Search

Purpose To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs). Methods In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence. Results Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays. Conclusion The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients. [ABSTRACT FROM AUTHOR]

Background: Studies show uneven access to Medicare-approved lung cancer screening (LCS) programs across the United States. The Veterans Health Administration (VA), the largest national US integrated health system, is potentially well positioned to coordinate LCS services across regional units to ensure that access matches distribution of need nationally.Research Question: To what extent does LCS access (considering both VA and partner sites) and use match the distribution of eligible Veterans at state and regional levels?Methods: In this retrospective analysis, we identified LCS examinations in VA facilities between 2013 and 2019 from the VA Corporate Data Warehouse and plotted VA facilities with LCS geographically. We compared estimated LCS rates (unique Veterans screened per LCS-eligible population) across states and VA regional units. Finally, we assessed whether the VA's new partnership with the GO2 Foundation for Lung Cancer (which includes more than 750 LCS centers) closes geographic gaps in LCS access.Results: We identified 71,898 LCS examinations in 96 of 139 (69.1%) VA facilities in 44 states between 2013 and 2019, with substantial variation across states (0-8 VA LCS facilities per state). Screening rates among eligible Veterans in the population varied more than 30-fold across regional networks (rate ratio, 33.6; 95% CI, 30.8-36.7 for VA New England vs Veterans Integrated Service Network 4), with weak correlation between eligible populations and LCS rates (coefficient, -0.30). Partnering with the GO2 Foundation for Lung Cancer expands capacity and access (eg, all states now have ≥ 1 VA or partner LCS site), but 9 of the 12 states with the highest proportions of rural Veterans still have ≤ 3 total LCS facilities.Interpretation: Disparities in LCS access exist based on where Veterans live, particularly for rural Veterans, even after partnering with the GO2 Foundation for Lung Cancer. The nationally integrated VA system has an opportunity to leverage regional resources to distribute and coordinate LCS services better to ensure equitable access. [ABSTRACT FROM AUTHOR]

Purpose The complexity of patients with mental healthcare needs cared for by clinical pharmacists is not well delineated. We evaluated the complexity of patients with schizophrenia, bipolar disorder, and major depressive disorder (MDD) in Veterans Affairs (VA) cared for by mental health clinical pharmacist practitioners (MH CPPs). Methods Patients at 42 VA sites with schizophrenia, bipolar disorder, or MDD in 2016 through 2019 were classified by MH CPP visits into those with 2 or more visits ("ongoing MH CPP care"), those with 1 visit ("consultative MH CPP care"), and those with no visits ("no MH CPP care"). Patient complexity for each condition was defined by medication regimen and service utilization. Results For schizophrenia, more patients in ongoing MH CPP care were complex than those with no MH CPP care, based on all measures examined: the number of primary medications (15.3% vs 8.1%), inpatient (13.7% vs 9.1%) and outpatient (42.6% vs 29.7%) utilization, and receipt of long-acting injectable antipsychotics (36.7% vs 25.8%) and clozapine (20.5% vs 9.5%). For bipolar disorder, more patients receiving ongoing or consultative MH CPP care were complex than those with no MH CPP care based on the number of primary medications (27.9% vs 30.5% vs 17.7%) and overlapping mood stabilizers (10.1% vs 11.6% vs 6.2%). For MDD, more patients receiving ongoing or consultative MH CPP care were complex based on the number of primary medications (36.8% vs 35.5% vs 29.2%) and augmentation of antidepressants (56.1% vs 54.4% vs 47.0%) than patients without MH CPP care. All comparisons were significant (P < 0.01). Conclusion MH CPPs provide care for complex patients with schizophrenia, bipolar disorder, and MDD in VA. [ABSTRACT FROM AUTHOR]

Tobacco use and exposure to secondhand smoke (SHS) remain leading causes of preventable disease, disability, and mortality in the United States. Rural populations are among those being left behind in the recent declining smoking rates and have become a focus of discussions on tobacco-related disparities. This article describes tobacco-related disparities in rural populations including tobacco use, exposure to SHS, smoke-free policies, and tobacco taxes. Nurses, as social justice and tobacco control policy advocates, are needed especially at the local level, where much of the policy work occurs and where nursing's voice is respected and can be powerful. [ABSTRACT FROM AUTHOR]

Background: Among patients receiving oral anticoagulation, a gap of > 56 days between international normalized ratio tests suggests loss to follow-up that could lead to poor anticoagulation control and serious adverse events.Methods: We studied long-term oral anticoagulation care for 56,490 patients aged 65 years and older at 100 sites of care in the Veterans Health Administration. We used the rate of gaps in monitoring per patient-year to predict percentage time in therapeutic range (TTR) at the 100 sites.Results: Many patients (45%) had at least one gap in monitoring during an average of 1.6 years of observation; 5% had two or more gaps per year. The median gap duration was 74 days (interquartile range, 62-107). The average TTR for patients with two or more gaps per year was 10 percentage points lower than for patients without gaps (P < .001). Patient-level predictors of gaps included nonwhite race, area poverty, greater distance from care, dementia, and major depression. Site-level gaps per patient-year varied from 0.19 to 1.78; each one-unit increase was associated with a 9.2 percentage point decrease in site-level TTR (P < .001).Conclusions: Site-level gap rates varied widely within an integrated care system. Sites with more gaps per patient-year had worse anticoagulation control. Strategies to address and reduce gaps in monitoring may improve anticoagulation control. [ABSTRACT FROM AUTHOR]

The article presents a study to identify monitoring gaps during oral anticoagulation to gain insights into care transitions, monitoring barriers and medication nonadherence. The study involved 56,490 patients over 64 years old and on long-term oral anticoagulation care from 100 sites under the U.S. Veterans Health Administration. It finds that site-level gap rates varied widely within an integrated care system and that sites with more gaps per patient-year had worse anticoagulation control.

Background: This is the first study, to our knowledge, to assess uptake of oral antiviral treatment (OAV) for COVID-19 in the US and assess whether it is reaching recommended groups. Objective: The study evaluated uptake among persons of all ages, with emphasis on utilization among individuals ages 65 + who comprise 75% of all COVID-19 deaths. To maximize public health outreach and benefit, we sought to understand reasons for use and non-use of OAV among individuals 65 + with at least mild COVID-19 symptoms. Design: Data were collected from phase 3.5 of the US Census Household Pulse Survey, during three 2022 time periods: June 1–13, June 29–July 11, and July 27–August 8. Participants: Respondents (n = 12,299) were ages 18 + with active or resolved COVID-19 within the last 4 weeks of their survey participation. Main Measure(s): Comparisons of demographic variables were made for OAV uptake using the chi-square test of independence. A logistic regression was conducted to identify characteristics of participants independently associated with receipt of an OAV. Comparisons were made with chi-square testing, between those ages 65 + with at least mild symptoms who endorsed one of a number of specific reasons for not using OAV. Key Results: Utilization was low—17.9% of all respondents, 20.5% of respondents ages 50–64, and 33.9% of respondents 65 years and older received guideline-concordant treatment for their infection. Receipt did not differ by income or sex. The average response across the three phases was 5.4%. Most common reasons for not receiving treatment included having minimal symptoms, not thinking that they needed treatment, and not receiving a recommendation from their healthcare provider. Conclusions: A minority of increased-risk US residents have accessed early therapy for COVID-19 despite being made available without cost. Responses suggest that efforts to improve patient and provider knowledge could improve utilization to mitigate future COVID-19 hospitalizations. [ABSTRACT FROM AUTHOR]

Problem: Depression is associated with a higher risk of macrovascular and microvascular complications and mortality in diabetes, but whether depression is linked to an increased risk of incident amputations is unknown. We examined the association between diagnosed depression and incident non-traumatic lower limb amputations in veterans with diabetes.Methods: This was a retrospective cohort study from 2000-2004 that included 531,973 veterans from the Diabetes Epidemiology Cohorts, a national Veterans Affairs (VA) registry with VA and Medicare data. Depression was defined by diagnostic codes or antidepressant prescriptions. Amputations were defined by diagnostic and procedural codes. We determined the HR and 95% CI for incident non-traumatic lower limb amputation by major (transtibial and above) and minor (ankle and below) subtypes, comparing veterans with and without diagnosed depression and adjusting for demographics, health care utilization, diabetes severity and comorbid medical and mental health conditions.Results: Over a mean 4.1 years of follow-up, there were 1289 major and 2541 minor amputations. Diagnosed depression was associated with an adjusted HR of 1.33 (95% CI: 1.15-1.55) for major amputations. There was no statistically significant association between depression and minor amputations (adjusted HR 1.01, 95% CI: 0.90-1.13).Conclusions: Diagnosed depression is associated with a 33% higher risk of incident major lower limb amputation in veterans with diabetes. Further study is needed to understand this relationship and to determine whether depression screening and treatment in patients with diabetes could decrease amputation rates. [ABSTRACT FROM AUTHOR]

Background: Diabetic foot infections are common, serious, and diverse. There is uncertainty about optimal antibiotic treatment, and probably substantial variation in practice. Our aim was to document whether this is the case: A finding that would raise questions about the comparative cost-effectiveness of different regimens and also open the possibility of examining costs and outcomes to determine which should be preferred. Methods: We used the Veterans Health Administration (VA) Diabetes Epidemiology Cohorts (DEpiC) database to conduct a retrospective observational study of hospitalized patients with diabetic foot infections. DEpiC contains computerized VA and Medicare patient-level data for VA patients with diabetes since 1998, including demographics, ICD-9-CM diagnostic codes, antibiotics prescribed, and VA facility. We identified all patients with ICD-9-CM codes for cellulitis/abscess of the foot and then sub-grouped them according to whether they had cellulitis/abscess plus codes for gangrene, osteomyelitis, skin ulcer, or none of these. For each facility, we determined: 1) The proportion of patients treated with an antibiotic and the initial route of administration; 2) The first antibiotic regimen prescribed for each patient, defined as treatment with the same antibiotic, or combination of antibiotics, for at least 5 continuous days; and 3) The antibacterial spectrum of the first regimen. Results: We identified 3,792 patients with cellulitis/abscess of the foot either alone (16.4%), or with ulcer (32.6%), osteomyelitis (19.0%) or gangrene (32.0%). Antibiotics were prescribed for 98.9%. At least 5 continuous days of treatment with an unchanged regimen of one or more antibiotics was prescribed for 59.3%. The means and (ranges) across facilities of the three most common regimens were: 16.4%, (22.8%); 15.7%, (36.1%); and 10.8%, (50.5%). The range of variation across facilities proved substantially greater than that across the different categories of foot infection. We found similar variation in the spectrum of the antibiotic regimen. Conclusions: The large variations in regimen appear to reflect differences in facility practice styles rather than case mix. It is unlikely that all regimens are equally cost-effective. Our methods make possible evaluation of many regimens across many facilities, and can be applied in further studies to determine which antibiotic regimens should be preferred. [ABSTRACT FROM AUTHOR]

Background: Diabetic foot infections are common, serious, and varied. Diagnostic and treatment strategies are correspondingly diverse. It is unclear how patients are managed in actual practice and how outcomes might be improved. Clarification will require study of large numbers of patients, such as are available in medical databases. We have developed and evaluated a system for identifying and classifying diabetic foot infections that can be used for this purpose. Methods: We used the (VA) Diabetes Epidemiology Cohorts (DEpiC) database to conduct a retrospective observational study of patients with diabetic foot infections. DEpiC contains computerized VA and Medicare patient-level data for patients with diabetes since 1998. We determined which ICD-9-CM codes served to identify patients with different types of diabetic foot infections and ranked them in declining order of severity: Gangrene, Osteomyelitis, Ulcer, Foot cellulitis/abscess, Toe cellulitis/abscess, Paronychia. We evaluated our classification by examining its relationship to patient characteristics, diagnostic procedures, treatments given, and medical outcomes. Results: There were 61,007 patients with foot infections, of which 42,063 were classifiable into one of our predefined groups. The different types of infection were related to expected patient characteristics, diagnostic procedures, treatments, and outcomes. Our severity ranking showed a monotonic relationship to hospital length of stay, amputation rate, transition to long-term care, and mortality. Conclusions: We have developed a classification system for patients with diabetic foot infections that is expressly designed for use with large, computerized, ICD-9-CM coded administrative medical databases. It provides a framework that can be used to conduct observational studies of large numbers of patients in order to examine treatment variation and patient outcomes, including the effect of new management strategies, implementation of practice guidelines, and quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Abstract: Background:: Newer insulins, such as long-acting analogues, offer promise of better glycemic control, reduced risk for diabetes complications, and moderation of health care use and costs. Objective:: We studied initiation of insulin glargine to evaluate its association with subsequent health service utilization and estimated expenditures. Methods:: Patients of the Veterans Health Administration, US Department of Veterans Affairs (VA) who initiated insulin glargine (n = 5064) in 2001–2002 were compared with patients receiving other insulin (n = 69,944), matched on prescription month (index date). Inpatient and outpatient VA care in the 12 months after a patient''s index date was evaluated using Tobit regression, controlling for prior utilization, demographic characteristics, comorbidities, glycosylated hemoglobin (HbA1c) levels, and diabetes severity. National average utilization costs and medication acquisition costs were used to estimate the value of VA expenditures. Results:: Compared with other insulin users, insulin glargine initiators had higher HbA1c values (8.72% vs 8.16%) prior to the index date, but greater subsequent HbA1c reduction (−0.50% vs −0.22%). After adjustment for age, prior utilization, HbA1c levels, and other factors, insulin glargine initiation was associated with 2.4 (95% CI, 1.1–3.7) fewer inpatient days for patients with any hospital admission (US $820 lower costs per initiator), 1.6 (1.2–1.9) more outpatient encounters ($279 higher costs per initiator), and $374 ($362–$387) higher costs for diabetes medications. The net difference was an average lower VA cost of $166 (−$290 to $622) per patient. Conclusions:: Insulin glargine use was associated with decreased inpatient days but increased outpatient care, and the value of the net change in utilization to VA offset the additional medication expenditures. Initiation of insulin glargine improves glycemic control and may reduce time in hospital without additional use of health resources. [Copyright &y& Elsevier]

Objectives: Report results of a randomized-clinical trial of the efficacy of periodontal care in the improvement of glycemic control in 165 veterans with poorly controlled diabetes over 4 months. Methods: Outcomes were change in Haemoglobin A1c (HbA1c) in the Early Treatment versus untreated (Usual Care) groups and percent of participants with decreases in HbA1c. Analyses included simple/multiple variable linear/logistic regressions, adjusted for baseline HbA1c, age, and duration of diabetes. Results: Unadjusted analyses showed no differences between groups. After adjustment for baseline HbA1c, age, and diabetes duration, the mean absolute HbA1c change in the Early Treatment group was −0.65% versus−0.51% in the Usual Care group ( p=0.47). Adjusted odds for improvement by 0.5% in the Early Treatment group was 1.67 (95% confidence interval: 0.84, 3.34, p=0.14). Usual Care subjects were twice as likely to increase insulin from baseline to 4 months (20% versus 11%, p=0.12) and less likely to decrease insulin (1% versus 6%, p=0.21) than Early Treatment subjects. Among insulin users at baseline, more increased insulin in the Usual Care group (40% versus 21%, p=0.06). Conclusions: No significant benefit was found for periodontal therapy after 4 months in this study; trends in some results were in favour of periodontal treatment. [ABSTRACT FROM AUTHOR]

Objectives: We are conducting a clinical trial of the efficacy of periodontal therapy in the improvement of glycaemic control in veterans with poorly controlled diabetes. This report describes study design, recruitment and randomization and compares baseline characteristics of the sample frame with those randomized into study groups. Methods: Veterans with poorly controlled diabetes were randomized in two groups: immediate periodontal therapy (“early treatment”) or usual care followed by periodontal therapy (“deferred treatment”). Half of each group continued care for 12 months; the other half returned to their usual care. We studied baseline patient characteristics, self-reported health measures, and clinical examination data. We examined means for continuous variables, frequencies for categorical variables and compared groups using t-tests and χ2 tests (α=0.05 for both). Results: The 193 randomized participants were younger (58 years) and had slightly higher HbA1c (10.2%) than the 2534 non-randomized participants (64 years, HbA1c =9.8%). The deferred treatment group was more likely than the early treatment group to have a history of stroke, transient ischaemic attacks, and less likely to be current or former smokers. Conclusions: The mechanism for randomization was largely successful in this study. [ABSTRACT FROM AUTHOR]

To optimize methods for identifying patients with diabetes based on computerized records and to obtain best estimates of diabetes prevalence in Department of Veterans Affairs (VA) patients. The VA Diabetes Epidemiology Cohort (DEpiC) is a linked national database of all VA patients since 1998 with data from VA medical visits, Medicare claims, pharmacy and laboratory records, and patient surveys. Using DEpiC, we examined concordance of diabetes indicators, including ICD-9-CM codes (250xx), prescription drug treatment, HbA1c tests, and patient self-report. We determined the optimal criterion for identifying diabetes and used it in estimating prevalence in the VA. The best criterion was a prescription for a diabetes medication in the current year and/or 2+ diabetes codes from inpatient and/or outpatient visits (VA and Medicare) over a 24-month period. This definition had high sensitivity (93%) and specificity (98%) against patient self-report, and resonable rates of HbA1c testing (75%). HbA1c testing alone added few additional cases, and a single diagnostic code added many patients, but without confirmation (reduced specificity). However, including codes from Medicare was critical. Applying this definition for 1998-2000, we identified an average of 500,000 VA patients with diabetes per year. We also estimated high and increasing diabetes prevalence rates of 16.7% in FY1998, 18.6% in FY1999, and 19.6% in FY2000 and an incidence estimated to be ~2% per year. Development and evaluation of methodology for analyzing computerized patient data can improve the identification of patients with diabetes. The increasing high prevalence of diabetes in VA patients will present challenges for clinicians and health system management. [ABSTRACT FROM AUTHOR]

Objectives. To identify groups for melanoma prevention and early detection programs, this study explored the hypothesis that survival with cutaneous melanoma is disproportionately lower for persons of lower socioeconomic status. Methods. Massachusetts Cancer Registry and Registry of Vital Records and Statistics data (1982 through 1987) on 3288 incident cases and 1023 deaths from cutaneous melanoma were analyzed. Mortality! incidence ratios were calculated and compared, predictors of late stage disease were examined with logistic regression analysis, and a proportional hazards regression analysis that used death registration as the outcome measure for incident cases was performed. Results. Lower socioeconomic status was associated with a higher mortality/incidence ratio after adjustment for age and sex. For education, the mortality/incidence ratio was 0.37 in the lower group vs 0.25 in the higher group (rate ratio = 1.48, 95% confidence interval [CI] = 1.08, 2.03). Late stage disease was independently associated with lower income (rate ratio for lowest vs highest tertile = 1.64, 95% CI = 1.20, 2.25), and melanoma mortality among case patients was associated with lower education (rate ratio = 1.52, 95% CI 1.09, 2.13). conclusions. Melanoma patients of lower socioeconomic status may be more likely to die from their melanoma than patients of higher socioeconomic status. Low-SES communities may be appropriate intervention targets. [ABSTRACT FROM AUTHOR]

Presents a study which was conducted to describe the health status of veterans in the United States, while examining the relationship between their health-related quality of life, age, comorbidity and socioeconomic and service-connected disability status. Information on the United States Department of Veterans Affairs Health Care System; Statistical analysis of the data collected during this study; Method used in this study; Results of this study.

Objective: Little is known about the significance of patient-perceived overmedication. We sought to determine its prevalence and relation to medication compliance, adverse drug reactions, health-related quality of life (HRQOL), and burden of illness.Design: Analysis of self-reported questionnaire data. PATIENTS/PARTICIPANT: There were 1,648 participants in a longitudinal study of male veterans.Intervention: Participants listed each of their medications with indication, missed doses, adverse reactions, and whether their amount of medication was "too much, the right amount, or too little." The survey included questions about medication adherence, "problems with medications," common symptoms, and screening questions for a number of chronic conditions. We assessed HRQOL with the Multiple Outcomes Study 36-Item Short Form Health Study (SF-36).Measurements and Main Results: Of the 1,256 respondents, 1,007 (80%) had taken medication within 4 weeks. Forty (4%) thought they were taking too much. They reported a 1.6-fold increase in prescription medications, a 5-8 fold increase in adverse effects, a 1.5-2 fold decrease in compliance, an increase in each of seven measured symptoms, and a decrease in six of eight SF-36 domains (p < .05 for all comparisons), the exceptions being the mental health and role-emotional scales. There was also a slight increase in the report of any chronic illness (95% vs 86%, p > .05).Conclusions: Patient perception of overmedication correlates with self-report of decreased compliance, adverse drug reactions, decreased HRQOL, and an increase in symptomatology that is compatible with unrecognized side effects of medication. Such patients warrant careful evaluation. [ABSTRACT FROM AUTHOR]

Background The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected more socioeconomically disadvantaged persons and areas. We sought to determine how certain sociodemographic factors were correlated to adolescents' COVID-19 vaccination rates in towns and cities ("communities") in the Commonwealth of Massachusetts. Methods Data on COVID-19 vaccination rates were obtained over a 20-week period from 30 March 2021 to 10 August 2021. Communities' adolescent (ages 12–19) vaccination rates were compared across quintiles of community-level income, COVID-19 case rate, and proportion of non-Hispanic Black or Hispanic individuals. Other variables included population density and earlier COVID-19 vaccination rates of adolescents and adults, averaged from 30 March to 11 May to determine their effects on vaccination rates on 10 August. Linear and logistic regression was used to estimate individual effects of variables on adolescent vaccination rates. Results Higher median household income, lower proportion of Black or Hispanic individuals, higher early adolescent COVID-19 vaccination rates, and higher early adult COVID-19 vaccination rates were associated with higher later adolescent COVID-19 vaccination rates. Income per $10 000 (adjusted odds ratio [aOR] = 1.01 [95% confidence interval [CI] = 1.01–1.02]), proportion of Hispanic individuals (aOR = 1.33 [95% CI: 1.13–1.56]), early adolescent COVID-19 vaccination rates (aOR = 5.28 [95% CI: 4.67–5.96]), and early adult COVID-19 vaccination rates (aOR = 2.31 [95% CI: 2.02–2.64]) were associated with higher adolescent COVID-19 vaccination on 10 August, whereas proportion of Black individuals approached significance (aOR = 1.26 [95% CI:.98–1.61]). Conclusions Vaccination efforts for adolescents in Massachusetts should focus on boosting vaccination rates early in communities with the lowest incomes and greatest proportion of Hispanic individuals and consider targeting communities with a greater proportion of Black individuals. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To characterize high type 1 diabetes (T1D) genetic risk in a population where type 2 diabetes (T2D) predominates. RESEARCH DESIGN AND METHODS: Characteristics typically associated with T1D were assessed in 109,594 Million Veteran Program participants with adult-onset diabetes, 2011–2021, who had T1D genetic risk scores (GRS) defined as low (0 to <45%), medium (45 to <90%), high (90 to <95%), or highest (≥95%). RESULTS: T1D characteristics increased progressively with higher genetic risk (P < 0.001 for trend). A GRS ≥90% was more common with diabetes diagnoses before age 40 years, but 95% of those participants were diagnosed at age ≥40 years, and their characteristics resembled those of individuals with T2D in mean age (64.3 years) and BMI (32.3 kg/m2). Compared with the low-risk group, the highest-risk group was more likely to have diabetic ketoacidosis (low GRS 0.9% vs. highest GRS 3.7%), hypoglycemia prompting emergency visits (3.7% vs. 5.8%), outpatient plasma glucose <50 mg/dL (7.5% vs. 13.4%), a shorter median time to start insulin (3.5 vs. 1.4 years), use of a T1D diagnostic code (16.3% vs. 28.1%), low C-peptide levels if tested (1.8% vs. 32.4%), and glutamic acid decarboxylase antibodies (6.9% vs. 45.2%), all P < 0.001. CONCLUSIONS: Characteristics associated with T1D were increased with higher genetic risk, and especially with the top 10% of risk. However, the age and BMI of those participants resemble those of people with T2D, and a substantial proportion did not have diagnostic testing or use of T1D diagnostic codes. T1D genetic screening could be used to aid identification of adult-onset T1D in settings in which T2D predominates. [ABSTRACT FROM AUTHOR]

Background Vaccine hesitancy persists alongside concerns about the safety of coronavirus disease 2019 (COVID-19) vaccines. We aimed to examine the effect of COVID-19 vaccination on risk of death among US veterans. Methods We conducted a target trial emulation to estimate and compare risk of death up to 60 days under two COVID-19 vaccination strategies: vaccination within 7 days of enrollment versus no vaccination through follow-up. The study cohort included individuals aged ≥18 years enrolled in the Veterans Health Administration system and eligible to receive a COVID-19 vaccination according to guideline recommendations from 1 March 2021 through 1 July 2021. The outcomes of interest included deaths from any cause and excluding a COVID-19 diagnosis. Observations were cloned to both treatment strategies, censored, and weighted to estimate per-protocol effects. Results We included 3 158 507 veterans. Under the vaccination strategy, 364 993 received vaccine within 7 days. At 60 days, there were 156 deaths per 100 000 veterans under the vaccination strategy versus 185 deaths under the no vaccination strategy, corresponding to an absolute risk difference of −25.9 (95% confidence limit [CL], −59.5 to 2.7) and relative risk of 0.86 (95% CL,.7 to 1.0). When those with a COVID-19 infection in the first 60 days were censored, the absolute risk difference was −20.6 (95% CL, −53.4 to 16.0) with a relative risk of 0.88 (95% CL,.7 to 1.1). Conclusions Vaccination against COVID-19 was associated with a lower but not statistically significantly different risk of death in the first 60 days. These results agree with prior scientific knowledge suggesting vaccination is safe with the potential for substantial health benefits. [ABSTRACT FROM AUTHOR]

We described insulin glargine (originator) and insulin glargine-yfgn (biosimilar) treatment patterns, assessed effectiveness and safety outcomes, and identified reasons for switching back to the originator product from the biosimilar. This retrospective study included 328,463 Veterans 18 years of age and older who received one or more outpatient prescriptions for insulin glargine and/or insulin glargine-yfgn between 1 June 2021 and 31 December 2022. Patients were assigned to subgroups based on the initial prescription during the study period, prevalent versus incident use for originator insulin glargine, and prior versus no prior use of the originator before the biosimilar (i.e., prevalent originator non-switcher (n = 189,734), originator switch to biosimilar (n = 81,010), incident originator non-switcher (n = 49,401), and incident biosimilar (n = 8318)). There were no differences in the outcome of mean HbA1c (7.9% for all subgroups). There were also no differences in the unadjusted rates of hospitalization and/or emergency room visits for hyper- and hypoglycemia between the prevalent originator non-switcher and originator switched to biosimilar subgroups (p = 0.09 and 0.38, respectively) or the incident originator non-switcher and incident biosimilar subgroups (p = 0.054 and 0.61, respectively). Finally, none of the HbA1c or hyperglycemia outcomes adjusted for baseline characteristics were statistically different. Adjusted analyses for rates of hospitalization and/or emergency room visits for hypoglycemia could not be performed due to the low number of events. Overall, patients who received insulin glargine-yfgn had similar effectiveness and safety outcomes as patients who received the originator. [ABSTRACT FROM AUTHOR]

Background: Tech-check-tech (TCT) programs in pharmacies are beneficial in facilitating a transition from fee for service dispensing tasks to advanced patient care, but they are underutilized. Objective: To describe the design, implementation, and evaluation of a transferable TCT program in several North Dakota pharmacies, with the goal of facilitating future efforts in other states. Methods: We developed a universal TCT implementation toolkit, recruited 6 pharmacies to implement it, developed an educational program for the pharmacies, and worked with the pharmacies over a year to assess success of the program. Pre- and post-implementation surveys assessed pharmacist and technician responses in regards to program effectiveness. Four outcomes were measured, and included pharmacist's time savings, descriptive comments on changes in workflow, incidence of errors and near misses, and barriers to implementation. Results: The implementation of TCT was unanimously perceived as successful and increasing efficiency in the post-site surveys completed by pharmacists. All 13 technicians who participated in the post-survey indicated the methods and materials used for training were sufficient and appropriate. The most commonly cited barrier to implementation of TCT stated by technicians was incorporating TCT into their current workflow. No dispensing errors which resulted in patient impact occurred throughout the duration of this study. Conclusions: A TCT implementation template provided a successful framework for TCT in various pharmacy settings and can serve as a model for other pharmacy settings, states, or regions. [ABSTRACT FROM AUTHOR]

Introduction: Among the most pressing clinical decisions in type 2 diabetes treatments are which drugs should be used after metformin is no longer sufficient, and whether sulfonylureas (SUs) should remain as a suitable second-line treatment. In this article we summarize current evidence on the long-term safety risks associated with SU therapy relative to other oral glucose-lowering therapies.Methods: The MEDLINE database and Clinicaltrials.gov were searched for observational and experimental studies comparing the safety of SUs to that of other diabetes medications in people with type 2 diabetes mellitus through December 15, 2015. Studies with at least 1 year of follow-up, which explicitly examined major cardiovascular events or death in patients who showed no evidence of serious conditions at baseline, were selected for inclusion in meta-analyses.Results: SU treatment was associated with an elevated risk relative to treatment with metformin (METF), thiazolidinedione (TZD), dipeptidyl peptidase-4 inhibitor (DPP-4), and glucagon-like peptide-1 (GLP-1) agonist classes, either when compared alone (as a monotherapy) or when used in combination with METF. Significant findings were almost entirely derived from nontrial data and not confirmed by smaller, efficacy designed randomized controlled trials whose effects were in the same direction but much more imprecise.Conclusion: Although much of the evidence is derived and will continue to come from observational studies, the methodological rigor of such studies is questionable. A key challenge for evaluators is the extent to which they should incorporate evidence from study designs that are quasi-experimental. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: We sought to compare lipid-lowering therapy among female and male veterans with diabetes and hyperlipidemia. Methods: We conducted a cross-sectional study of veterans serviced by the Veterans Health Administration in 2006 who had both diabetes and hyperlipidemia and compared all female patients to age- and facility-matched males. We compared proportions of patients with any prescription for lipid-lowering therapy in the year and, among those with elevated low-density lipoprotein cholesterol (LDL >100 mg/dL) and no prior treatment, we compared initiation of lipid-lowering therapy. We used multiple logistic regression to estimate odds ratios (AOR) and 95% confidence intervals (CI), adjusting for race, VA eligibility, health care utilization, cardiovascular diseases, mental health conditions, and a comprehensive list of other comorbidities. We also performed the analysis stratified by age. Findings: Women had higher LDL levels than men (110 ± 38 vs. 101 ± 36 mg/dL) and were less likely to be receiving lipid-lowering therapy (80% vs. 84%; AOR, 0.79; 95% CI, 0.76–0.82) or to be initiated on such therapy (37% vs. 42%; AOR, 0.82; 95% CI, 0.74–0.90). Differences were greatest in the youngest women (<45 years old) for both any lipid-lowering therapy (61% vs. 75%; AOR, 0.50; 95% CI, 0.45–0.56) and initiation of therapy (26% vs. 38%; AOR, 0.55; 95% CI, 0.42–0.73). Adjustment for potential confounders did not change the risk estimates. Conclusion: Women veterans with diabetes and hyperlipidemia receive less aggressive lipid-lowering therapy than men, especially among younger age groups. This disparity is of concern, because early intervention to control hyperlipidemia can reduce the later burden of cardiovascular disease among diabetic women. [Copyright &y& Elsevier]

There is evidence that risk of cardiovascular disease (CVD) may be increased by prolonged periods of hyperglycemia. It is also possible that CVD events may be precipitated by hypoglycemia in those with pre-existing CVD. Thus, better glycemic control, such as that offered by newer insulin formulations, may reduce CVD risk. We studied insulin glargine (a long-acting insulin analog) to evaluate its association with subsequent CVD using national computerized medical and pharmacy data for diabetes patients served by the Veterans Health Administration (VA). We identified those who were first prescribed a basal insulin in 2002-2003 and matched patients initiating insulin glargine (N=4,309) with those initiating another basal insulin (mostly NPH). We matched 4:1 on prescription month, prior myocardial infarction (MI) and stroke, and quintile of propensity score obtained from a logistic regression model of insulin glargine prescribing with terms for demographics, health care eligibility, medical history, and use of other medications. Matching factors and model variables were well balanced in the final sample of 21,404. Patients were followed from the time of first basal insulin prescription to CVD event, death, or study end on September 30, 2005 (up to 3.5 years). Cox proportional hazards regression was used to evaluate risk of CVD events, including MI, stroke, cardiac surgery, new unstable angina, or new transient ischemic attack. New CVD events were observed in 5.5% of insulin glargine initiators as compared to 5.8% of other basal insulin initiators. The hazards ratio for MI was 0.85 (95% confidence interval: 0.71-1.02). There were no differences for stroke (1.06 (0.87-1.31)) or mortality (1.01 (0.91-1.13)). Further adjustment for available measures of potential confounding factors made little difference in the estimates but selection, ascertainment, or unadjusted confounding bias remain as possible explanations. These preliminary results suggest that there may be MI risk benefits with insulin glargine use, but weighing the evidence must await further analyses of data in this study and reports from other studies. [ABSTRACT FROM AUTHOR]

Deciding on a medical regimen for diabetes patients with an alcohol use disorder (AUD), clinicians must balance the risks of hypoglycemia from insulin and sulfonylureas with the risk of liver toxicity from thiazolidinediones (TZD) and lactic acidosis from metformin. We describe the medical regimens of diabetics with and without an AUD. We analyzed a national database containing pharmacy, laboratory, and other medical data of patients with diabetes served by the Veteran Health Administration. We identified those who had an elevated HbA1C (>8 mg/dL) and were thus candidates for the addition of a new medication. We used multivariate logistic regression models to calculate the odds of having one of four classes of medications (sulfonylureas, metformin, TZD, and insulin) added to a subject's medication regimen, after adjusting for age and comorbidities. Of the 124,654 subjects who met our inclusion criteria, 4,818 (3.7%) were categorized as having an AUD. Among those subjects who were on no medications at baseline, and who had an oral medication added following the elevated HbA1C (n=9,173), diabetes patients with an AUD were 20% less likely to be started on metformin (OR 0.80, 95%CI 0.63-1.00) than on a sulfonylurea, and 62% less likely to be started on a TZD (OR 0.38, 95% CI 0.12-1.22) than on a sulfonylurea, when compared to those without an AUD. In subjects whose baseline regimen consisted of metformin and a sulfonylurea, and who had either insulin or a TZD added to their regimen (n=6,375), diabetics with an AUD were 72% more likely to be started on insulin (OR 1.72, 95% CI 1.29-2.31). When faced with the dilemma of choosing a medication regimen for diabetes patients with an alcohol use disorder, physicians are more likely to use insulin and sulfonylureas, and less likely to use TZD and metformin. [ABSTRACT FROM AUTHOR]

The article focuses on a study of trends in the proportion of VA diabetes patients achieving less than 7% A1c. National computerized databases for patients receiving care in fiscal year 1999 with subsequent A1c testing was used in this study. It is said that mean A1c decreased from 7.77% to 7.55% in prevalent diabetes patients.

Presents structured abstracts of information on newly published medical literature. 'Studying a Study and Testing a Test: How to Read the Medical Evidence,' fourth edition, by R.K. Riegelman; 'Drug Interactions: A Source Book of Adverse Interactions, Their Mechanisms, Clinical Importance and Management,' fifth edition, by I.H. Stockley.

Background: Little is known about rates of invasive procedures and associated complications after lung cancer screening (LCS) in nontrial settings.Research Question: What are the frequency of invasive procedures, complication rates, and factors associated with complications in a national sample of veterans screened for lung cancer?Study Design and Methods: We conducted a retrospective cohort analysis of veterans who underwent LCS in any Veterans Health Administration (VA) facility between 2013 and 2019 and identified veterans who underwent invasive procedures within 10 months of initial LCS. The primary outcome was presence of a complication within 10 days after an invasive procedure. We conducted hierarchical mixed-effects logistic regression analyses to determine patient- and facility-level factors associated with complications resulting from an invasive procedure.Results: Our cohort of 82,641 veterans who underwent LCS was older, more racially diverse, and had more comorbidities than National Lung Screening Trial (NLST) participants. Overall, 1,741 veterans (2.1%) underwent an invasive procedure after initial screening, including 856 (42.3%) bronchoscopies, 490 (24.2%) transthoracic needle biopsies, and 423 (20.9%) thoracic surgeries. Among veterans who underwent procedures, 151 (8.7%) experienced a major complication (eg, respiratory failure, prolonged hospitalization) and an additional 203 (11.7%) experienced an intermediate complication (eg, pneumothorax, pleural effusion). Veterans who underwent thoracic surgery (OR, 7.70; 95% CI, 5.48-10.81), underwent multiple nonsurgical procedures (OR, 1.49; 95% CI, 1.15-1.92), or carried a dementia diagnosis (OR, 3.91; 95% CI, 1.79-8.52) were more likely to experience complications. Invasive procedures were performed less often than in the NLST (2.1% vs 4.2%), but veterans were more likely to experience complications after each type of procedure.Interpretation: These findings may reflect a higher threshold to perform procedures in veteran populations with multiple comorbidities and higher risks of complications. Future work should focus on optimizing the identification of patients whose chance of benefit likely outweighs the complication risks. [ABSTRACT FROM AUTHOR]

This study examined if lithium's association with suicide risk varies by diagnosis. We performed separate 1:1 high-dimensional propensity score (hdPS)-matching in US Veterans with and without bipolar disorder starting lithium or valproate. Among individuals with bipolar disorder, actively receiving lithium (compared to valproate) was not associated with suicide risk. However, in intent-to-treat analyses (following all individuals with bipolar disorder starting lithium or valproate for all 365 days, regardless of whether they stopped the medication), starting lithium was significantly associated with higher one-year risks of suicide (HR = 1.50, 95% CI: 1.05–2.15, p = 0.03). These intent-to-treat risks were attributable entirely to transiently elevated suicide risks observed among individuals no longer receiving lithium (significant at 180 days [HR = 6.10, CI: 1.37–27.3, p = 0.02] but not 365 days [HR = 2.05, CI: 0.88–4.79, p = 0.10]). Among individuals without bipolar disorder, depending on the analysis, actively receiving lithium was associated with nonsignificantly (HR = 0.43, CI: 0.15–1.20, p = 0.11) or significantly (HR = 0.28, CI: 0.08–0.98, p = 0.047) decreased one-year suicide risks. Study limitations included limited power, brief follow-up, and potential residual confounding. Residual confounding is suggested by the observation that more individuals diagnosed with suicidal ideation started lithium than valproate (with this difference being statistically significant for individuals with bipolar disorder, p = 0.0012). If it were possible to correct for this potential confounding, then the suicide-related risks associated with among individuals discontinuing lithium would be expected to be less, and the suicide-related benefits associated with actively receiving lithium (already statistically significant in some analyses among individuals without bipolar disorder) would be expected to increase. Further research is needed. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Identifying major bleeding is fundamental to assessing the outcomes of anticoagulation therapy. This drives the need for a credible implementation in automated data for the International Society of Thrombosis and Haemostasis (ISTH) definition of major bleeding. Materials and Methods: We studied 102,395 patients who received 158,511 person-years of warfarin treatment from the Veterans Health Administration (VA) between 10/1/06-9/30/08. We constructed a list of ICD-9-CM codes of “candidate” bleeding events. Each candidate event was identified as a major hemorrhage if it fulfilled one of four criteria: 1) associated with death within 30days; 2) bleeding in a critical anatomic site; 3) associated with a transfusion; or 4) was coded as the event that precipitated or was responsible for the majority of an inpatient hospitalization. Results: This definition classified 11,240 (15.8%) of 71, 338 candidate events as major hemorrhage. Typically, events more likely to be severe were retained at higher rates than those less likely to be severe. For example, Diverticula of Colon with Hemorrhage (562.12) and Hematuria (599.7) were retained 46% and 4% of the time, respectively. Major, intracranial, and fatal hemorrhage were identified at rates comparable to those found in randomized clinical trials however, higher than those reported in observational studies: 4.73, 1.29, and 0.41 per 100 patient years, respectively. Conclusions: We describe here a workable definition for identifying major hemorrhagic events from large automated datasets. This method of identifying major bleeding may have applications for quality measurement, quality improvement, and comparative effectiveness research. [Copyright &y& Elsevier]

Objective The aim of this study was to measure the relationship between days spent waiting for primary care and health outcomes among patients diagnosed with diabetes, especially among the elderly population. Data Source Secondary data from VA administrative databases and Medicare claims. Study Design This is a retrospective observational study. Outcome variables include primary care utilization, mortality, heart attack, stroke, and ambulatory-care sensitive condition ( ACSC) hospitalization. The main explanatory variable of interest is VA primary care wait time. Negative binomial models predict utilization and stacked logistic regression models predict the probability of experiencing each health outcome. Models are stratified by the presence of a selected health condition and age. Principal Findings Longer wait times were predicted to decrease utilization between 2 and 4 percent. There was no significant relationship between wait times and health outcomes for the overall sample. In stratified analyses, longer waits were associated with undesirable outcomes for those over age 70 with one of the selected health conditions or in certain narrower 5-year age groups, but the overall pattern of results does not indicate a systematic and significant effect. Conclusions There was a modest effect of long wait times on primary care utilization but no robust effect of longer wait times on health outcomes. Waiting for care did not significantly compromise long-term health outcomes for veterans with diabetes. [ABSTRACT FROM AUTHOR]

OBJECTIVE--To evaluate temporal trends in rates of initial lower extremity amputation (ILEA) among patients with diabetes in the Veterans Health Administration (VHA). RESEARCH DESIGN AND METHODS--Retrospective administrative data analysis of VHA clinic users with diabetes in fiscal years (FY) 2000 to 2004 (1 October 1999-30 September 2004). We calculated annual age- and sex-standardized rates of initial major, minor, and total amputations for the overall population and for various racial/ethnic groups (African Americans, Hispanics, and whites). Trends in ILEA risk were evaluated with and without adjustment for demographic characteristics and other potential risk factors, including presence of microvascular and macrovascular diseases, and antiglycemic treatment. RESULTS--Study populations of VHA patients with diabetes and without prior amputations ranged from 405,580 in FY 2000 to 739,377 in FY 2004. Age- and sex-standardized ILEA rates decreased by 34% (7.08/1,000 patients in FY 2000 to 4.65/1,000 patients in FY 2005) during the 5-year period. Minor and major amputation rates decreased by 33% (4.59 to 3.06/1,000) and 36% (2.49 to 1.50/1,000), respectively. Of major amputations, below-knee rates decreased from 1.08 to 0.87/1,000 (-19%), and above-knee decreased from 1.41 to 0.72/1,000 (-49%). Similar trends were seen for all racial groups. ILEA risk decreased by 28% (odds ratio 0.72 [95% CI 0.68-0.75]) when FY 2004 was compared with FY 2000 in the model, adjusting for demographic characteristics. This risk decrease was 22% in the model adjusting for all independent variables (odds ratio 0.78 [95% CI 0.74-0.82]). CONCLUSIONS--Downward 5-year trends in ILEA rates were observed for all amputation levels and among all racial groups, even after adjustment for risk differences over time. [ABSTRACT FROM AUTHOR]

The article offers information on a study concerning nephrologic care's survival benefits to patients diagnosed to have diabetes mellitus and chronic disease. A retrospective cohort study of clinic users at the Veterans Health Administration with diabetes mellitus and stage 3 or 4 chronic kidney disease was conducted with the use of data from 1997 to 2000. The results show that patients with more visits from nephrologists expressed lower mortality as against the patients who had few or no visits from nephrologists.

Objective. To determine prevalence of chronic kidney disease (CKD) in patients with diabetes, and accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify such patients. Data Sources/Study Setting. Secondary data from 1999 to 2000. We linked all inpatient and outpatient administrative and clinical records of U.S. veterans with diabetes dually enrolled in Medicare and the Veterans Administration (VA) health care systems. Study Design. We used a cross-sectional, observational design to determine the sensitivity and specificity of renal-related ICD-9-CM diagnosis codes in identifying individuals with chronic kidney disease. Data Collection/Extraction Methods. We estimated glomerular filtration rate (eGFR) from serum creatinine and defined CKD as Stage 3, 4, or 5 CKD by eGFR criterion according to the Kidney Disease Outcomes Quality Initiative guidelines. Renal-related ICD-9-CM codes were grouped by algorithm. Principal Findings. Prevalence of CKD was 31.6 percent in the veteran sample with diabetes. Depending on the detail of the algorithm, only 20.2 to 42.4 percent of individuals with CKD received a renal-related diagnosis code in either VA or Medicare records over 1 year. Specificity of renal codes for CKD ranged from 93.2 to 99.4 percent. Patients hospitalized in VA facilities were slightly more likely to be correctly coded for CKD than patients hospitalized in facilities reimbursed by Medicare (OR 5.4 versus 4.1, p=.0330) Conclusions. CKD is a common comorbidity for patients with diabetes in the VA system. Diagnosis codes in administrative records from Medicare and VA systems are insensitive, but specific markers for patients with CKD. [ABSTRACT FROM AUTHOR]

Background Emerging evidence indicates that patients with mental health conditions (MHCs) may receive less intensive medical care. Diabetes serves as a useful condition in which to test for MHC-related disparities in care. We examined whether quality measures for diabetes care are worse for patients with or without MHCs. Methods This national, cross-sectional study included 313 586 noninstitutionalized Veterans Health Administration patients with diabetes (identified from diagnostic codes and prescriptions) whose Veterans Health Administration facility transmitted laboratory data to a central database; 76 799 (25%) had MHCs (based on diagnostic codes for depressed mood, anxiety, psychosis, manic symptoms, substance use disorders, personality disorders, and other categories). National data from Veterans Health Administration records, Medicare claims, and a national survey were linked to characterize 1999 diabetes care. Results Failure to meet diabetes performance measures was more common in patients with MHCs: unadjusted odds ratio (95% confidence interval) was 1.24 (1.22-1.27) for no hemoglobin A1c testing, 1.25 (1.23-1.28) for no low-density lipoprotein cholesterol testing, 1.05 (1.03-1.07) for no eye examination, 1.32 (1.30-1.35) for poor glycemic control, and 1.17 (1.15-1.20) for poor lipemic control. Disparities persisted after case mix adjustment and were more pronounced with specific MHCs (psychotic, manic, substance use, and personality disorders). The percentage not meeting diabetes care standards increased with increasing number of MHCs. Conclusion Patients with mental illness merit special attention in national diabetes quality improvement efforts. [ABSTRACT FROM AUTHOR]

Objectives: This project examined psychometric characteristics of four measures of oral-specific health-related quality of life.Methods: We selected participants from two samples of community-dwelling male veterans from Boston (USA): (1) 538 users of VA outpatient medical care from the Veterans Health Study (VHS: mean age = 62); and (2) 211 relatively healthy men from the VA Dental Longitudinal Study (DLS: mean age = 70). Patient-based measures included the Geriatric Oral Health Assessment Instrument, the Oral Health Impact Profile (OHIP), the Oral Health-related Quality of Life instrument and the single-item self-report of oral health. Clinical variables included number of teeth, coronal decayed surfaces (CDS), a modification of the Root Caries Index (RCI_D), and the Community Periodontal Index of Treatment Need (CPITN).Results: Cronbach's alpha ranged from 0.73 to 0.97. Percent of participants with floor and ceiling scores varied widely by instrument and by item. Patient-based measures were associated with all clinical measures in the combined sample. Number of teeth was associated with patient-based measures (p < 0.001). However, CDS, RCI_D and CPITN scores were associated with patient-based scores in the VHS but not in the DLS. The Geriatric Oral Health Assessment Instrument, the OHIP, the Oral Health-related Quality of Life instrument were strongly linearly related to the single-item global self-report of oral health (p < 0.0001).Conclusion: All multi-item measures have high internal consistency and all are valid for measuring oral-specific health-related quality of life. [ABSTRACT FROM AUTHOR]

Studies encounters with environmental facilitators and barriers of an adult wheelchair-users in the U.S. Accounts on the efforts to facilitate social participation; Factors influencing the improvement of civility; Creation of a reliable measures of environmental encounters.

Background. Undergraduate medical education needs revision to ensure that medical students graduate with the skills necessary to assist their patients in cancer prevention and detection. We sought to implement and incorporate a cancer education curriculum into the students'' core curriculum and to assess their skill levels prior to (1996), during (1997), and at the peak (1998–1999) of the incorporation of new hours.Methods. We conducted pretest and posttest surveys of students at Boston University School of Medicine (medical student years 1–4) enrolled in each of the four study years (1996–1999). A total of 1,956 surveys (response rate, 82%) were completed. The primary outcome measure was the student''s self-reported skill level (with responses ranging from 1 (very unskilled) to 5 (very skilled)) for counseling for tobacco cessation, tobacco prevention, and sun protection and for the early detection of breast, skin, and cervical cancer. Mean scores were computed for each chronological year of the study and medical school year. Differences and trends over time in mean scores of students in each medical school year were evaluated using multiple regression analysis.Results. The number of hours of cancer education increased from 6 in 1996 to 15 in 1999. Strong improvements in self-rated skill levels were recorded for four of the six measures. In particular, tobacco cessation counseling skill rose from 2.16 (1996) to 3.13 (1999) for second year students (P < 0.001) and from 3.27 (1996) to 4.17 (1999) for fourth year students (P < 0.001). Among fourth year students, the percentage reporting that cancer prevention was given too little emphasis declined from 62% (1996) to 26% (1999) (P < 0.001), suggesting that the expanded curriculum reflected the students'' preferences.Conclusions. Cancer education can be interwoven into the existing medical school curriculum and produce improvements in students'' skill levels for counseling and examinations. Strategies to enhance prevention teaching can use this model. [Copyright &y& Elsevier]

Examines the need for dental care in older veterans. Assessment of health from the department of veterans reference; Criteria standard for patients; Implications of securities and screening Mike.

Background: Lean management has been successfully employed in healthcare to improve outcomes and efficiencies. Facilitation is increasingly being used to support evidence-based practice uptake in healthcare. However, while both Lean and Facilitation are used in healthcare quality improvement, limited research has explored their integration and the sustainability of their combined effects. Objective: To improve hepatitis C virus (HCV) screening rates among persons born between 1945 and 1965 through the design and evaluation of a multi-modal Lean-Facilitation intervention (LFI) for Department of Veterans Affairs primary care community clinics. Design: We conducted a mixed methods quasi-experimental evaluation in eight clinics, guided by the integrated Promoting Action on Research Implementation in Health Services framework. Participants: We engaged regional and local leadership (N = 9), implemented our LFI with clinicians and staff (N = 68), and conducted summative interviews with participants (N = 13). Intervention: The LFI included six implementation strategies: (1) external facilitation, (2) stakeholder engagement, (3) champion activation, (4) rapid process improvement sessions, (5) Plan-Do-Study-Act cycles, and (6) audit-feedback. Measures: The primary outcome was rate of new HCV screening among previously untested patients with a primary care visit. Using interrupted time series, we analyzed intervention and time effects on HCV testing rates, and administered organizational readiness surveys, conducted summative qualitative interviews, and tracked facilitation events. Results: The LFI was associated with significant, immediate, and sustained increases in HCV testing. No change was detected at matched comparison clinics. Staff accepted the LFI and the philosophy of "bottom-up" solution development yet had mixed feedback on its appropriateness and feasibility. Enablers of implementation and early sustainment included lower satisfaction with baseline HCV testing processes and staff culture, while later sustainment was related to implementation climate support, measurement, and evaluation. Conclusions: High-reach and relatively low effort, but persistent intervention led to significant improvement in guideline-concordant HCV testing rates which were sustained. Trial Registration: ClinicalTrials.gov Identifier: NCT02936648 [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the association between fluoroquinolone (FQ) use and the occurrence of aortic aneurysm/dissection (AA/AD), acute myocardial infarction (AMI), ventricular arrhythmias (VenA), and all-cause mortality vs other commonly used antibiotics. We conducted a self-controlled case series analysis of patients who experienced the outcomes of AA/AD, AMI, and VenA, based on diagnosis codes from emergency department visits and hospitalizations within Veterans Health Administration, and death in FY2014-FY2018. These Veterans also received outpatient prescriptions for FQs. Conditional Poisson regression models were used to estimate the association between FQs and each of the outcomes vs antibiotics of interest (ie amoxicillin or amoxicillin/clavulanate, azithromycin, doxycycline, cefuroxime or cephalexin, or sulfamethoxazole-trimethoprim), adjusted for time-varying covariates. Using a 30-day risk period after each antibiotic prescription, adjusted incidence rate ratios (aIRRs) for FQs vs each comparator antibiotic were not statistically different for outcomes of VenA or AMI. For AA/AD, incidence was higher during FQ risk periods vs amoxicillin [aIRR 1.50 (95% CI 1.01, 2.25)] and azithromycin [aIRR 2.15 (95% CI 1.27, 3.64)] risk periods. A significantly increased risk of mortality was observed with FQs vs each antibiotic of interest. FQs were associated with an increased risk of AA/AD vs amoxicillin and azithromycin and an increased risk of all-cause mortality vs multiple antibiotics commonly used for outpatient infections. Although the differences in event rates are small, FQ use should be limited to serious infections without appropriate alternatives. [ABSTRACT FROM AUTHOR]

Background & aims: Given ongoing challenges in non-invasive non-alcoholic liver disease (NAFLD) diagnosis, we sought to validate an ALT-based NAFLD phenotype using measures readily available in electronic health records (EHRs) and population-based studies by leveraging the clinical and genetic data in the Million Veteran Program (MVP), a multi-ethnic mega-biobank of US Veterans. Methods: MVP participants with alanine aminotransferases (ALT) >40 units/L for men and >30 units/L for women without other causes of liver disease were compared to controls with normal ALT. Genetic variants spanning eight NAFLD risk or ALT-associated loci (LYPLAL1, GCKR, HSD17B13, TRIB1, PPP1R3B, ERLIN1, TM6SF2, PNPLA3) were tested for NAFLD associations with sensitivity analyses adjusting for metabolic risk factors and alcohol consumption. A manual EHR review assessed performance characteristics of the NAFLD phenotype with imaging and biopsy data as gold standards. Genetic associations with advanced fibrosis were explored using FIB4, NAFLD Fibrosis Score and platelet counts. Results: Among 322,259 MVP participants, 19% met non-invasive criteria for NAFLD. Trans-ethnic meta-analysis replicated associations with previously reported genetic variants in all but LYPLAL1 and GCKR loci (P<6x10-3), without attenuation when adjusted for metabolic risk factors and alcohol consumption. At the previously reported LYPLAL1 locus, the established genetic variant did not appear to be associated with NAFLD, however the regional association plot showed a significant association with NAFLD 279kb downstream. In the EHR validation, the ALT-based NAFLD phenotype yielded a positive predictive value 0.89 and 0.84 for liver biopsy and abdominal imaging, respectively (inter-rater reliability (Cohen's kappa = 0.98)). HSD17B13 and PNPLA3 loci were associated with advanced fibrosis. Conclusions: We validate a simple, non-invasive ALT-based NAFLD phenotype using EHR data by leveraging previously established NAFLD risk-associated genetic polymorphisms. [ABSTRACT FROM AUTHOR]

Background: Approximately 13% of black individuals carry 2 copies of the apolipoprotein L1 (APOL1) risk alleles G1 or G2, which are associated with 1.5- to 2.5-fold increased risk of chronic kidney disease. There have been conflicting reports as to whether an association exists between APOL1 risk alleles and cardiovascular disease (CVD) that is independent of the effects of APOL1 on kidney disease. We sought to test the association of APOL1 G1/G2 alleles with coronary artery disease, peripheral artery disease, and stroke among black individuals in the Million Veteran Program.Methods: We performed a time-to-event analysis of retrospective electronic health record data using Cox proportional hazard and competing-risks Fine and Gray subdistribution hazard models. The primary exposure was APOL1 risk allele status. The primary outcome was incident coronary artery disease among individuals without chronic kidney disease during the 12.5-year follow-up period. We separately analyzed the cross-sectional association of APOL1 risk allele status with lipid traits and 115 cardiovascular diseases using phenome-wide association.Results: Among 30 903 black Million Veteran Program participants, 3941 (13%) carried the 2 APOL1 risk allele high-risk genotype. Individuals with normal kidney function at baseline with 2 risk alleles had slightly higher risk of developing coronary artery disease compared with those with no risk alleles (hazard ratio, 1.11 [95% CI, 1.01-1.21]; P=0.039). Similarly, modest associations were identified with incident stroke (hazard ratio, 1.20 [95% CI, 1.05-1.36; P=0.007) and peripheral artery disease (hazard ratio, 1.15 [95% CI, 1.01-1.29l; P=0.031). When both cardiovascular and renal outcomes were modeled, APOL1 was strongly associated with incident renal disease, whereas no significant association with the CVD end points could be detected. Cardiovascular phenome-wide association analyses did not identify additional significant associations with CVD subsets.Conclusions: APOL1 risk variants display a modest association with CVD, and this association is likely mediated by the known APOL1 association with chronic kidney disease. [ABSTRACT FROM AUTHOR]

Objectives To determine whether elderly veterans with posttraumatic stress disorder ( PTSD) and dementia are more likely to be prescribed second-generation antipsychotics ( SGAs) than those with PTSD alone. Design National serial cross-sectional study. Setting Veterans Health Affairs inpatient and outpatient settings. Participants Veterans aged 65 and older with PTSD (excluding schizophrenia or bipolar disorder) with or without concomitant dementia who received care from the Veterans Health Administration between 2003 and 2010 were identified using International Classification of Diseases, Ninth Revision, codes (N = 93,068; 11.1% with dementia). Measurements Trends in SGA prescribing and odds of being prescribed an SGA were determined using a multivariable logistic regression model adjusted for clinical, sociodemographic, and geographic covariates. Results Between 2004 and 2009, SGA prescribing declined annually from 7.0% to 5.1% of elderly veterans with PTSD without dementia and 13.2% to 8.9% in those with dementia; findings over time consistently indicated that veterans with PTSD and dementia had at least twice the odds of being prescribed an SGA as those without PTSD (odds ratios 2.03 (95% confidence interval ( CI) = 1.82-2.26) to 2.33 (95% CI = 2.10-2.58). Conclusion Although the prescribing of SGAs to elderly veterans with PTSD has decreased, prescribing an SGA to those with dementia remained consistently higher than for those with PTSD alone and is problematic given the high prevalence of medical comorbidities in this aging population coupled with the lack of compelling evidence for effectiveness of SGAs in individuals with dementia. [ABSTRACT FROM AUTHOR]

Background: There has been concern about the growing off-label use of testosterone. Understanding the context within which testosterone is prescribed may contribute to interventions to improve prescribing.Objective: To evaluate patient characteristics associated with receipt of testosterone.Design: Cross-sectional.Setting: A national cohort of male patients, who had received at least one outpatient prescription within the Veterans Affairs (VA) system during Fiscal Year 2008- Fiscal Year 2012.Participants: The study sample consisted of 682,915 non-HIV male patients, of whom 132,764 had received testosterone and a random 10% sample, 550,151, had not.Main Measures: Conditions and medications associated with testosterone prescription.Key Results: Only 6.3% of men who received testosterone from the VA during the study period had a disorder of the testis, pituitary or hypothalamus associated with male hypogonadism. Among patients without a diagnosed disorder of hypogonadism, the use of opioids and obesity were the strongest predictors of testosterone prescription. Patients receiving >100 mg/equivalents of oral morphine daily (adjusted odds ratio = 5.75, p < 0.001) and those with body mass index (BMI) >40 kg/m2 (adjusted odds ratio = 3.01, p < 0.001) were more likely to receive testosterone than non-opioid users and men with BMI <25 kg/m2. Certain demographics (age 40-54, White race), comorbid conditions (sleep apnea, depression, and diabetes), and medications (antidepressants, systemic corticosteroids) also predicted a higher likelihood of testosterone receipt, all with an adjusted odds ratio less than 2 (p < 0.001).Conclusions: In the VA, 93.7% of men receiving testosterone did not have a diagnosed condition of the testes, pituitary, or hypothalamus. The strongest predictors of testosterone receipt (e.g., obesity, receipt of opioids), which though are associated with unapproved, off-label use, may be valid reasons for therapy. Interventions should aim to increase the proportion of testosterone recipients who have a valid indication. [ABSTRACT FROM AUTHOR]

Objectives To determine the effectiveness of warfarin in older adults with dementia. Design Retrospective cohort study. Setting Department of Veterans Affairs national healthcare system. Participants Veterans aged 65 and older (73% aged ≥75, 99% male, 91% white) who had been receiving warfarin for nonvalvular atrial fibrillation for at least 6 months, were newly diagnosed with dementia in fiscal year 2007 or 2008, and were not enrolled in Medicare Advantage (n = 2,572). Measurements The onset of dementia was defined according to International Classification of Diseases, Ninth Revision, code. Participants were followed for up to 4 years for persistence of warfarin therapy, anticoagulation control, major hemorrhage, ischemic stroke, and all-cause mortality. Results The average CHADS2 score was 3.3 ± 1.3. After a diagnosis of dementia, 405 individuals (16%) persisted on warfarin therapy. Unadjusted Cox proportional hazards analysis demonstrated a protective effect of warfarin in prevention of ischemic stroke (hazard ratio ( HR) = 0.64, 95% confidence interval ( CI) = 0.46-0.89, P = .008), major bleeding ( HR = 0.72, 95% CI = 0.55-0.94, P = .02), and all-cause mortality ( HR = 0.66, 95% CI = 0.55-0.79, P < .001). Using propensity score matching, the protective effect of continuing warfarin persisted in prevention of stroke ( HR = 0.74, 95% CI = 0.54-0.996, P = .047) and mortality ( HR = 0.72, 95% CI = 0.60-0.87, P < .001), with no statistically significant decrease in risk of major bleeding ( HR = 0.78, 95% CI = 0.61-1.01, P = .06). Conclusion Discontinuing warfarin after a diagnosis of dementia is associated with a significant increase in stroke and mortality. [ABSTRACT FROM AUTHOR]

Aims We compared the risk of mental health episodes requiring hospitalization (primary aim) or out-patient clinic visits (secondary aim) associated with varenicline versus the nicotine patch (NP) in an era prior to psychiatric boxed warnings. Design Retrospective cohort. Setting Department of Veterans Affairs (VA), USA. Participants VA patients with or without psychiatric comorbidities and a new prescription for varenicline (15 255) were propensity score-matched (1 : 2) to new users of NP (123 054) between 1 May 2006 and 30 September 2007, resulting in 11 774 and 23 548 patients in the varenicline and NP groups, respectively. Measurements The primary outcomes were hospitalizations with a primary discharge diagnosis of a range of mental health disorders: depression, schizophrenia, bipolar disorder, suicide attempt, post-traumatic stress disorder, other psychosis and drug-induced mental disorders. Secondary outcomes were out-patient clinic visits with a primary diagnosis of the above list of mental health disorders. Findings Background characteristics of the treatment groups were similar after matching. There was no statistically significant difference in risk of hospitalization for any of the studied mental health disorders with varenicline compared with NP. Among secondary outcomes there was an increased risk of out-patient clinic visits for schizophrenia among patients who received varenicline [hazard ratio (HR) = 1.27; 95% confidence interval (CI) = 1.07, 1.51], this increase being evident only in those with a pre-existing mental health disorder. Conclusion In US VA patients studied prior to the boxed warning being implemented, use of varenicline for smoking cessation was not associated with a detectable increase compared with nicotine patches in hospitalization for any mental health outcomes. There was an increased rate of out-patient attendances with a primary diagnosis of schizophrenia amounting to five per 100 person years of treatment. This increase was found only in patients with a pre-existing mental health disorder. [ABSTRACT FROM AUTHOR]