, volume, and cost. In partnership with the ordering physicians and hospital informatics, reflexive testing was eliminated, resulting in persistent decreases in the volume of Dext (162–10 tests/month) and synthetic cannabinoid tests (155–19 tests/month) ordered. The proportion of unnecessary repeat tests also dropped from 71.5% to 5.5%, the test positivity rate increased from 0.87% to 3.49%, and the approximate monthly cost of both tests decreased ten-fold from $21,250 to $2087 for a yearly savings of $229,000 at a single VA. Conclusions: Improved laboratory utilization is central to the VA’ strategic objective to reduce waste. A relatively simple intervention involving partnership with the treating physicians and hospital informatics in combination with data- and performance-focused decision-making can yield substantial reductions in health-care waste.
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Affiliation(s)
- Gregory D Scott
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Pathology, Palo Alto Division, Veterans Affairs Health Care System, Palo Alto, CA, USA
| | - Thomas F Osborne
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Radiology, VA Palo Alto Healthcare System, Veterans Affairs Health Care System, Palo Alto, CA, USA
| | - Sang P Gross
- Department of Pathology, Palo Alto Division, Veterans Affairs Health Care System, Palo Alto, CA, USA
| | - Dean Fong
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Pathology, Palo Alto Division, Veterans Affairs Health Care System, Palo Alto, CA, USA
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30
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Wray CM, Vali M, Abraham A, Zhang A, Walter LC, Keyhani S. Validation of Administrative Measures of Social and Behavioral Risk in Veterans Affairs Medical Records. J Gen Intern Med 2019; 34:796-798. [PMID: 30604115 PMCID: PMC6544671 DOI: 10.1007/s11606-018-4792-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Charlie M Wray
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA. .,Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, Clement Street, San Francisco, CA, USA.
| | - Marzieh Vali
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Ann Abraham
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Alysandra Zhang
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Louise C Walter
- Division of Geriatrics, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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31
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Taylor LJ, Xu K, Maloney JD, Voils CI, Weber SM, Funk LM, Abbott DE. Deficiencies in postoperative surveillance for veterans with gastrointestinal cancer. J Surg Oncol 2018; 119:273-277. [PMID: 30554412 DOI: 10.1002/jso.25333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/26/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES National guidelines for gastrointestinal (GI) cancers offer surveillance algorithms to facilitate detection of recurrent disease, yet adherence rates are unknown. We sought to characterize postoperative surveillance patterns for veterans with GI cancer at a tertiary care Veterans Affairs Hospital. METHODS A single-center retrospective cohort study identified patients who underwent surgical resection for colorectal, gastroesophageal or hepatopancreaticobiliary malignancy from 2010-2016. We calculated the annual rate of cancer-directed clinic visits and abdominal imaging and used National Comprehensive Cancer Network guidelines as a benchmark by which to assess adequate surveillance. RESULTS Ninety-seven patients met inclusion criteria. Median surveillance time was 1203 days. Overall, 44% of patients had insufficient surveillance. Specifically, 11% received no postoperative imaging and 7% had no cancer-directed clinic visits. An additional 30% received less than recommended surveillance imaging and 12% attended fewer than recommended clinic visits. By disease site, insufficient imaging was most common for patients with hepatopancreaticobiliary cancer (63%), while inadequate clinic follow-up was highest for colorectal cancer (24%). CONCLUSION A significant proportion of veterans with GI cancer received either inadequate postoperative surveillance based on national guidelines. This deficiency represents an opportunity for improvement through targeted efforts, including telemedicine and education of patients and providers.
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Affiliation(s)
- Lauren J Taylor
- Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kerui Xu
- Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - James D Maloney
- Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Corrine I Voils
- Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sharon M Weber
- Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Luke M Funk
- Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Daniel E Abbott
- Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Kramer JR, Puenpatom A, Erickson K, Cao Y, Smith D, El-Serag H, Kanwal F. Real-world effectiveness of elbasvir/grazoprevir In HCV-infected patients in the US veterans affairs healthcare system. J Viral Hepat 2018; 25:1270-1279. [PMID: 29851265 PMCID: PMC6202183 DOI: 10.1111/jvh.12937] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/16/2018] [Indexed: 12/12/2022]
Abstract
Elbasvir/grazoprevir (EBR/GZR) is an all-oral direct-acting antiviral agent (DAA) with high sustained virologic response (SVR) in clinical trials. This study's primary objective was to evaluate effectiveness of EBR/GZR among HCV-infected patients in a real-world clinical setting. We conducted a nationwide retrospective observational cohort study of HCV-infected patients in the US Department of Veterans Affairs (VA) using the VA Corporate Data Warehouse. The study population included patients with positive HCV RNA who initiated EBR/GZR from February 1 to August 1, 2016. We calculated the 95% confidence interval for binomial proportions for SVR overall and by demographic subgroups. Clinical and demographic characteristics were also evaluated. We included 2436 patients in the study cohort. Most were male (96.5%), African American (57.5%), with mean age of 63.5 (SD = 5.9) and 95.4% infected with genotype (GT) 1 [GT1a (34.7%), GT1b (58.6%)]. Other comorbidities included diabetes (53.2%), depression (57.2%) and HIV (3.0%). More than 50% had history of drug or alcohol abuse (53.9% and 60.5%, respectively). 33.2% of the cohort had cirrhosis. A total of 95.6% (2,328/2,436; 95% CI: 94.7%-96.4%) achieved SVR. The SVR rates by subgroups were: male, 95.5% (2245/2350); female, 96.5% (83/86); GT1a, 93.4%, GT1b, 96.6%, GT4, 96.9%, African American, 95.9% (1,342/1,400); treatment-experienced, 96.3% (310/322); cirrhosis, 95.6% (732/766); stage 4-5 CKD, 96.3% (392/407); and HIV, 98.6% (73/74). SVR rates were high overall and across patient subgroups regardless of gender, race/ethnicity, cirrhosis, renal impairment or HIV. This study provided important data regarding the effectiveness of EBR/GZR in a large clinical setting.
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Affiliation(s)
- Jennifer R. Kramer
- Center for Innovation for Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | | | - Kevin Erickson
- Center for Innovation for Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Yumei Cao
- Center for Innovation for Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, TX
| | - Donna Smith
- Center for Innovation for Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, TX
| | - Hashem El-Serag
- Center for Innovation for Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Fasiha Kanwal
- Center for Innovation for Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center (MEDVAMC), Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
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McDonald JR, Liang SY, Li P, Maalouf S, Murray CK, Weintrob AC, Schnaubelt ER, Kuhn J, Ganesan A, Bradley W, Tribble DR. Infectious Complications After Deployment Trauma: Following Wounded US Military Personnel Into Veterans Affairs Care. Clin Infect Dis 2018; 67:1205-1212. [PMID: 29659771 PMCID: PMC6160604 DOI: 10.1093/cid/ciy280] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 11/20/2017] [Accepted: 04/05/2018] [Indexed: 11/14/2022] Open
Abstract
Background Infectious complications related to deployment trauma significantly contribute to the morbidity and mortality of wounded service members. The Trauma Infectious Disease Outcomes Study (TIDOS) collects data on US military personnel injured in Iraq and Afghanistan in an observational cohort study of infectious complications. Patients enrolled in TIDOS may also consent to follow-up through the Department of Veterans Affairs (VA). We present data from the first 337 TIDOS enrollees to receive VA healthcare. Methods Data were collected from the Department of Defense (DoD) Trauma Registry, TIDOS infectious disease module, DoD and VA electronic medical records, and telephone interview. Cox proportional hazard analysis was performed to identify predictors of post-discharge infections related to deployment trauma. Results Among the first 337 TIDOS enrollees who entered VA healthcare, 111 (33%) had 244 trauma-related infections during their initial trauma hospitalization (2.1 infections per 100 person-days). Following initial discharge, 127 (38%) enrollees had 239 trauma-related infections (170 during DoD follow-up and 69 during VA time). Skin and soft-tissue infections and osteomyelitis were predominant during and after the initial trauma hospitalization. In a multivariate model, a shorter time to development of a new infection following discharge was independently associated with injury severity score ≥10 and occurrence of ≥1 inpatient infection during initial trauma hospitalization. Conclusions Incident infections related to deployment trauma continue well after initial hospital discharge and into VA healthcare. Overall, 38% of enrolled patients developed a new trauma-related infection after their initial hospital discharge, with 29% occurring after the patient left military service.
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Affiliation(s)
- Jay R McDonald
- Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
- Washington University School of Medicine, St. Louis, Missouri
| | - Stephen Y Liang
- Washington University School of Medicine, St. Louis, Missouri
| | - Ping Li
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Salwa Maalouf
- Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
| | - Clinton K Murray
- San Antonio Military Medical Center, JBSA Fort Sam Houston, Texas
| | - Amy C Weintrob
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Janis Kuhn
- Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
- Washington University School of Medicine, St. Louis, Missouri
| | - Anuradha Ganesan
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
- San Antonio Military Medical Center, JBSA Fort Sam Houston, Texas
| | - William Bradley
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences
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Abstract
Transgender patients often experience health disparities, including higher rates of psychiatric comorbidity, tobacco and substance use disorders, higher suicide risk, and reduced access and initiation of medical and mental health services. In 2011, the Department of Veterans Affairs (VA) health care system released a directive outlining the provision of transgender health care services. Since 2011, the number of transgender veterans seeking services has increased. To address these health care disparities and ensure competent comprehensive medical and mental health care for this population, an interprofessional team collaborated to develop the first formalized Transgender Healthcare Clinic at the VA Loma Linda Medical Center. The team consisted of an endocrinologist, primary care provider, clinical pharmacist, psychologist, and social worker. Each member of the team plays a key role in the management of mental and medical health care for transgender veterans. After implementation of the Transgender Healthcare Clinic and its respective model for appointments, access to gender transition–related health care has improved and expanded. Although the role of the clinical pharmacist is well established in this clinic, the addition of a psychiatric pharmacist to the transgender health care team could improve patient care through the integration of an expert understanding of behavioral and pharmacologic aspects facing transgender individuals. The psychiatric pharmacist is trained with the unique skill set required to address these concerns and facilitate the optimal management of co-occurring mental illnesses commonly seen in this patient population. Further research focusing on the integration of psychiatric pharmacists into transgender health care teams is needed.
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Affiliation(s)
- Allie Kaigle
- Clinical Pharmacist Specialist, Mental Health at VA Loma Linda Healthcare System, Loma Linda, California,
| | - Ranya Sawan-Garcia
- Clinical Pharmacist Specialist and LGBT Veteran Care Coordinator at VA Loma Linda Healthcare System, Loma Linda, California
| | - Anthony Firek
- Chief of Endocrinology, VA Loma Linda Healthcare System, Loma Linda, California
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Miller EA, Gidmark S, Gadbois E, Rudolph JL, Intrator O. Nursing Home Referral Within the Veterans Health Administration: Practice Variation by Payment Source and Facility Type. Res Aging 2017; 40:687-711. [PMID: 28899261 DOI: 10.1177/0164027517730383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Veterans enrolled within the Veterans Health Administration (VHA) of the U.S. Department of Veterans Affairs (VA) may receive nursing home (NH) care in VHA-operated Community Living Centers (CLCs), State Veterans Homes (SVHs), or community NHs, which may or may not be under contract with the VHA. This study examined VHA staff perceptions of how Veterans' eligibility for VA and other payment impacts NH referrals within VA Medical Centers (VAMCs). Thirty-five semistructured interviews were performed with discharge planning and contracting staff from 12 VAMCs from around the country. VA staff highlights the preeminent role that VA priority status played in determining placement in VA-paid NH care. VHA staff reported that Veterans' placement in a CLC, community NH, or SVH was contingent, in part, on potential payment source (VA, Medicare, Medicaid, and other) and anticipated length of stay. They also reported that variation in Veteran referral to VA-paid NH care across VAMCs derived, in part, from differences in local and regional policies and markets. Implications for NH referral within the VHA are drawn.
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Affiliation(s)
- Edward Alan Miller
- 1 Department of Gerontology, John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston, Boston, MA, USA.,3 Providence VA Medical Center, Providence, RI, USA
| | | | | | - James L Rudolph
- 2 Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI, USA.,3 Providence VA Medical Center, Providence, RI, USA.,4 The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Orna Intrator
- 2 Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI, USA.,5 Canandaigua VA Medical Center, Canandaigua, NY, USA.,6 Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
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Barry RG, Amiri FA, Gress TW, Nease DB, Canterbury TD. Laparoscopic vertical sleeve gastrectomy: A 5-year veterans affairs review. Medicine (Baltimore) 2017; 96:e7508. [PMID: 28858079 PMCID: PMC5585473 DOI: 10.1097/md.0000000000007508] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/21/2017] [Accepted: 06/23/2017] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to evaluate the outcomes after laparoscopic sleeve gastrectomy (SG) in a VA population.SG has recently gained popularity as a definitive bariatric surgery procedure. Data are lacking on long-term outcomes, particularly in a Veterans Affairs population.We retrospectively reviewed 223 patients who underwent SG for morbid obesity between January 2009 and June 2014. Data on length of stay, complications, interval weight loss, comorbidities, and number of therapies preoperatively and at long-term follow-up were collected.There were 164 males and 59 females who underwent SG. The mean body mass index was 45.4 kg/m. Mean excess weight loss at 1 year was 62.9%, and 47.0% at 5 years. Weight loss continued until 12 to 18 months, when there was a nadir in weight loss (P < .001). There were 4 deaths and 4 staple-line leaks, with 3 deaths related to late cardiac events. One early death occurred in a very high-risk patient. All staple-line leaks were managed nonoperatively. Of the 223 patients, 193 had hypertension, 137 diabetes, 158 hyperlipidemia, 119 obstructive sleep apnea (OSA), and 125 had gastroesophageal reflux disease. Preoperatively, patients were on a mean of 1.9 antihypertensive and 0.9 hyperlipidemic, anti-reflux and oral hypoglycemic agents. Fifty percent of patients with diabetes were on insulin and 68% with OSA used continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP). We found significant absolute reductions in mean antihypertensive medications (-0.8), hyperlipidemic agents (-0.4), antireflux agents (-0.4), oral hypoglycemics (-0.6), insulin use (-25%), and use of CPAP/BiPAP (-55%) (all P < .001).Laparoscopic sleeve gastrectomy is a safe and effective bariatric surgery procedure, resulting in significant early weight loss up to 18 months and long-term improvement in all major obesity-related comorbid conditions.
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Affiliation(s)
- Rahman G. Barry
- Department of Surgery, Marshall University
- Department of Surgery, Huntington Veterans Affairs Medical Center, Huntington, WV
| | - Farzad A. Amiri
- Department of Surgery, Marshall University
- Department of Surgery, Huntington Veterans Affairs Medical Center, Huntington, WV
| | - Todd W. Gress
- Department of Surgery, Marshall University
- Department of Surgery, Huntington Veterans Affairs Medical Center, Huntington, WV
| | - D. Blaine Nease
- Department of Surgery, Marshall University
- Department of Surgery, Huntington Veterans Affairs Medical Center, Huntington, WV
| | - Timothy D. Canterbury
- Department of Surgery, Marshall University
- Department of Surgery, Huntington Veterans Affairs Medical Center, Huntington, WV
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Varkovitzky RL, Sherrill AM, Reger GM. Effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Among Veterans With Posttraumatic Stress Disorder: A Pilot Study. Behav Modif 2017; 42:210-230. [PMID: 28845680 DOI: 10.1177/0145445517724539] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 11/15/2022]
Abstract
Effective treatment options are needed for veterans who do not participate in trauma-focused psychotherapy. Research has yet to examine the effectiveness of transdiagnostic psychotherapy in veterans with posttraumatic stress disorder (PTSD) and co-occurring psychological disorders. This pilot study examined the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) delivered in a 16-week group format. We examined treatment outcomes in male and female veterans ( n = 52) in an outpatient specialty PTSD clinic at a large Veterans Affairs (VA) medical center. We hypothesized significant decreases in emotion regulation difficulty (Difficulties in Emotion Regulation Scale), PTSD symptom severity (PTSD Checklist for DSM-5), and depressive symptom severity (Patient Health Questionnaire-9). In addition, we hypothesized that reductions in emotion regulation difficulty across treatment would negatively predict PTSD and depressive symptoms at posttreatment. PTSD symptoms, depressive symptoms, and emotion regulation difficulty all evidenced significant improvements at the end of treatment relative to baseline ( ps < .001). In addition, reductions in emotion regulation across treatment were associated with lower PTSD and depressive symptoms at posttreatment ( ps < .001). This pilot study provides preliminary evidence supporting use of UP among veterans with PTSD and co-occurring disorders. Well-designed clinical trials evaluating efficacy of UP among veterans are needed.
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Affiliation(s)
- Ruth L Varkovitzky
- 1 VA Puget Sound Health Care System-American Lake Division, Tacoma, WA, USA.,2 University of Washington School of Medicine, Seattle, WA, USA
| | | | - Greg M Reger
- 1 VA Puget Sound Health Care System-American Lake Division, Tacoma, WA, USA.,2 University of Washington School of Medicine, Seattle, WA, USA
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Thorpe JM, Thorpe CT, Gellad WF, Good CB, Hanlon JT, Mor MK, Pleis JR, Schleiden LJ, Van Houtven CH. Dual Health Care System Use and High-Risk Prescribing in Patients With Dementia: A National Cohort Study. Ann Intern Med 2017; 166:157-163. [PMID: 27919104 PMCID: PMC8048048 DOI: 10.7326/m16-0551] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [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: 12/31/2022] Open
Abstract
BACKGROUND Recent federal policy changes attempt to expand veterans' access to providers outside the Department of Veterans Affairs (VA). Receipt of prescription medications across unconnected systems of care may increase the risk for unsafe prescribing, particularly in persons with dementia. OBJECTIVE To investigate the association between dual health care system use and potentially unsafe medication (PUM) prescribing. DESIGN Retrospective cohort study. SETTING National VA outpatient care facilities in 2010. PARTICIPANTS 75 829 veterans with dementia who were continuously enrolled in Medicare from 2007 to 2010; 80% were VA-only users, and 20% were VA-Medicare Part D (dual) users. MEASUREMENTS Augmented inverse propensity weighting was used to estimate the effect of dual-system versus VA-only prescribing on 4 indicators of PUM prescribing in 2010: any exposure to Healthcare Effectiveness Data and Information Set (HEDIS) high-risk medication in older adults (PUM-HEDIS), any daily exposure to prescriptions with a cumulative Anticholinergic Cognitive Burden (ACB) score of 3 or higher (PUM-ACB), any antipsychotic prescription (PUM-antipsychotic), and any PUM exposure (any-PUM). The annual number of days of each PUM exposure was also examined. RESULTS Compared with VA-only users, dual users had more than double the odds of exposure to any-PUM (odds ratio [OR], 2.2 [95% CI, 2.2 to 2.3]), PUM-HEDIS (OR, 2.4 [CI, 2.2 to 2.8]), and PUM-ACB (OR, 2.1 [CI, 2.0 to 2.2]). The odds of PUM-antipsychotic exposure were also greater in dual users (OR, 1.5 [CI, 1.4 to 1.6]). Dual users had an adjusted average of 44.1 additional days of any-PUM exposure (CI, 37.2 to 45.0 days). LIMITATION Observational study design of veteran outpatients only. CONCLUSION Among veterans with dementia, rates of PUM prescribing are significantly higher among dual-system users than with VA-only users. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- Joshua M Thorpe
- From the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Carolyn T Thorpe
- From the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Walid F Gellad
- From the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Chester B Good
- From the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Joseph T Hanlon
- From the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Maria K Mor
- From the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - John R Pleis
- From the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Loren J Schleiden
- From the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Courtney Harold Van Houtven
- From the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
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Winters B, Plymate S, Zeliadt SB, Holt S, Zhang X, Hu E, Lin DW, Morrissey C, Wooldridge B, Gore JL, Porter MP, Wright JL. Metformin effects on biochemical recurrence and metabolic signaling in the prostate. Prostate 2015. [PMID: 26201966 PMCID: PMC4578998 DOI: 10.1002/pros.23049] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Metformin has received considerable attention as a potential anti-cancer agent. Animal and in-vitro prostate cancer (PCa) models have demonstrated decreased tumor growth with metformin, however the precise mechanisms are unknown. We examine the effects of metformin on PCa biochemical recurrence (BCR) in a large clinical database followed by evaluating metabolic signaling changes in a cohort of men undergoing prostate needle biopsy (PNB). METHODS Men treated for localized PCa were identified in a comprehensive clinical database between 2001 and 2010. Cox regression was performed to determine association with BCR relative to metformin use. We next identified a separate case-control cohort of men undergoing prostate needle biopsy (PNB) stratified by metformin use. Differences in mean IHC scores were compared with linear regression for phosphorylated IR, IGF-IR, AKT, and AMPK. RESULTS One thousand seven hundred and thirty four men were evaluated for BCR with mean follow up of 41 months (range 1-121 months). "Ever" metformin use was not associated with BCR (HR 1.12, 0.77-1.65), however men reporting both pre/post-treatment metformin use had a 45% reduction in BCR (HR = 0.55 (0.31-0.96)). For the tissue-based study, 48 metformin users and 42 controls underwent PNB. Significantly greater staining in phosphorylated nuclear (p-IR, p-AKT) and cytoplasmic (p-IR, p-IGF-1R) insulin signaling proteins were seen in patients with PCa detected compared to those with negative PNB (P-values all <0.006). When stratified by metformin use, IGF-1R remained significantly elevated (P = 0.01) in men with PCa detected whereas p-AMPK (P = 0.05) was elevated only in those without PCa. CONCLUSION Metformin use is associated with reduced BCR after treatment of localized PCa when considering pre-diagnostic and cumulative dosing. In men with cancer detected on PNB, insulin signaling markers were significantly elevated compared to negative PNB patients. The finding of IGF-1R elevation in positive PNBs versus p-AMPK elevation in negative PNBs suggests altered metabolic pathway activation precipitated by metformin use.
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Affiliation(s)
- Brian Winters
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Stephen Plymate
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
- Health Services Research & Development and GRECC, VA Puget Sound Health Care System, Seattle, WA
| | - Steven B Zeliadt
- Health Services Research & Development and GRECC, VA Puget Sound Health Care System, Seattle, WA
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sarah Holt
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Xiaotun Zhang
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Elaine Hu
- Health Services Research & Development and GRECC, VA Puget Sound Health Care System, Seattle, WA
| | - Daniel W. Lin
- Department of Urology, University of Washington School of Medicine, Seattle, WA
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Colm Morrissey
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Bryan Wooldridge
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - John L Gore
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Michael P Porter
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - Jonathan L Wright
- Department of Urology, University of Washington School of Medicine, Seattle, WA
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
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40
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Kramer JR, Fischbach LA, Richardson P, Alsarraj A, Fitzgerald S, Shaib Y, Abraham NS, Velez M, Cole R, Anand B, Verstovsek G, Rugge M, Parente P, Graham DY, El-Serag HB. Waist-to-hip ratio, but not body mass index, is associated with an increased risk of Barrett's esophagus in white men. Clin Gastroenterol Hepatol 2013; 11:373-381.e1. [PMID: 23220167 DOI: 10.1016/j.cgh.2012.11.028] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 10/25/2012] [Accepted: 11/19/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Abdominal obesity increases the risk of gastroesophageal reflux disease (GERD) and also might contribute to the development of Barrett's esophagus (BE), although results are inconsistent. We examined the effects of waist-to-hip ratio (WHR) and body mass index (BMI) on the risk of BE and investigated whether race, GERD symptoms, or hiatus hernia were involved. METHODS We conducted a case-control study using data from eligible patients who underwent elective esophagogastroduodenoscopy; 237 patients had BE and the other 1021 patients served as endoscopy controls. We also analyzed data and tissue samples from enrolled patients who were eligible for screening colonoscopies at a primary care clinic (colonoscopy controls, n = 479). All patients underwent esophagogastroduodenoscopy, completed a survey, and had anthropometric measurements taken. WHR was categorized as high if it was 0.9 or greater for men or 0.85 or greater for women. Data were analyzed with logistic regression. RESULTS There was no association between BMI and BE. However, more patients with BE had a high WHR (92.4%) than endoscopy controls (79.5%) or colonoscopy controls (84.6%) (P < .001 and P = .008, respectively). In adjusted analysis, patients with BE were 2-fold more likely to have a high WHR than endoscopy controls (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.1-3.5), this association was stronger for patients with long-segment BE (OR, 2.81; 95% CI, 1.0-7.9). A high WHR was associated significantly with BE only in whites (OR, 2.5; 95% CI, 1.2-5.4), but not in blacks or Hispanics. GERD symptoms, hiatus hernia, or gastroesophageal valve flap grade could not account for the association. CONCLUSIONS High WHR, but not BMI, is associated with a significant increase in the risk of BE, especially long-segment BE and in whites. The association is not caused by GERD symptoms or hiatus hernia.
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Ho SB, Aqel B, Dieperink E, Liu S, Tetrick L, Falck-Ytter Y, DeComarmond C, Smith CI, McKee DP, Boyd W, Kulig CC, Bini EJ, Pedrosa MC. U.S. multicenter pilot study of daily consensus interferon (CIFN) plus ribavirin for "difficult-to-treat" HCV genotype 1 patients. Dig Dis Sci 2011; 56:880-8. [PMID: 21221804 PMCID: PMC3041922 DOI: 10.1007/s10620-010-1504-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 11/17/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with chronic hepatitis C genotype 1 (HCV-1) and difficult-to-treat characteristics respond poorly to pegylated interferon alfa and ribavirin (RBV), and could benefit from an interferon with increased activity (consensus interferon or CIFN), favorable viral kinetics from daily dosing, and a longer duration of therapy. The purpose of this pilot study was to determine the efficacy and safety of daily CIFN + RBV for initial treatment of patients with HCV-1 infection. METHODS Patients with difficult-to-treat characteristics (92% male, 33% African American, 78% Veterans Affairs [VA]; 67% high viral load, 59% stage 3-4 fibrosis, and mean weight of 204 lbs) were enrolled at seven VA and two community medical centers. They were randomized to daily CIFN (15 mcg/day SQ) and RBV (1-1.2 g/d PO) given for either 52 weeks (group A, n = 33) or 52-72 weeks (from time of viral response +48 weeks) (group B, n = 31). RESULTS Intention to treat analysis for treatment groups A and B demonstrated 33% (11/33) and 32% (10/31) sustained virologic response (SVR), respectively. Only 2/31 patients in group B received more than 52 weeks of treatment. The overall group demonstrated a 31% (20/64) rapid virologic response rate (RVR), 54% (34/64) end of treatment virologic response and a 33% (21/64) SVR. Patients with RVR at 4 weeks, early virologic response from 8-12 weeks, and late virologic response from 16-24 weeks demonstrated SVR of 75% (15/20), 31% (4/13), and 22% (2/9), respectively. Overall early non-protocol discontinuation occurred in 26/64 (40%) patients. CONCLUSION Daily CIFN and ribavirin for initial treatment of HCV-1 patients has potential for achieving a relatively high RVR rate, but discontinuations are frequent and successful use of this regimen is highly dependent on adequate patient support to maintain adherence.
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Affiliation(s)
- Samuel B Ho
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
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Singh JA, Ayub S. Accuracy of VA databases for diagnoses of knee replacement and hip replacement. Osteoarthritis Cartilage 2010; 18:1639-42. [PMID: 20950694 PMCID: PMC2997184 DOI: 10.1016/j.joca.2010.10.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [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: 04/06/2010] [Revised: 08/24/2010] [Accepted: 10/04/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine the validity of International Classification of Diseases-Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes for knee replacement and hip replacement in Veterans Affairs (VA) databases. METHODS From a cohort of veterans who received health care at Minneapolis VA Medical Center and/or affiliated medical facilities, we obtained four random samples of 50 patients each with: neither hip nor knee replacement code, knee replacement code only, hip replacement code only and both knee and hip replacement codes. The gold standard was documentation of knee or hip replacement surgery in patient medical records. Accuracy of ICD-9 or CPT code for knee and hip replacement was assessed by calculating sensitivity, specificity, positive and negative predictive values (PPV and NPV). RESULTS Of the 200 patients, medical records were available for 166:140 (70%) had complete medical records and 26 (13%) had incomplete medical records. Knee replacement codes were accurate with excellent PPV of 95%, sensitivity of 95%, specificity of 96% and NPV of 96%. Hip replacement codes were accurate with excellent PPV of 98%, sensitivity of 96%, specificity of 99% and NPV of 96%. Sensitivity analyses that included incomplete charts had little impact on these estimates. The procedure dates found in VA databases matched exactly with medical records in 96%. CONCLUSIONS The ICD-9 and CPT codes for knee replacement and hip replacement in VA databases are valid. These codes may be used to identify cohorts of veterans with knee replacement and hip replacement for research studies.
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Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical Center and University of Alabama, Birmingham, AL, Center for Surgical Medical Acute care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, AL, Departments of Health Sciences Research and Orthopedic Surgery, Mayo Clinic School of Medicine, Rochester, MN, VA Medical Center, Minneapolis, MN
| | - Semi Ayub
- VA Medical Center, Minneapolis, MN, Division of Rheumatology, University of Minnesota, Minneapolis, MN
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Abstract
BACKGROUND Disparities in survival for black patients with HIV in the United States have been reported. The VA is an equal access health care system. OBJECTIVE To determine whether such disparities are present in the VA health care system. DESIGN Retrospective cohort study using national VA administrative databases. PATIENTS Two thousand three hundred and four white and 3,641 black HIV-infected patients first hospitalized for HIV between October 1, 1996 and September 30, 2000. MEASUREMENTS Thirty-day mortality after first hospitalization with HIV, and subsequent long-term survival. Follow-up ended at death or September 30, 2002. Data were adjusted for age, sex, HIV disease severity, non-HIV-related comorbidities, primary discharge diagnosis, hepatitis C status, and facility effects. RESULTS The mean follow-up was 3.2 years. Overall survival was similar for black patients compared with white patients (adjusted hazard ratio 1.09, P=.09). Hospital mortality was 7.0% for black and 6.4% for white patients (P=.35). Adjusted hospital mortality for black patients was similar to that of white patients (odds ratio 1.20, P=.10). Long-term survival after hospitalization did not significantly differ by race (adjusted hazard ratio 1.07, P=.21, for black patients compared with white patients). CONCLUSIONS Survival during and after first hospitalization with HIV in the VA did not significantly differ for white and black patients, possibly indicating similar effectiveness of care for HIV. Further research is needed to understand the reasons for the lack of disparities for VA patients with HIV and whether the VA's results could be replicated.
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Affiliation(s)
- Thomas P Giordano
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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Lavela SL, Weaver FM, Goldstein B, Chen K, Miskevics S, Rajan S, Gater DR. Diabetes mellitus in individuals with spinal cord injury or disorder. J Spinal Cord Med 2006; 29:387-95. [PMID: 17044389 PMCID: PMC1864854 DOI: 10.1080/10790268.2006.11753887] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Accepted: 05/15/2006] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE To examine diabetes prevalence, care, complications, and characteristics of veterans with a spinal cord injury or disorder (SCI/D). METHODS A national survey of veterans with an SCI/D was conducted using Behavioral Risk Factor Surveillance System (BRFSS) survey questions. Data were compared with national Centers for Disease Control and Prevention BRFSS data for veteran and nonveteran general populations. RESULTS Overall prevalence of diabetes in individuals with an SCI/D was 20% (3 times higher than in the general population). Veterans with an SCI/D and veterans, in general, had a higher prevalence of diabetes across all age groups; however, those with an SCI/D who were 45 to 59 years of age had a higher prevalence than other veterans. One fourth of the persons with an SCI/D and diabetes reported that diabetes affected their eyes or that they had retinopathy (25%), and 41% had foot sores that took more than 4 weeks to heal. More veterans, both with (63%) and without an SCI/D (60%), took a class on how to manage their diabetes than the general population (50%). Veterans with an SCI/D and diabetes were more likely to report other chronic conditions and poorer quality of life than those without diabetes. CONCLUSIONS Diabetes prevalence is greater among veterans with an SCI/D compared with the civilian population, but is similar to that of other veterans, although it may occur at a younger age in those with an SCI/D. Veterans with an SCI/D and diabetes reported more comorbidities, more slow-healing foot sores, and poorer quality of life than those without diabetes. Efforts to prevent diabetes and to provide early intervention in persons with SCI/D are needed.
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Affiliation(s)
- Sherri L Lavela
- Spinal Cord Injury Quality Enhancement Research Initiative, Midwest Center for Health Services and Policy Research, Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois 60141, USA.
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