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OBJECTIVE: The primary aim of this study was to examine differences in yoga practice between persons with and without chronic pain. Secondarily, we describe use of the Essential Properties of Yoga Questionnaire, Short Form (EPYQ-SF) for self-report. DESIGN: Participants were members of an existing cohort of veterans who completed a 2015-2016 survey focused on pain and nonpharmacological health practices. Cohort members who reported yoga in the past year (n=174 [9.4%] of 1850) were eligible for the present study, which used multiple-contact mixed-mode survey methodology to collect data on yoga practices. The EPYQ-SF was used to assess properties and context of yoga practice. Practice patterns were compared for participants with and without chronic pain. To explore potential reasons for reported yoga practice patterns, focused semi-structured interviews were conducted with a subset of participants. RESULTS: Of 174 participants contacted, 141 (82%) returned the yoga questionnaire and 110 (78% of respondents) were still practicing yoga. Among yoga practitioners, 41 (37%) had chronic pain. Practitioners with chronic pain reported gentler (2.8 vs 3.1, 5-point scale) and less active (2.9 versus 3.3) yoga practice than those without. Those with chronic pain attended yoga studios less frequently and reported shorter yoga practices than those without. Most yoga practice was self-directed and at home. CONCLUSIONS: Differences in yoga practice of persons with and without chronic pain have implications for implementation of yoga interventions for chronic pain. Future interventions should focus on alternative individual delivery formats or addressing barriers to group practice among people with chronic pain.

Background Yoga interventions can improve function and reduce pain in persons with chronic low back pain (cLBP). Objective Using data from a recent trial of yoga for military veterans with cLBP, we analyzed the incremental cost-effectiveness of yoga compared with usual care. Methods Participants (n=150) were randomized to either 2× weekly, 60-minute yoga sessions for 12 weeks, or to delayed treatment (DT). Outcomes were measured at 12 weeks, and 6 months. Quality-adjusted life years (QALYs) were measured using the EQ-5D scale. A 30% improvement on the Roland-Morris Disability Questionnaire (primary outcome) served as an additional effectiveness measure. Intervention costs including personnel, materials, and transportation were tracked during the study. Health care costs were obtained from patient medical records. Health care organization and societal perspectives were examined with a 12-month horizon. Results Incremental QALYs gained by the yoga group over 12 months were 0.043. Intervention costs to deliver yoga were $307/participant. Negligible differences in health care costs were found between groups. From the health care organization perspective, the incremental cost-effectiveness ratio to provide yoga was $4488/QALY. From the societal perspective, yoga was "dominant" providing both health benefit and cost savings. Probabilistic sensitivity analysis indicates an 89% chance of yoga being cost-effective at a willingness-to-pay of $50,000. A scenario comparing the costs of yoga and physical therapy suggest that yoga may produce similar results at a much lower cost. Discussion/conclusions Yoga is a cost-effective treatment for reducing pain and disability among military veterans with cLBP.

Previous studies measuring the health-related quality of life (HRQoL) of individuals with dengue focused on treatment seeking populations. However, the vast majority of global dengue cases are unlikely to be detected by health systems. Representative measurements of HRQoL should therefore include patients with disease not likely to trigger treatment-seeking behavior. This study based in Iquitos, Peru used the Quality of Wellbeing Scale-Self Administered, a survey that enquires about not only physical health, but also psychological health, self-care, mobility, and usual social activities, and rates HRQoL between 0 (death) and 1 (optimum function), to evaluate the impact of dengue on HRQoL. In order to enroll treatment and non treatment-seeking participants, three modalities of participant recruitment were used. In addition to clinic and community-based febrile surveillance, a contact-cluster methodology was also employed to identify infected individuals less likely to seek treatment. We measured changes in HRQoL and identified common areas of health impairment in 73 virologically confirmed dengue cases at 3 time points during the participant’s illness; the early-acute (days 0–6 post symptom onset), late-acute (days 7–20), and convalescent illness phases (days 21 +). Participants reported HRQoL related impairments at significantly higher frequency during the early-acute versus convalescent illness phase (Fisher’s exact: P, Author summary Dengue, a viral illness occurring following the bite of an infected mosquito, is common in tropical urban areas of the globe. Using a survey that enquires about not only physical health but also psychological health, self-care, mobility and usual social activities, this study assesses the overall impact of dengue on the well-being of those with the disease. Of the estimated 390 million annual infections, approximately 75 percent do not cause individuals to attend medical facilities, possibly because many infections do not result in significant symptoms or because access to healthcare is limited. Unlike previous studies, this study recruited those who would have been unlikely to seek healthcare as well as individuals who attended health facilities. This study adds to the growing body of evidence that healthcare professionals should regard dengue as a disease that affects not only physical, but also psychological health and aspects of social functioning. Furthermore, it suggests that those not seeking treatment may also have a substantial reduction in quality of life during their infection. Given the millions of dengue infected people who do not attend healthcare facilities annually this could amount to a very meaningful societal impact.

Objectives Yoga demonstrates beneficial effects in many populations, yet our understanding of how yoga brings about these effects is quite limited. Among the proposed mechanisms of yoga are increasing psychological resources (mindfulness, body consciousness, self-transcendence, spiritual peace, and social connectedness) that may bring about salutary effects on emotional wellbeing. Further, yoga is a complex practice comprising meditation, active and restorative postures, and breathwork; however little is known about how different components may affect mechanisms. We aimed to determine how an acute session of yoga (and its specific components) related to pre- to post- session changes in proposed mechanisms (psychological resources) and whether those changes were associated with positive changes in emotions. Design 144 regular yoga practitioners completed measures of mindfulness, body consciousness, self-transcendence, social connectedness, spiritual peace, and exercise-induced emotions (positive engagement, revitalization, tranquility, exhaustion) immediately before and after a yoga session (N = 11 sessions, each a different type of yoga). Perceived properties of each yoga session, exercise exertion and engagement with the yoga teacher were assessed immediately following the session. Results Pre-to post- yoga, levels of positive emotions (engagement, tranquility and revitalization) increased while exhaustion decreased. Further, all psychological resources increased and closely tracked improved emotions. Additionally, aspects of the yoga session correlated with changes in psychological resources (mechanisms) and emotions. Conclusions Yoga may influence multiple psychological mechanisms that influence emotional well-being. Further, different types of yoga may affect different mechanisms. Results can inform yoga interventions aiming to optimize effects through specific mechanisms such as mindfulness or spirituality.

Background The Lifestyle Interventions and Independence for Elders (LIFE) Study physical activity (PA) intervention was found to be cost-effective compared to health education (HE). However, long-term effects postintervention are unknown. Method This was a secondary analysis of LIFE Study data linked to Medicare claims data (2014–2016). Participants were linked via Social Security Numbers to Medicare claims data. Utilization and cost variables were analyzed using generalized linear models with negative binomial and Tweedie distributions. Unadjusted means and 95% confidence intervals were compared by year and overall stratified. Each model compared PA versus HE and adjusted for other baseline characteristics and stratified by study site. Additional models were stratified by baseline physical functioning assessment scores. Results Of the 1,635 LIFE Study participants, 804 (53.5%) were linked to Medicare claims with an average of 33 months of follow-up time during the 3-year data linkage period. Mean outpatient (6.6 vs 6.8), inpatient (0.40 vs 0.40), and other utilization metrics were similar between PA and HE groups. Costs were also similar for each group and each type of service, for example, outpatient: $2,070 versus $2,093 and inpatient: $4,704 versus $4,792. Regression results indicated no statistically significant differences between PA and HE groups. Conclusions While the LIFE Study demonstrated that PA reduced mobility disability in older adults and was cost-effective, it did not appear to affect long-term health care utilization costs posttrial. These findings suggest that it remains challenging to affect long-term health care costs using PA interventions effects.

Objective Millions of military personnel and veterans live with chronic mental and physical health conditions that often do not respond well to pharmacological treatments. Serious side effects and lack of treatment response have led to widespread efforts to study and promote non-pharmacological and behavioral health treatments for many chronic health conditions. Yoga is an increasingly popular mind-body intervention that has growing research support for its efficacy and safety. Our objective was to explore the attitudes, perspectives, and preferences of military personnel and veterans toward yoga as a therapeutic modality, thus providing needed information for designing and promoting yoga interventions for this population. Methods Participants included 24 individuals with yoga experience and current or past military service and 12 instructors who have taught yoga for military personnel and/or veterans. A semi-structured set of questions guided interviews with each participant. Results Five themes emerged from the interviews: (1) mental health benefits experienced from yoga practice; (2) physical health benefits experienced from yoga practice; (3) important yoga elements and conditions that support effective practice; (4) facilitators for engaging military in yoga practice; and (5) challenges and barriers to yoga practice for military. Conclusions The study highlights consistent reports of mental and physical benefits of yoga practice, ongoing stigma resulting in the need for combatting and demystifying yoga and other complementary and integrative health (CIH) practices, the importance of designing interventions to address the unique mental health issues and perspectives of this population, and the importance of efforts by military leadership to bring CIH to military personnel and veterans. Rigorous research addressing these findings, along with further research on the efficacy and effectiveness of yoga interventions for treating various conditions are needed.

Objective The purpose of this study was to examine the relationship between dynapenia and metabolic risk factors in obese and nonobese older adults. Methods A total of 1453 men and women (age ≥70 years) from the Lifestyle Interventions and Independence for Elders (LIFE) Study were categorized as (1) nondynapenic/nonobese (NDYN-NO), (2) dynapenic/nonobese (DYN-NO), (3) nondynapenic/obese (NDYN-O), or (4) dynapenic/obese (DYN-O), based on muscle strength (Foundation for the National Institute of Health criteria) and body mass index. Dependent variables were blood lipids, fasting glucose, blood pressure, presence of at least 3 metabolic syndrome (MetS) criteria, and other chronic conditions. Results A significantly higher likelihood of having abdominal obesity criteria in NDYN-NO compared with DYN-NO groups (55.6 vs 45.1%, P ≤ .01) was observed. Waist circumference also was significantly higher in obese groups (DYN-O = 114.0 ± 12.9 and NDYN-O = 111.2 ± 13.1) than in nonobese (NDYN-NO = 93.1 ± 10.7 and DYN-NO = 92.2 ± 11.2, P ≤ .01); and higher in NDYN-O compared with DYN-O ( P = .008). Additionally, NDYN-O demonstrated higher diastolic blood pressure compared with DYN-O (70.9 ± 10.1 vs 67.7 ± 9.7, P ≤ .001). No significant differences were found across dynapenia and obesity status for all other metabolic components ( P > .05). The odds of having MetS or its individual components were similar in obese and nonobese, combined or not with dynapenia (nonsignificant odds ratio [95% confidence interval]). Conclusion Nonobese dynapenic older adults had fewer metabolic disease risk factors than nonobese and nondynapenic older adults. Moreover, among obese older adults, dynapenia was associated with lower risk of meeting MetS criteria for waist circumference and diastolic blood pressure. Additionally, the presence of dynapenia did not increase cardiometabolic disease risk in either obese or nonobese older adults.

Background The loss of mobility during aging impacts independence and leads to further disability, morbidity, and reduced life expectancy. Our objective was to examine the feasibility and safety of conducting a randomized controlled trial of yoga for older adults at risk for mobility limitations. Methods Sedentary older adults (n = 46; age 60–89) were recruited and randomized to either yoga or a health education comparison group. Yoga sessions (60-min) occurred 2x weekly, and 90-min health education sessions occurred weekly, for 10 weeks. The primary outcomes were recruitment rate, intervention attendance, and retention at assessments. Adverse event rates and participant satisfaction were also measured. Physical performance measures of gait, balance, and strength and self-report outcome measures were administered at baseline and 10-weeks. Results Recruitment lasted 6 months. Retention of participants at the 10-week follow-up was high (89% - performance measures; 98% - self-report questionnaires). Attendance was good with 82% of yoga and 74% of health education participants attending at least 50% of the sessions. No serious adverse events were reported. Patient satisfaction with the interventions was high. The mean effect size for the physical performance measures was 0.35 with some over 0.50. The mean effect size for self-report outcome measures was 0.36. Conclusions Results indicate that it is feasible to conduct a larger RCT of yoga for sedentary older adults at risk for mobility problems. The yoga and comparison interventions were safe, well accepted, and well attended. Effect sizes suggest yoga may have important benefits for this population and should be studied further. Trial Registration ClinicalTrials # NCT03544879; Retrospectively registered 4 June, 2018.

BACKGROUND The spectrum of gastroenterology-related diseases related to obesity is growing. Few clinical tools exist to aid in clinician-guided dietary counseling. GOALS (1) Develop and validate a 1-page diet history form that would provide information on dietary factors that can contribute to gastrointestinal (GI) illness and to assess adherence to the Mediterranean diet; and (2) evaluate the form in a general GI clinic to determine its potential utility as a clinical tool. STUDY A 1-page diet history form was developed and underwent qualitative and quantitative validation in comparison to a formal diet evaluation by a registered dietitian. The form was then evaluated in consecutive patients attending a general GI clinic, and analyzed for overall diet content, compliance with a Mediterranean diet, and presence of high-risk (red flag) dietary behaviors. RESULTS The form was evaluated in 134 patients. In a validation cohort (n=30) the qualitative dietary components measured were highly concordant with a formal dietary interview. Total daily calorie intake correlated with formal dietary review (R=0.61), but tended to underestimate total calories due to less precision in portion size. The prospective cohort (n=104) patients had a mean body mass index of 29.8. Overall, 52.9% were obese, 50% had metabolic syndrome, and 51% had a primary GI illness directly impacted by dietary factors (gastroesophageal reflux, irritable bowel, fatty liver). Overall, 85.6% of patients documented red flag behaviors. Patients with obesity trended for more red flags than overweight or normal body mass index groups. CONCLUSION A 1-page diet questionnaire correlated well with formal dietary assessment and identified clinically relevant dietary interventions in a high percentage of GI patients.

Algorithms for the diagnosis, management, and follow-up have been proposed for patients hospitalized for inflammatory bowel disease (IBD) colitis flare. The degree to which providers adhere to these algorithms is unknown. This study evaluated the quality of care in IBD patients hospitalized for disease-associated exacerbations and factors correlated with higher degrees of care. Retrospective chart review of 34 patients during 60 admissions to the medicine service for IBD colitis exacerbation between 2005 and 2012 at the Veterans Affairs San Diego Medical Center. Examined factors included laboratory testing, timing of consultation and intravenous steroids, abdominal imaging, endoscopic examination, venous thromboembolism (VTE) prophylaxis, narcotic use, Clostridium difficile and cytomegalovirus testing, symptomatology at discharge, timing of follow-up, and rates of readmission and mortality. Quality of care varied among the factors studied, ranging from 30.5 % for pharmacologic VTE prophylaxis to 84.7 % for gastroenterology consultation within 24 h. Of 60 admissions, 22 % were not tested for C. difficile. Fifteen percent of patients were discharged before meeting commonly used discharge criteria. Eighty percent were seen in clinic at any time post-discharge; 6.7 % were readmitted; 10 % were lost to follow-up; 1.7 % opted for outside follow-up; and 1.7 % expired. The quality of care for patients admitted with IBD colitis flares is variable. These data outline opportunities for improvement, particularly in regard to pain management, VTE prophylaxis, and follow-up. Further studies are needed to test intervention strategies for practice improvement.

BACKGROUND: Hospitalization reduces mobility for many older adults, which in turn is associated with an increased risk of hospitalization. Physical function screening may identify an at-risk population for intervention. The Mobility Assessment Tool – short form (MAT-sf) is a brief, animated, computer-based means of assessing mobility that predicts mobility disability. This study explored whether baseline MAT-sf scores are associated with number of hospitalizations and time to first hospitalization across a median follow-up of 2.7 years. DESIGN: Post-hoc analysis of prospectively-gathered data from the Lifestyle Interventions and Independence for Elders (LIFE) Study, a randomized clinical trial of lifestyle interventions to preserve mobility in older adults, conducted in eight U.S. academic medical centers. PARTICIPANTS: Among 1635 sedentary community-dwelling older adults enrolled in LIFE, 1574 completed baseline physical function screening including the MAT-sf, with baseline scores ranging from 30.2 (low function) to 69.8 (high function) on a scale from 30-80. MEASUREMENTS: Number of hospitalizations and time to first hospitalization, adjusted for age, gender, race, living alone, clinical site, baseline comorbidities, # prescription medications, and cognition. RESULTS: Of the 1557 participants with data regarding hospitalization status, 726 (47%) experienced at least one hospitalization; the majority (78%) of these experienced 1-2 hospitalizations. For every 10-point difference in MAT-sf score, the rate of all hospitalizations was higher by 19% in those with lower scores (adjusted rate ratio 1.20, 95% CI: 1.08-1.32, p

Yoga-based practices (YBP) typically involve a combination of movement sequences, conscious regulation of the breath, and techniques to engage attention. However, little is known about whether effects of YBP result from the synergistic combination of these components, or whether a subset may yield similar effects. In this study we compared the effect of a movement-focused practice and a breath-focused practice on stress parameters (perceived stress and salivary cortisol) and sustained attention (response inhibition) in yoga naive university students. While participants of both programs showed a reduction in perceived stress and salivary cortisol, only the breath-focused group showed improvements in sustained attention. In addition, improvement in sustained attention was correlated with reduction in perceived stress but not with reduction in salivary cortisol. We discuss these findings in the context of a theoretical framework outlining bottom-up neurophysiological and top-down neurocognitive mechanisms hypothesized to be engaged by YBP.

Background & Aims The Veterans Health Administration (VHA) is the largest single provider of care for hepatitis C virus (HCV) infection in the United States. We analyzed the cost effectiveness of treatment with the HCV protease inhibitors boceprevir and telaprevir in a defined managed care population of 102,851 patients with untreated chronic genotype 1 infection. Methods We used a decision-analytic Markov model to examine 4 strategies: standard dual-therapy with pegylated interferon-alfa and ribavirin (PR), the combination of boceprevir and PR triple therapy, the combination of telaprevir and PR, or no antiviral treatment. A sensitivity analysis was performed. Sources of data included published rates of disease progression, the census bureau, and VHA pharmacy and hospitalization cost databases. Results The estimated costs for treating each patient were $8000 for PR, $31,300 for boceprevir and PR, and $41,700 for telaprevir and PR. Assuming VHA treatment rates of 22% and optimal rates of sustained virologic response, PR, boceprevir and PR, and telaprevir and PR would reduce relative liver-related deaths by 5.2%, 10.9%, and 11.5%, respectively. Increasing treatment rates to 50% would reduce liver-related deaths by 12%, 24.7%, and 26.1%, respectively. The incremental cost-effectiveness ratios were $29,184/quality-adjusted life-years for boceprevir and PR and $44,247/quality-adjusted life-years for telaprevir and PR vs only PR. With the current 22% treatment rate, total system-wide costs to adopt boceprevir and PR or telaprevir and PR would range from $708 to $943 million. Conclusions Despite substantial up-front costs of treating HCV-infected patients in the VHA with PR, or telaprevir and PR, each regimen improves quality of life and extends life expectancy by reducing liver-related morbidity and mortality, and should be cost effective. Further efforts to expand access to direct-acting antiviral therapy are warranted.

OBJECTIVES: To describe several recruitment parametersderived from the Lifestyle Interventions and Independencefor Elders pilot (LIFE-P) study for use in a full-scale trial ofmobility disability prevention.DESIGN: A description of the recruiting methods andbaseline characteristics of a four-site randomized, con-trolled trial testing the effectiveness of a physical activityintervention at preventing mobility disability.SETTING: The Cooper Institute, Dallas, Texas; StanfordUniversity, Stanford, California; University of Pittsburgh,Pittsburgh,Pennsylvania;andWakeForestUniversity,Win-ston-Salem, North Carolina.PARTICIPANTS: Community-livingpersonsaged70to89whowereabletowalk400mwithin15minutesandwereathigh risk for disability (scoringo10 on the Short PhysicalPerformance Battery (SPPB)) but without comorbidity se-vere enough to preclude full study participation.MEASUREMENTS: Measures of efficiency includednum-ber of randomized participants per recruitment techniqueand costsper randomized participantacross randomizationtechniques.RESULTS: The 9-month recruiting period resulted in3,141 telephone screens, of which 424 (13.5%) partici-pants were randomized (68.9% women, 25.7% minorities,41.5% with SPPB scoreso8). Forty percent of telephone-screened participants were excluded primarily because ofregular participation in physical activity, health exclusions,or self-reported mobility disability. Of the 1,252 personsattempting the physical performance assessments, 41%scored above the SPPB cutoff. Of the 566 remaining eligi-ble, 9.9% could not complete the 400-m walk, and another18.9% had various medical exclusions. Direct mailing wasthe most productive recruitment strategy (61.6% of allrandomized participants). Recruitment cost approximately$439 per randomized participant.CONCLUSION: The LIFE study achieved all recruitmentgoals and demonstrated the feasibility of recruiting high-risk community-dwelling older persons for trials of disabi-lity prevention in diverse geographic areas. J Am GeriatrSoc 55:674–683, 2007.Key words: recruitment; clinical trials; prevention ofmobility disability; physical activity

Introduction Chronic low back pain (cLBP) is prevalent, especially among military veterans. Many cLBP treatment options have limited benefits and are accompanied by side effects. Major efforts to reduce opioid use and embrace nonpharmacological pain treatments have resulted. Research with community cLBP patients indicates that yoga can improve health outcomes and has few side effects. The benefits of yoga among military veterans were examined. Design Participants were randomized to either yoga or delayed yoga treatment in 2013–2015. Outcomes were assessed at baseline, 6 weeks, 12 weeks, and 6 months. Intention-to-treat analyses occurred in 2016. Setting/Participants One hundred and fifty military veterans with cLBP were recruited from a major Veterans Affairs Medical Center in California. Intervention Yoga classes (with home practice) were led by a certified instructor twice weekly for 12 weeks, and consisted primarily of physical postures, movement, and breathing techniques. Main outcome measures The primary outcome was Roland−Morris Disability Questionnaire scores after 12 weeks. Pain intensity was identified as an important secondary outcome. Results Participant characteristics were mean age 53 years, 26% were female, 35% were unemployed or disabled, and mean back pain duration was 15 years. Improvements in Roland−Morris Disability Questionnaire scores did not differ between the two groups at 12 weeks, but yoga participants had greater reductions in Roland−Morris Disability Questionnaire scores than delayed treatment participants at 6 months −2.48 (95% CI= −4.08, −0.87). Yoga participants improved more on pain intensity at 12 weeks and at 6 months. Opioid medication use declined among all participants, but group differences were not found. Conclusions Yoga improved health outcomes among veterans despite evidence they had fewer resources, worse health, and more challenges attending yoga sessions than community samples studied previously. The magnitude of pain intensity decline was small, but occurred in the context of reduced opioid use. The findings support wider implementation of yoga programs for veterans. Trial registration This study is registered at www.clinicaltrials.gov NCT02524158.

Background. Despite the emergence of new hepatitis C virus (HCV) antiviral medications, many people with chronic HCV know little about their disease, are at risk for transmitting HCV to others, and/or are not considered good treatment candidates. Self-management interventions can educate HCV-infected persons, improve their quality of life, and prepare them for treatment. Purpose. A cost-effectiveness analysis of the HCV Self-Management Program is presented. Method. Effectiveness data in quality-adjusted life years (QALYs) were derived from the previously published prospective, randomized controlled trial ( n = 134). Health care utilization was abstracted from medical records in 2011 for the 12 months before and after study enrollment. Intervention costs were tracked from the payer’s perspective and combined with health care costs. Sensitivity analyses were used to examine assumptions. Data were analyzed in 2014. Results. Estimated intervention costs including organizational overhead were $1,760 per 6-week workshop, or $229/person. Health care costs were $815 lower/person for self-management participants, resulting in a cost savings of $586/person. Self-management participants had an average net gain of 0.02975 QALYs after 1 year. When removing inpatient substance use treatment days from analyses, costs were similar between groups, producing an incremental cost-effectiveness ratio of $6,218/QALY. Sensitivity analyses showed that the results and conclusions change little when assumptions were varied. Conclusions. When compared to information-only, the HCV Self-Management Program led to more QALYs and cost savings in the randomized controlled trial. Independent of health care costs, the intervention is low-cost and educates HCV-infected individuals about antiviral treatment and avoiding viral transmission. Low-cost interventions that can enhance the outcomes derived from expensive antiviral treatments should be studied further.

To evaluate the extent of variability in functional responses in participants in the Lifestyle Interventions and Independence for Elders (LIFE) study and to identify the relative contributions of intervention adherence, physical activity, and demographic and health characteristics to this variability.Secondary analysis.Multicenter institutions.A volunteer sample (N=1635) of sedentary men and women aged 70 to 89 years who were able to walk 400m but had physical limitations, defined as a Short Physical Performance Battery (SPPB) score of ≤9.Moderate-intensity physical activity (n=818) consisting of aerobic, resistance, and flexibility exercises performed both center-based (2times/wk) and home-based (3-4times/wk) sessions or health education program (n=817) consisting of weekly to monthly workshops covering relevant health information.Physical function (gait speed over 400m) and lower extremity function (SPPB score) assessed at baseline and 6, 12, and 24 months.Greater baseline physical function (gait speed, SPPB score) was negatively associated with change in gait speed (regression coefficient β=-.185; P.001) and change in SPPB score (β=-.365; P.001), whereas higher number of steps per day measured by accelerometry was positively associated with change in gait speed (β=.035; P.001) and change in SPPB score (β=.525; P.001). Other baseline factors associated with positive change in gait speed and/or SPPB score include younger age (P.001), lower body mass index (P.001), and higher self-reported physical activity (P=.002).Several demographic and physical activity-related factors were associated with the extent of change in functional outcomes in participants in the LIFE study. These factors should be considered when designing interventions for improving physical function in older adults with limited mobility.

The Illness Management and Recovery (IMR) scale was created to measure recovery outcomes produced by the IMR program. However, many other mental health care programs are now designed to impact recovery-oriented outcomes, and the IMR has been identified as a potentially valuable measure of recovery-oriented mental health outcomes. The purpose of this study was to examine the psychometric properties and structural validity of the IMR clinician scale within a variety of therapeutic modalities other than IMR in a large multiethnic sample (N=10,659) of clients with mental illness from a large U.S. county mental health system. Clients completed the IMR on a single occasion. Our estimates of internal consistency were stronger than those found in previous studies (α=0.82). The scale also related to other measures of theoretically similar constructs, supporting construct and criterion validity claims. Additionally, confirmatory factor analyses supported the multidimensional representation of the IMR clinician scale. The three-factor model of illness self-management and recovery was represented by dimensions of recovery, management, and substance use. These reliable psychometric properties support the use of both the original one-factor and revised three-factor models to assess illness self-management and recovery among a broad spectrum of clients with mental illness.

Chronic low back (CLBP) pain is prevalent among military veterans and often leads to functional limitations, psychologic symptoms, lower quality of life, and higher health care costs. An increasing proportion of U.S. veterans are women, and women veterans may have different health care needs than men veterans. The purpose of this study was to assess the impact of a yoga intervention on women and men with CLBP. SUBJECTS/SETTING/INTERVENTION: VA patients with CLBP were referred by primary care providers to a clinical yoga program.Research participants completed a brief battery of questionnaires before their first yoga class and again 10 weeks later in a single-group, pre-post study design.Questionnaires included measures of pain (Pain Severity Scale), depression (CESD-10), energy/fatigue, and health-related quality of life (SF-12). Yoga attendance and home practice of yoga were also measured. Repeated-measures analysis of variance was used to analyze group differences over time while controlling for baseline differences.The 53 participants who completed both assessments had a mean age of 53 years, and were well educated, 41% nonwhite, 49% married, and had varying employment status. Women participants had significantly larger decreases in depression (p=0.046) and pain "on average" (p=0.050), and larger increases in energy (p=0.034) and SF-12 Mental Health (p=0.044) than men who participated. The groups did not differ significantly on yoga attendance or home practice of yoga.These results suggest that women veterans may benefit more than men veterans from yoga interventions for chronic back pain. Conclusions are tentative because of the small sample size and quasi-experimental study design. A more rigorous study is being designed to answer these research questions more definitively.

Chronic back pain affects a large proportion of both the general population and of military veterans. Although numerous therapies exist for treating chronic back pain, they can be costly and tend to have limited effectiveness. Thus, demonstrating the efficacy and cost-effectiveness of additional treatment alternatives is important. The purpose of our study was to examine the benefits of a yoga intervention for Veterans Administration (VA) patients. SUBJECTS/INTERVENTION: VA patients with chronic back pain were referred by their primary care providers to a yoga program as part of clinical care. Before starting yoga, a VA physician trained in yoga evaluated each patient to ensure that they could participate safely.The research study consisted of completing a short battery of questionnaires at baseline and again 10 weeks later.Questionnaires included measures of pain, depression, energy/fatigue, health-related quality of life, and program satisfaction. Paired t-tests were used to compare baseline scores to those at the 10-week follow-up for the single group, pre-post design. Correlations were used to examine whether yoga attendance and home practice were associated with better outcomes.Baseline and follow-up data were available for 33 participants. Participants were VA patients with a mean age of 55 years. They were 21% female, 70% white, 52% married, 68% college graduates, and 44% were retired. Significant improvements were found for pain, depression, energy/fatigue, and the Short Form-12 Mental Health Scale. The number of yoga sessions attended and the frequency of home practice were associated with improved outcomes. Participants appeared highly satisfied with the yoga instructor and moderately satisfied with the ease of participation and health benefits of the yoga program.Preliminary data suggest that a yoga intervention for VA patients with chronic back pain may improve the health of veterans. However, the limitations of a pre-post study design make conclusions tentative. A larger randomized, controlled trial of the yoga program is planned.

Objectives. We examined the impact of transitioning clients from a mental health clinic to a patient-centered medical home (PCMH) on mental health recovery. Methods. We drew data from a large US County Behavioral Health Services administrative data set. We used propensity score analysis and multilevel modeling to assess the impact of the PCMH on mental health recovery by comparing PCMH participants (n = 215) to clients receiving service as usual (SAU; n = 22 394) from 2011 to 2013 in San Diego County, California. We repeatedly assessed mental health recovery over time (days since baseline assessment range = 0–1639; mean = 186) with the Illness Management and Recovery (IMR) scale and Recovery Markers Questionnaire. Results. For total IMR (log-likelihood ratio χ2[1] = 4696.97; P 2[1] = 7.9; P = .005), increases in mental health recovery over time were greater for PCMH than SAU participants. Increases on all other measures over time were similar for PCMH and SAU participants. Conclusions. Greater increases in mental health recovery over time can be expected when patients with severe mental illness are provided treatment through the PCMH. Evaluative efforts should be taken to inform more widespread adoption of the PCMH.

Background Losing the ability to walk safely and independently is a major concern for many older adults. The Lifestyle Interventions and Independence for Elders study recently demonstrated that a physical activity (PA) intervention can delay the onset of major mobility disability. Our objective is to examine the resources required to deliver the PA intervention and calculate the incremental cost-effectiveness compared with a health education intervention. Methods The Lifestyle Interventions and Independence for Elders study enrolled 1,635 older adults at risk for mobility disability. They were recruited at eight field centers and randomly assigned to either PA or health education. The PA program consisted of 50-minute center-based exercise 2× weekly, augmented with home-based activity to achieve a goal of 150 min/wk of PA. Health education consisted of weekly workshops for 26 weeks, and monthly sessions thereafter. Analyses were conducted from a health system perspective, with a 2.6-year time horizon. Results The average cost per participant over 2.6 years was US$3,302 and US$1,001 for the PA and health education interventions, respectively. PA participants accrued 0.047 per person more Quality-Adjusted Life-Years (QALYs) than health education participants. PA interventions costs were slightly higher than other recent PA interventions. The incremental cost-effectiveness ratios were US$42,376/major mobility disability prevented and US$49,167/QALY. Sensitivity analyses indicated that results were relatively robust to varied assumptions. Conclusions The PA intervention costs and QALYs gained are comparable to those found in other studies. The ICERS are less than many commonly recommended medical treatments. Implementing the intervention in non-research settings may reduce costs further.

© 2015 Catanzaro et al. Background: The aim of this study was to compare the performance of several recently developed assays for the detection of multi- and extensively drug-resistant tuberculosis (M/XDR-TB) in a large, multinational field trial. Methods: Samples from 1,128 M/XDR-TB suspects were examined by Line Probe Assay (LPA), Pyrosequencing (PSQ), and Microscopic Observation of Drug Susceptibility (MODS) and compared to the BACTEC MGIT960 reference standard to detect M/XDR-TB directly from patient sputum samples collected at TB clinics in India, Moldova, and South Africa. Results: Specificity for all three assays was excellent: 97-100% for isoniazid (INH), rifampin (RIF), moxifloxacin (MOX) and ofloxacin (OFX) and 99-100% for amikacin (AMK), capreomycin (CAP) and kanamycin (KAN) resistance. Sensitivities were lower, but still very good: 94-100% for INH, RIF, MOX and OFX, and 84-90% for AMK and CAP, but only 48-62% for KAN. In terms of agreement, statistically significant differences were only found for detection of RIF (MODS outperformed PSQ) and KAN (MODS outperformed LPA and PSQ) resistance. Mean time-to-result was 1.1 days for LPA and PSQ, 14.3 days for MODS, and 24.7 days for MGIT. Conclusions: All three rapid assays evaluated provide clinicians with timely detection of resistance to the drugs tested; with molecular results available one day following laboratory receipt of samples. In particular, the very high specificity seen for detection of drug resistance means that clinicians can use the results of these rapid tests to avoid the use of toxic drugs to which the infecting organism is resistant and develop treatment regiments that have a higher likelihood of yielding a successful outcome. Copyright

Objectives: Methamphetamine (MA) use has increased in the United States in the last 20 years and is a risk factor for hepatitis C virus(HCV) infection. The purpose of this study was to determine the characteristics and HCV infection outcomes of patients with a history of MA use. Methods: Subjects consisted of newly entered patients in the Veterans Affairs (VA) HCV registry at a single VA medical center from January 1, 2004, to June 30, 2004, and from January 1, 2007, to June 30, 2007. Univariate and multivariate analyses related to HCV infection antiviral treatment outcomes through 2010 was performed. Results: A total of 198 consecutive eligible HCV registry patients were analyzed, and 40% had a history of MA use. Of patients with MA use history, 46% (36/79) had active use (within 6 months) at initial contact. Active MA users were significantly younger (mean age, 45.5 years), with more concomitant drug use (86%), compared with patients without MA use (mean age, 53.5 years; 42% minority; 29% other drug use). Overall, 71% of the 198 patients reported a history of problematic alcohol use, and 47% of those reported active abuse. Logistic regression analyses indicated that MA use did not significantly adversely affect antiviral treatment initiation, completion, or sustained virological response rates compared with that in patients without MA use. Active alcohol users had lower treatment initiation than patients without alcohol use. Conclusions: MA use is common in recent US veterans with HCV infection and occurs in younger patients with polysubstance use. Prior history or active MA use does not seem to adversely affect HCV infection clinic treatment compared with that in HCV-infected patients without MA use.

Objective. To determine whether experimentally developed social support, education about appropriate use of the health care system, and their combination are effective in reducing health care costs for people with osteoarthritis at a 3-year followup assessment. Method. Three hundred sixty-three health maintenance organization members with osteoarthritis were randomly assigned to 1 of 3 intervention groups or to a control group. Two hundred fifty-six participants completed the 3-year assessment. Health status and health care use were assessed upon entering the study, and after 1, 2, and 3 years. Results. Health care costs in the combined experimental groups were lower than those in the control group by $1,279/participant/year in year 3. There were no significant changes in health status between participants' entry into the study and the year 3 assessment. The 3 interventions had nearly equal effects on health status and health care costs. Implementation costs were least for the social support intervention, but the group that combined education and social support had less attrition and greater persistence. Conclusion. Interventions that target appropriate use of the health care system can be highly costeffective without adversely affecting health status.

Adult men (n = 132; 92% of the population) with histories of alcohol/drug use disorders were interviewed upon their entry to 11 Oxford Houses located in the state of Illinois. Individuals still in residence at a six-month follow-up (n = 48) were reinterviewed; prior to the follow-up interview, 42 men had left voluntarily and 42 men had been evicted for abuse or disruptive behavior. The men remaining in residence tended to be older (M age = 37 years), were disproportionately African American (56%), and were less pessimistic about their future. At the intake interview, individuals who would be evicted reported a lower expectation for abstinence social support from the other residents in Oxford House. The Oxford House model of social support for recovery from alcohol and drug dependence appears to help some residents maintain sobriety.

Objective. Chronic hepatitis C infection afflicts millions of people worldwide. Although antiviral treatments are increasingly effective, many hepatitis C virus (HCV) patients avoid treatment, do not complete or respond to treatment, or have contraindications. Self-management interventions are one option for promoting behavioral changes leading to liver wellness and improved quality of life. Our objective was to evaluate whether the effects of the HCV self-management program were sustained at the 12-month follow-up assessment. Methods. Veteran Affairs patients with hepatitis C ( N = 134; mean age = 54.6 years, 95% male, 41% ethnic minority, 48% homeless in last 5 years) were randomized to either a 6-week self-management workshop or an information-only intervention. The weekly 2-hour self-management sessions were based on a cognitive–behavioral program with hepatitis C–specific modules. Outcomes including hepatitis C knowledge, depression, energy, and health-related quality of life were measured at baseline, 6 weeks, 6 months, and 12 months later. Data were analyzed using repeated measures ANOVA. Results. Compared with the information-only group, participants attending the self-management workshop improved more on HCV knowledge ( p < .005), SF-36 energy/vitality ( p = .016), and the Quality of Well-Being Scale ( p = .036). Similar trends were found for SF-36 physical functioning and Center for Epidemiologic Studies Short Depression Scale. Conclusion. Better outcomes were sustained among self-management participants at the 12-month assessment despite the intervention only lasting 6 weeks. HCV health care providers should consider adding self-management interventions for patients with chronic HCV.

Most individuals infected with the hepatitis C have not received antiviral treatment, with mental health and substance abuse problems being the primary barrier. Interventions have been developed to address these barriers among HCV patients considered "high-risk" for antiviral treatment. We present the design and methods of a prospective, randomized controlled multisite trial being conducted in the Veterans Affairs Healthcare System. The study employed a parallel design and the three study sites randomized a total of 364 VA patients with HCV to either Integrated Care (IC) or Usual Care (UC). The IC intervention consisted of a mental health provider (MHP) performing a) brief interventions to address risk factors; b) collaborative consultation with the HCV treatment clinicians; and c) case management prior to and during antiviral treatment. Clinical outcomes were abstracted from patient medical records and self-report questionnaires were completed at baseline, 4-months, 16-months, and 22-months after enrollment. The primary outcome of the study was sustained viral response (SVR). Secondary clinical outcomes were HCV treatment initiation and completion rates. Other secondary outcomes included substance use, depression, PTSD symptoms, quality of life, healthcare satisfaction, and healthcare utilization. The Integrated Care intervention has the potential to transform HCV antiviral treatment by increasing the number of HCV-infected individuals that can be successfully treated.

The purpose of this study was to create and validate a mental health subscale for the Quality of Well-Being Self-Administered (QWB-SA).The QWB-SA and other measures such as the Profile of Mood States (POMS), Medical Outcomes Study 36 Item Short Form (SF-36), EuroQOL 5D (EQ-5D), and Health Utilities Index Mark 2 (HUI) were administered to three samples: a general population (N = 3,844), a non-psychiatric medical population (N = 535), and a psychiatric population (N = 915). Independent expert ratings of which items represented the construct of mental health were used along with psychometric methods to develop and validate a 10-item QWB-SA mental health scale.The mental health scale demonstrated high internal consistency (Cronbach's alpha = 0.827-0.842) and strong correlations with other measures of mental health, such as the POMS (r = -0.77), mental health scale from the SF-36 (r = 0.72), EQ-5D mood item (r = 0.61), and HUI Emotion Scale (r = 0.59). It was not highly correlated with measures of physical health. Among the psychiatric population, the new mental health scale was moderately correlated with indicators of psychiatric problem severity.It is now possible to report outcomes and relationships with mental health in studies that use the QWB-SA. This new mental health subscale can also be used with the large volume of previously collected data using the QWB-SA to examine the impact of illnesses and interventions on mental health-related quality of life.

Cataracts are the leading cause of blindness worldwide and cause visual impairment for millions of adults in the United States. We compared the sensitivity of a vision-specific health-related quality of life (HRQOL) measure to that of multiple generic measures of HRQOL before and at 2 time points after cataract surgery. Participants completed 1 vision-specific and 5 generic quality of life measures before cataract surgery, and again 1 and 6 months after surgery. Random effects modeling was used to measure changes over the three assessment points. The NEI-VFQ25 total score and all 11 subscales showed significant improvements during the first interval (baseline and 1 month). During the second interval (1–6 months post-surgery), significant improvements were observed on the total score and 5 of 11 NEI-VFQ25 subscales. There were significant increases in HRQOL during the first interval on some preference-based generic HRQOL measures, though changes during the second interval were mostly non-significant. None of the SF-36v2™ or SF6D scales changed significantly between any of the assessment periods. The NEI-VFQ25 was sensitive to changes in vision-specific domains of QOL. Some preference-based generic HRQOL measures were also sensitive to change and showed convergence with the NEI-VFQ25, but the effects were small. The SF-36v2™ and SF-6D did not change in a similar manner, possibly reflecting a lack of vision-related content. Studies seeking to document both the vision-specific and generic HRQOL improvements of cataract surgery should consider these results when selecting measures.

Iron deficiency anemia (IDA) is a common problem among the elderly, and often no cause is identified after routine upper endoscopy and colonoscopy exams. The purpose of this study was to determine the long-term outcomes and predictors of gastrointestinal pathology and death in patients with endoscopy-negative IDA.This was a retrospective review of consecutive endoscopy negative-IDA patients during 2002-2004 at the VA San Diego Healthcare System.Mean age was 69.3 years (range 42-93), and included 105 men and nine women. Mean length of follow-up was 65.1 months. IDA resolved in 56 patients. None of these patients developed evidence of any clinically significant gastrointestinal pathology. The remaining 58 patients had persistent anemia (n = 47) or recurrent anemia (n = 11). Only 2/47 patients with persistent anemia were found to have clinically significant but benign gastrointestinal pathology during follow-up. In contrast, 6/11 patients with recurrent anemia were subsequently found to have gastrointestinal pathology. Deaths during follow-up occurred in 7 (12.5 %) patients with resolved anemia, compared with 20 (34.5 %) patients with recurrent or persistent anemia (p = 0.006). Significant independent predictors of death included persistent or recurrent anemia, anti-platelet or anticoagulant use, and congestive heart failure.Patients with iron deficiency anemia and negative upper endoscopy and colonoscopy often have a favorable outcome, especially if the anemia resolves with treatment. In patients with recurrent anemia a malignancy within reach of standard endoscopy and colonoscopy are possible, and repeating these procedures is warranted before consideration of further investigations.

San Diego County Mental Health system clients completed a questionnaire after the October 2007 wildfires. As compared to those not in an evacuation area, those residing in an evacuation area reported significantly more impact of the fires. Clients who evacuated were most affected, followed by those in an evacuation area who did not evacuate. Evacuation strongly impacted client-reported emotional effects of the fire, confusion about whether to evacuate, and ability to obtain medications. Gender and clinical diagnosis interacted with evacuation status for some fire impact variables. Loss of control and disruption of routine are discussed as possibly related factors.

Background The financial burden and human losses associated with noncommunicable diseases necessitate cost-effective and efficacious interventions. Purpose An economic analysis of the Lifestyle Education for Activity and Nutrition (LEAN) Study; an RCT that examined the efficacy of traditional and technology-based approaches to weight loss. Methods Economic analyses from an organizational perspective were conducted for four approaches: standard care control (SC); group weight-loss education (GWL); a multisensor armband (SWA); and the armband in combination with group weight-loss education (GWL+SWA). Data were collected in 2008–2009. Weight loss was the primary outcome. Total costs, costs per participant, costs per kilogram lost, and incremental cost-effectiveness ratios (ICERs) were calculated in 2010–2011. All costs are the actual expenses (i.e., staff time and materials) incurred by the LEAN study (except where noted) and reported in 2010 U.S. dollars. Results In the sample population of 197 sedentary, overweight, and obese adults (mean [±SD] age=46.9 ± 0.8 years, BMI=33.3 ± 5.2, weight=92.8 ± 18.4 kg), the GWL+SWA was the most expensive intervention in costs/participant ($365/partic) while yielding the greatest weight loss/partic (6.59 kg). The GWL was next in cost/partic ($240), but the SWA was less expensive in cost/partic ($183) and more efficacious (3.55 vs 1.86 kg/partic). The SC did not achieve significant weight loss. The SWA was the most cost effective ($51/partic/kg lost), followed by the GWL+SWA ($55) and GWL alone ($129). The ICER suggests that for each additional kilogram lost, the GWL+SWA cost $60 more than the SWA alone. Conclusions The SWA was the most cost-effective intervention ($51/partic/kg lost). The addition of the GWL increased the efficacy of the SWA intervention but increased costs by $60/partic for each additional kilogram lost. The technology-based approaches were more cost effective and efficacious than traditional approaches in promoting weight loss via lifestyle changes in sedentary, overweight, and obese adults.

Social health is important to measure when assessing outcomes in community mental health. Our objective was to validate social health scales using items from two broader commonly used measures that assess mental health outcomes. Participants were 609 adults receiving psychological treatment services. Items were identified from the California Quality of Life (CA-QOL) and Mental Health Statistics Improvement Program (MHSIP) outcome measures by their conceptual correspondence with social health and compared to the Social Functioning Questionnaire (SFQ) using correlational analyses. Pearson correlations for the identified CA-QOL and MSHIP items with the SFQ ranged from .42 to .62, and the identified scale scores produced Pearson correlation coefficients of .56, .70, and, .70 with the SFQ. Concurrent validity with social health was supported for the identified scales. The current inclusion of these assessment tools allows community mental health programs to include social health in their assessments.

Background Colorectal cancer (CRC) screening rates are low in many areas and cost-effective interventions to promote CRC screening are needed. Recently in a randomized controlled trial, a mailed educational reminder increased CRC screening rates by 16.2% among U.S. Veterans. The aim of our study was to assess the costs and cost-effectiveness of a mailed educational reminder on fecal occult blood test (FOBT) adherence. Methods In a blinded, randomized, controlled trial, 769 patients were randomly assigned to the usual care group (FOBT alone, n = 382) or the intervention group (FOBT plus a mailed reminder, n = 387). Ten days after picking up the FOBT cards, a 1-page reminder with information related to CRC screening was mailed to the intervention group. Primary outcome was number of returned FOBT cards after 6 months. The costs and incremental cost-effectiveness ratio (ICER) of the intervention were assessed and calculated respectively. Sensitivity analyses were based on varying costs of labor and supplies. Results At 6 months after card distribution, 64.6% patients in the intervention group returned FOBT cards compared with 48.4% in the control group (P < 0.001). The total cost of the intervention was $962 or $2.49 per patient, and the ICER was $15 per additional person screened for CRC. Sensitivity analysis based on a 10% cost variation was $13.50 to $16.50 per additional patient screened for CRC. Conclusions A simple mailed educational reminder increases FOBT card return rate at a cost many health care systems can afford. Compared to other patient-directed interventions (telephone, letters from physicians, mailed reminders) for CRC screening, our intervention was more effective and cost-effective.

In addition to higher morbidity and mortality, Black adults have reported lower self-rated health than White adults. The purpose of this study was to evaluate the diminishing difference in self-rated health between races from 1972 to 2008. Data from 37,936 participants over a 36-year span of the General Social Survey were used to evaluate the effects of race and time on self-rated health. Results confirmed that Black adults reported significantly worse health than White adults. Overall health was rated slightly better across both groups as time went on ( $$ \hat{\beta } $$ = .002, P

BACKGROUND Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the United States. Randomized controlled trials have shown that annual screening fecal occult blood testing (FOBT) reduces CRC mortality and incidence. However, patient compliance with FOBT is low. OBJECTIVE To determine whether a mailed educational reminder increases FOBT card return rates and to examine predictors of FOBT compliance. DESIGN Blinded, randomized, controlled trial at the Veteran Affairs Medical Center, San Diego, California. PATIENTS Seven hundred and seventy-five consecutive patients ≥50 years of age referred by their primary care physicians for FOBT. INTERVENTION Patients were randomly assigned to the usual care group or the intervention group. Ten days after picking up the FOBT cards, a 1-page reminder with information related to CRC screening was mailed to the intervention group only. MEASUREMENTS The primary outcome was proportion of returned FOBT cards after 6 months. Patient demographic, clinical characteristics and prior FOBT completed were collected for multivariate regression analysis. RESULTS At 6 months after card distribution, 64.6% of patients in the intervention group returned cards compared with 48.4% in the control group (P

Chronic hepatitis C (HCV) infection affects millions of people in the USA and prevalence rates are higher in US veterans. The consequences of HCV infection include reduced quality of life, liver damage, and reduced longevity.Our objective was to describe the experiences of US veterans living with chronic HCV infection and use this information in the development of an HCV self-management intervention.Twenty-two male HCV-infected veterans completed qualitative interviews. Participants were recruited via flyers and hepatitis C clinic providers at a major VA medical center. Participants were asked about their medical history, being diagnosed with HCV, and general experiences living with HCV.The study gathered the following findings: the impact of HCV on interpersonal relationships was pronounced, recovery from substance use disorders and getting care for HCV were connected, receiving the HCV diagnosis was more troubling to non-IV drug users, participants had misconceptions about HCV and its treatment, psychological problems were prevalent as were barriers to participating in antiviral treatment and HCV care in general.The themes derived from our analysis indicate that affected veterans may benefit from interventions or support to improve HCV-related health education, social/relationship issues, psychological issues, and exploration of the connection between substance use recovery and motivation to get care for HCV infection.

To describe several recruitment parameters derived from the Lifestyle Interventions and Independence for Elders pilot (LIFE-P) study for use in a full-scale trial of mobility disability prevention.A description of the recruiting methods and baseline characteristics of a four-site randomized, controlled trial testing the effectiveness of a physical activity intervention at preventing mobility disability.The Cooper Institute, Dallas, Texas; Stanford University, Stanford, California; University of Pittsburgh, Pittsburgh, Pennsylvania; and Wake Forest University, Winston-Salem, North Carolina.Community-living persons aged 70 to 89 who were able to walk 400 m within 15 minutes and were at high risk for disability (scoring10 on the Short Physical Performance Battery (SPPB)) but without comorbidity severe enough to preclude full study participation.Measures of efficiency included number of randomized participants per recruitment technique and costs per randomized participant across randomization techniques.The 9-month recruiting period resulted in 3,141 telephone screens, of which 424 (13.5%) participants were randomized (68.9% women, 25.7% minorities, 41.5% with SPPB scores8). Forty percent of telephone-screened participants were excluded primarily because of regular participation in physical activity, health exclusions, or self-reported mobility disability. Of the 1,252 persons attempting the physical performance assessments, 41% scored above the SPPB cutoff. Of the 566 remaining eligible, 9.9% could not complete the 400-m walk, and another 18.9% had various medical exclusions. Direct mailing was the most productive recruitment strategy (61.6% of all randomized participants). Recruitment cost approximately $439 per randomized participant.The LIFE study achieved all recruitment goals and demonstrated the feasibility of recruiting high-risk community-dwelling older persons for trials of disability prevention in diverse geographic areas.

Background & Aims Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR). Methods We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR. Results Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15−4.44; P = .018). There were no differences in serious adverse events between groups. Conclusions Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.

Background The number of older adults living in the United States continues to increase, and recent research has begun to target interventions to older adults who have mobility limitations and are at risk for disability. The objective of this study is to describe and examine correlates of health-related quality of life in this population subgroup using baseline data from a larger intervention study. Methods The Lifestyle Interventions and Independence for Elders-Pilot study (LIFE-P) was a randomized controlled trial that compared a physical activity intervention to a non-exercise educational intervention among 424 older adults at risk for disability. Baseline data (collected in April–December 2004, analyzed in 2006) included demographics, medical history, the Quality of Well-Being Scale (QWB-SA), a timed 400-m walk, and the Short Physical Performance Battery (SPPB). Descriptive health-related quality of life (HRQOL) data are presented. Hierarchical linear regression models were used to examine correlates of HRQOL. Results The mean QWB-SA score for the sample was 0.630 on an interval scale ranging from 0.0 (death) to 1.0 (asymptomatic, optimal functioning). The mean of 0.630 is 0.070 lower than a comparison group of healthy older adults. The variables associated with lower HRQOL included white ethnicity, more comorbid conditions, slower 400-m walk times, and lower SPPB balance and chair stand scores. Conclusions Older adults who are at risk for disability had reduced HRQOL. Surprisingly, however, mobility was a stronger correlate of HRQOL than an index of comorbidity, suggesting that interventions addressing mobility limitations may provide significant health benefits to this population.

Assessment of health-related quality of life (HR-QOL) in people with rheumatoid arthritis (RA) has become important in health research and can inform clinical care. Many studies have found sociodemographic differences in the HR-QOL of people with RA, and interpreting these differences can be challenging. Biological, health disparity, reporting and assessment instrument differences are a few of the possible explanations that should be considered when interpreting results. Our review of the evidence of sociodemographic differences in HR-QOL in people with RA produced 34 articles describing 49 studies. Typically, patients with RA who were older, female, less educated, non-employed and/or less affluent tended to have significantly lower HR-QOL than other groups. Some evidence also indicated that people with RA who are non-White or who live in rural settings may also tend to have lower HR-QOL scores, but the number of studies supporting these findings was sparse. Researchers and clinicians can optimise their assessment of HR-QOL by finding well validated instruments for the context they are working in. Additional research is needed to identify the exact causes of HR-QOL differences so that quality treatment can be provided to those in need.

We sought to evaluate 3 methods for imputing utility-based outcomes from clinical trial data measured using the Medical Outcomes Study 36-Item Short Form (SF-36).Our subjects included 131 male and 505 female adults (mean age, 55.42 +/- 12.59 years) who were participating in a randomized clinical trial evaluating a new treatment of adults with rheumatoid arthritis (RA).Participants completed the SF-36, 2 versions of the Health Utilities Index (HUI-2 and HUI-3), the EuroQol EQ-5D, and the Health Assessment Questionnaire (HAQ). SF-36 scores were transformed to utility-based scores using 4 methods developed independently by Fryback, Nichol, and Brazier.All 4 imputed scores were significantly correlated with HUI-2, HUI-3, EQ-5D, and the disease-specific HAQ scores at baseline and at the end of the clinical trial period (P0.05). Changes in the imputed scores from baseline to end of study also were significantly correlated with corresponding changes in the measured utility scores and the HAQ score (P0.0001). For all imputed and measured scores, changes from baseline were associated with the clinical assessments, ACR20 and ACR50. The associations were stronger for the utility-based measures than the imputed indices. Both imputed and measured scores were sensitive to change in the clinical trial. However, mean scores for the HUI-3 and the Brazier VAS were significantly lower than for the other measures.Imputed utility-based score estimates are significantly correlated with measured utility outcomes. However, the imputed measures had more constrained variability, showed poorer correspondence to the ACR20 and ACR50 benchmarks, and predicted less than half of the variance in actual utility-based outcomes. Therefore, directly assessed, not imputed, utility-based measures should continue to be favored for cost-effectiveness analysis.

To evaluate the self-administered Quality of Well-Being (QWB-SA) Scale for patients with rheumatic diseases.Family medicine patients (n = 562) and rheumatology patients (n = 334) were assessed using the following tools: QWB-SA, Health Assessment Questionnaire (HAQ), Arthritis Impact Measurement Scales (AIMS), and Rapid Assessment of Disease Activity in Rheumatology (RADAR).Patients with arthritis had significantly lower QWB-SA scores and significantly higher HAQ scores than family medicine patients with and without adjustment for covariates. The QWB-SA was significantly associated with quartiles from the RADAR, AIMS, and HAQ, providing evidence for the validity of the generic measure in patients with arthritis. Discriminant function analysis was used to create an arthritis-specific scoring system for the QWB-SA. Analyses demonstrated systematic relationships between the Quality of Well-Being arthritis composite and the disease-specific RADAR, AIMS, and HAQ.Evidence supports the validity of the QWB-SA for patients with rheumatic diseases. QWB-SA items can be used to calculate an arthritis-specific score. The QWB-SA can be used to gain generic information for cost-utility analysis and disease-specific outcomes information for patients with arthritis.

Objective To examine the sensitivity of the Quality of Well-Being Scale (QWB) as a measure of health-related quality of life (HRQOL) in people with osteoarthritis (OA). Methods The QWB was administered, along with the Arthritis Impact Measurement Scale (AIMS) and other health measures. Health care utilization data were also obtained. Results People with OA had a mean QWB score of 0.643. The QWB scores were significantly correlated with total AIMS scores, self-rated health status, health care costs, depression scores, and most AIMS subscales. In addition, changes in QWB scores after 1 year were significantly correlated with changes in total AIMS scores and some AIMS subscales. Conclusion The QWB appears to be a useful and sensitive generic, utility-based measure of HRQOL in people with OA.

Importance In older adults reduced mobility is common and is an independent risk factor for morbidity, hospitalization, disability, and mortality. Limited evidence suggests that physical activity may help prevent mobility disability; however, there are no definitive clinical trials examining whether physical activity prevents or delays mobility disability. Objective To test the hypothesis that a long-term structured physical activity program is more effective than a health education program (also referred to as a successful aging program) in reducing the risk of major mobility disability. Design, Setting, and Participants The Lifestyle Interventions and Independence for Elders (LIFE) study was a multicenter, randomized trial that enrolled participants between February 2010 and December 2011, who participated for an average of 2.6 years. Follow-up ended in December 2013. Outcome assessors were blinded to the intervention assignment. Participants were recruited from urban, suburban, and rural communities at 8 centers throughout the United States. We randomized a volunteer sample of 1635 sedentary men and women aged 70 to 89 years who had physical limitations, defined as a score on the Short Physical Performance Battery of 9 or below, but were able to walk 400 m. Interventions Participants were randomized to a structured, moderate-intensity physical activity program (n = 818) conducted in a center (twice/wk) and at home (3-4 times/wk) that included aerobic, resistance, and flexibility training activities or to a health education program (n = 817) consisting of workshops on topics relevant to older adults and upper extremity stretching exercises. Main Outcomes and Measures The primary outcome was major mobility disability objectively defined by loss of ability to walk 400 m. Results Incident major mobility disability occurred in 30.1% (246 participants) of the physical activity group and 35.5% (290 participants) of the health education group (hazard ratio [HR], 0.82 [95% CI, 0.69-0.98], P = .03). Persistent mobility disability was experienced by 120 participants (14.7%) in the physical activity group and 162 participants (19.8%) in the health education group (HR, 0.72 [95% CI, 0.57-0.91]; P = .006). Serious adverse events were reported by 404 participants (49.4%) in the physical activity group and 373 participants (45.7%) in the health education group (risk ratio, 1.08 [95% CI, 0.98-1.20]). Conclusions and Relevance A structured, moderate-intensity physical activity program compared with a health education program reduced major mobility disability over 2.6 years among older adults at risk for disability. These findings suggest mobility benefit from such a program in vulnerable older adults. Trial Registration clinicaltrials.gov Identifier:NCT01072500

Injection of botulinum toxin (BT) into the muscles of the larynx is an effective treatment for the symptoms of spasmodic dysphonia (SD). To date, however, there have been no studies that have used blinded raters to assess the efficacy of BT injections on overall symptom severity in a cohort of SD patients followed over a prolonged period. In this study, 102 subjects with SD were treated with serial BT injections for up to 2 years. Voice recordings were obtained at several time points during treatment and were played to a panel of expert and novice listeners who rated them based on overall symptom severity in a single-blind fashion. Subjects demonstrated significant improvement over baseline at all time points. In addition, patients showed a sustained responsiveness to therapy over time. These results provide support for the efficacy of serial BT injections for SD and suggest that successful treatment may depend, in part, on patients' early recognition of returning symptoms.

The soaring cost of health care is a national problem that needs response at multiple levels, including that of the community. Reducing or limiting health care costs through interventions that emphasize the self-management of health may promote broader health care coverage, better quality of health care, and a sense of control over one's health. Therefore, it behooves community psychologists to perform cost analyses when testing interventions for people in a community. The present study investigated the effects of social support and education interventions on psychosocial variables, health status, and health care costs in older people with osteoarthritis. Participants were 363 members of a health maintenance organization (HMO), 60 years of age and older, with osteoarthritis. Participants were randomly assigned to one of three intervention groups (social support, education, or a combination of both) or to a control group. The results indicated that feelings of helplessness decreased in the intervention groups but not in the control group. All groups showed increases in self-efficacy and overall health status. In addition, health care costs increased less in the intervention groups than in the control group. Cost analysis was used to demonstrate that the monetary savings of the intervention greatly outweighed the cost of conducting the intervention. It appears that interventions can limit health care costs while improving health and increasing feelings of control for older people with osteoarthritis. Further, this paper demonstrates how a cost-benefit focus can benefit community studies.

Objective. To determine whether experimentally developed social support and education about appropriate use of the health care system decrease health care costs without negatively affecting health status. Method. Three hundred sixty-three health maintenance organization members with osteoarthritis were randomly assigned to 1 of 3 intervention groups or to a control group. Health status and health care use were assessed upon entering the study, and after 1 year and 2 years. Results. A savings of $1, 1561 participant/year was obtained when health care costs of the experimental groups were compared with those of the control group. Production or implementation costs were least for the social support intervention. The nearly equal effects of the 3 interventions on health care costs make implementation costs the primary focus when deciding which intervention to use. Conclusion. We believe that the social support treatment is the most cost-effective intervention.

Objective. To determine whether older people who volunteered for a health intervention study used the health care system differently from a randomly selected group of eligible non-volunteers. Methods. Three hundred sixty-three volunteers and 92 non-volunteers were compared; both groups were members of a large health maintenance organization (HMO). Results. Volunteers were more educated and had been members of the HMO longer. Volunteers used the health care system significantly more at all time periods, but their cost per contact was significantly lower than that for non-volunteers. Non-volunteers were more likely to have a comorbid condition and had fewer arthritis-related health care contacts. Conclusions. There will always be problems in generalizing results of studies with volunteers, but volunteers are, nevertheless, the most appropriate controls if the experimental participants are also volunteers. Designs should ideally include both volunteer and non-volunteer controls.