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Veterans Affairs (veteran + affair)
Terms modified by Veterans Affairs Selected AbstractsTrauma history and risk of the irritable bowel syndrome in women veteransALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 4 2010D. L. White Aliment Pharmacol Ther 2010; 32: 551,561 Summary Background, Over 1.8 million women in the U.S. are veterans of the armed services. They are at increased risk of occupational traumas, including military sexual trauma. Aim, To evaluate the association between major traumas and irritable bowel syndrome among women veterans accessing Veteran Affairs (VA) healthcare. Methods, We administered questionnaires to assess trauma history as well as IBS, post-traumatic stress disorder (PTSD) and depression symptoms to 337 women veterans seen for primary care at VA Women's Clinic between 2006 and 2007. Logistic regression was used to evaluate the association between individual traumas and IBS risk after adjustment for age, ethnicity, PTSD and depression. Results, Irritable bowel syndrome prevalence was 33.5%. The most frequently reported trauma was sexual assault (38.9%). Seventeen of eighteen traumas were associated with increased IBS risk after adjusting for age, ethnicity, PTSD and depression, with six statistically significant [range of adjusted odds ratios (OR) between 1.85 (95% CI, 1.08,3.16) and 2.6 (95% CI, 1.28,3.67)]. Depression and PTSD were significantly more common in IBS cases than controls, but neither substantially explained the association between trauma and increased IBS risk. Conclusions, Women veterans report high frequency of physical and sexual traumas. A lifetime history of a broad range of traumas is independently associated with an elevated risk of the irritable bowel syndrome. [source] Predictors of injury-related and non-injury-related mortality among veterans with alcohol use disordersADDICTION, Issue 10 2010Sylwia Fudalej ABSTRACT Aims To describe the association between alcohol use disorders (AUDs) and mortality and to examine risk factors for and all-cause, injury-related and non-injury-related mortality among those diagnosed with an AUD. Setting Department of Veterans Affairs, Veterans Health Administration (VHA). Participants A cohort of individuals who received health care in VHA during the fiscal year (FY) 2001 (n = 3 944 778), followed from the beginning of FY02 through the end of FY06. Measurements Demographics and medical diagnoses were obtained from VHA records. Data on mortality were obtained from the National Death Index. Findings Controlling for age, gender and race and compared to those without AUDs, individuals with AUDs were more likely to die by all causes [hazard ratio (HR) = 2.30], by injury-related (HR = 3.29) and by non-injury-related causes (HR = 2.21). Patients with AUDs died 15 years earlier than individuals without AUDs on average. Among those with AUDs, Caucasian ethnicity and all mental illness diagnoses that were assessed were associated more strongly with injury-related than non-injury-related mortality. Also among those with AUDs, individuals with medical comorbidity and older age were at higher risk for non-injury related compared to injury-related mortality. Conclusions In users of a large health-care system, a diagnosis of an AUD is associated significantly with increased likelihood of dying by injury and non-injury causes. Patients with a diagnosis of an AUD who die from injury differ significantly from those who die from other medical conditions. Prevention and intervention programs could focus separately upon selected groups with increased risk for injury or non-injury-related death. [source] Inpatient substance abuse care and the outcome of subsequent community residential and outpatient careADDICTION, Issue 6 2000Rudolf H. Moos Aim. To compare participation in treatment and 1-year substance use, symptom and functioning outcomes between patients with substance use disorders who did versus those who did not have an episode of inpatient care immediately prior to an episode of community residential and outpatient mental health care. Design. Two matched groups of 257 patients each with substance use disorders were assessed at entry to and discharge from a community residential facility (CRF) and at a 1-year follow-up. Findings. Patients in the two treatment groups received a comparable amount of CRF and outpatient mental health care. Nevertheless, patients who had prior inpatient care were more likely to be employed at 1-year follow-up. In addition, when they entered CRF care directly, patients with co-morbid psychiatric disorders were more likely to continue use of alcohol and drugs in the CRF and less likely to complete the program. These patients also experienced more distress and psychiatric symptoms, and were less likely to be employed at the 1-year follow-up. Conclusions. Among patients who seek treatment at Department of Veterans Affairs (VA) facilities, those who have both substance use and psychiatric disorders and enter CRF care directly have somewhat worse outcomes than those who have an immediately prior episode of inpatient care. [source] Capturing the power of academic medicine to enhance health and health care of the elderly in the USAGERIATRICS & GERONTOLOGY INTERNATIONAL, Issue 1 2004William R Hazzard As in Japan, the US population is aging progressively, a trend that will challenge the health-care system to provide for the chronic, multiple and complex needs of its elderly citizens. and as in Japan, the US academic health enterprise has only belatedly mounted a response to that challenge. Herein is reviewed a quarter of a century of the author's personal experience in developing new programs in gerontology and geriatric medicine from a base in the Department of Internal Medicine at three US academic health centers (AHC): The University of Washington (as Division Head), Johns Hopkins University (as Vice-Chair), and Wake Forest University (as Chair). Rather than to build a program from a new department of geriatrics, this strategy was chosen to capture the power and resources of the department of internal medicine, the largest university department, to ,gerontologize' the institution, beginning with general internal medicine and all of the medical subspecialties (the approach also chosen to date at all but a handful of US AHC). The keystone of success at each institution has been careful faculty development through fellowship training in clinical geriatrics, education and research. Over the same interval major national progress has occurred, including expanded research and training at the National Institute on Aging and the Department of Veterans Affairs, and accreditation of more than 100 fellowship programs for training and certification of geriatricians. However, less than 1% of US medical graduates elect to pursue such training. Hence such geriatricians will remain concentrated at AHC, and most future geriatric care in the USA will be provided by a broad array of specialists, who will be educated and trained in geriatrics by these academic geriatricians. [source] Health care funding levels and patient outcomes: a national studyHEALTH ECONOMICS, Issue 4 2007Margaret M. Byrne Abstract Background: Health care funding levels differ significantly across geographic regions, but there is little correlation between regional funding levels and outcomes of elderly Medicare beneficiaries. Our goal was to determine whether this relationship holds true in a non-Medicare population cared for in a large integrated health care system with a capitated budget allocation system. Methods: We explored the association between health care funding and risk-adjusted mortality in the 22 Veterans Affairs (VA) geographic Networks over a six-year time period. Allocations to Networks were adjusted for illness burden using Diagnostic Cost Groups. To test the association between funding and risk-adjusted three-year mortality, we ran logistic regressions with single-year patient cohorts, as well as hierarchical regressions on a six year longitudinal data set, clustering on VA Network. Results: A $1000 increase in funding per unit of patient illness burden was associated with a 2,8% reduction in three-year mortality in cross sectional regressions. However, in longitudinal hierarchical regressions clustering on Network, the significant effect of funding level was eliminated. Conclusions: When longitudinal data are used, the significant cross sectional effect of funding levels on mortality disappear. Thus, the factors driving differences in mortality are Network effects, although part of the Network effect may be due to past levels of funding. Our results provide a caution for cross sectional examinations of the association between regional health care funding levels and health outcomes. Copyright © 2006 John Wiley & Sons, Ltd. [source] Clinical Practice Guideline Implementation Strategy Patterns in Veterans Affairs Primary Care ClinicsHEALTH SERVICES RESEARCH, Issue 1p1 2007Sylvia J. Hysong Background. The Department of Veterans Affairs (VA) mandated the system-wide implementation of clinical practice guidelines (CPGs) in the mid-1990s, arming all facilities with basic resources to facilitate implementation; despite this resource allocation, significant variability still exists across VA facilities in implementation success. Objective. This study compares CPG implementation strategy patterns used by high and low performing primary care clinics in the VA. Research Design. Descriptive, cross-sectional study of a purposeful sample of six Veterans Affairs Medical Centers (VAMCs) with high and low performance on six CPGs. Subjects. One hundred and two employees (management, quality improvement, clinic personnel) involved with guideline implementation at each VAMC primary care clinic. Measures. Participants reported specific strategies used by their facility to implement guidelines in 1-hour semi-structured interviews. Facilities were classified as high or low performers based on their guideline adherence scores calculated through independently conducted chart reviews. Findings. High performing facilities (HPFs) (a) invested significantly in the implementation of the electronic medical record and locally adapting it to provider needs, (b) invested dedicated resources to guideline-related initiatives, and (c) exhibited a clear direction in their strategy choices. Low performing facilities exhibited (a) earlier stages of development for their electronic medical record, (b) reliance on preexisting resources for guideline implementation, with little local adaptation, and (c) no clear direction in their strategy choices. Conclusion. A multifaceted, yet targeted, strategic approach to guideline implementation emphasizing dedicated resources and local adaptation may result in more successful implementation and higher guideline adherence than relying on standardized resources and taxing preexisting channels. [source] Comparative Effectiveness Research Priorities at Federal Agencies: The View from the Department of Veterans Affairs, National Institute on Aging, and Agency for Healthcare Research and QualityJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2010Timothy J. O'Leary MD In the last year, attention has been focused on translating federally sponsored health research into better health for Americans. Since the passage of the American Recovery and Reinvestment Act (ARRA) on February 17, 2009, ARRA funds to support Comparative Effectiveness Research (CER) have increased this focus. A large proportion of topical areas of interest in CER affects the older segment of the population. The Department of Veterans Affairs (VA), the National Institute on Aging (NIA), and the Agency for Healthcare Research and Quality (AHRQ) have supported robust research portfolios focused on aging populations that meet the varying definitions of CER. This short article briefly describes the research missions of the AHRQ, NIA, and VA. The various definitions of CER as the Congressional Budget Office, the Institute of Medicine, and the ARRA-established Federal Coordinating Council have put forward, as well as important topics for which CER is particularly needed, are then reviewed. Finally, approaches in which the three agencies support CER involving the aging population are set forth and opportunities for future CER research outlined. [source] Use of Medicare and Department of Veterans Affairs Health Care by Veterans with Dementia: A Longitudinal AnalysisJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2009Carolyn W. Zhu PhD The objectives of this study were to examine longitudinal patterns of Department of Veterans Affairs (VA),only use, dual VA and Medicare use, and Medicare-only use by veterans with dementia. Data on VA and Medicare use were obtained from VA administrative datasets and Medicare claims (1998,2001) for 2,137 male veterans who, in 1997, used some VA services, had a formal diagnosis of Alzheimer's disease or vascular dementia in the VA, and were aged 65 and older. Generalized ordered logit models were used to estimate the effects of patient characteristics on use group over time. In 1998, 41.7% of the sample were VA-only users, 55.4% were dual users, and 2.9% were Medicare-only users. By 2001, 30.4% were VA-only users, 51.5% were dual users, and 18.1% were Medicare-only users. Multivariate results show that greater likelihood of Medicare use was associated with older age, being white, being married, having higher education, having private insurance or Medicaid, having low VA priority level, and living in a nursing home or dying during the year. Higher comorbidities were associated with greater likelihood of dual use as opposed to any single system use. Alternatively, number of functional limitations was associated with greater likelihood of Medicare-only use and less likelihood of VA-only use. These results imply that different aspects of veterans' needs have differential effects on where they seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure that patients receive high-quality care, especially patients with multiple comorbidities. [source] Do Palliative Consultations Improve Patient Outcomes?JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 4 2008David Casarett MD OBJECTIVES: To determine whether inpatient palliative consultation services improve outcomes of care. DESIGN: Retrospective telephone surveys conducted with family members of veterans who received inpatient or outpatient care from a Department of Veterans Affairs (VA) medical facility in the last month of life. SETTING: Five VA Medical Centers or their affiliated nursing homes and outpatient clinics. PARTICIPANTS: Veterans had received inpatient or outpatient care from a participating VA in the last month of life. One family member completed each survey. MEASUREMENTS: The telephone survey assessed nine aspects of the care the patient received in his or her last month of life: the patient's well-being and dignity (4 items), adequacy of communication (5 items), respect for treatment preferences (2 items), emotional and spiritual support (3 items), management of symptoms (4 items), access to the inpatient facility of choice (1 item), care around the time of death (6 items), access to home care services (4 items), and access to benefits and services after the patient's death (3 items). RESULTS: Interviews were completed with 524 respondents. In a multivariable linear regression model, after adjusting for the likelihood of receiving a palliative consultation (propensity score), palliative care patients had higher overall scores: 65 (95% confidence interval (CI)=62,66) versus 54 (95% CI=51,56; P<.001) and higher scores for almost all domains. Earlier consultations were independently associated with better overall scores (,=0.003; P=.006), a difference that was attributable primarily to improvements in communication and emotional support. CONCLUSION: Palliative consultations improve outcomes of care, and earlier consultations may confer additional benefit. [source] Functional Incidental Training: A Randomized, Controlled, Crossover Trial in Veterans Affairs Nursing HomesJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2005Joseph G. Ouslander MD Objectives: To test the effects of a rehabilitative intervention directed at continence, mobility, endurance, and strength (Functional Incidental Training (FIT)) in older patients in Department of Veterans Affairs (VA) nursing homes. Design: Randomized, controlled, crossover trial. Setting: Four VA nursing homes. Participants: All 528 patients in the nursing homes were screened; 178 were eligible, and 107 were randomized to an immediate intervention group (Group 1; n=52) and a delayed intervention group (Group 2; n=55). Intervention: Trained research staff provided the FIT intervention, which included prompted voiding combined with individualized, functionally oriented endurance and strength-training exercises offered four times per day, 5 days per week, for 8 weeks. Group 1 received the intervention while Group 2 served as a control group; then Group 2 received the intervention while Group 1 crossed over to no intervention. A total of 64 subjects completed the intervention phase of the trial. Measurements: Timed measures of walking or wheeling a wheelchair (mobility), sit-to-stand exercises, independence in locomotion and toileting as assessed using the Functional Independence Measure (FIM), one-repetition maximum weight for several measures of upper and lower body strength, frequency of urine and stool incontinence, and appropriate toileting ratios. Results: There was a significant effect of the FIT intervention on virtually all measures of endurance, strength, and urinary incontinence but not on the FIM for locomotion or toileting. The effects of FIT were observed when Group 1 received the intervention and was compared with the control group and when Group 2 crossed over to the intervention. Group 1 deteriorated in all measures during the 8-week crossover period. Within-person comparisons also demonstrated significant effects on all measures in the 64 participants who completed the intervention; 43 (67%) of these participants were "responders" based on maintenance or improvement in at least one measure of endurance, strength, and urinary incontinence. No adverse events related to FIT occurred during the study period. Conclusion: FIT improves endurance, strength, and urinary incontinence in older patients residing in VA nursing homes. Translating these positive benefits achieved under research conditions into practice will be challenging because of the implications of the intervention for staff workload and thereby the costs of care. [source] Quality and Outcomes of Heart Failure Care in Older Adults: Role of Multidisciplinary Disease-Management ProgramsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2002Ali Ahmed MD, FACP PURPOSE: To determine whether the management of heart failure by specialized multidisciplinary heart failure disease-management programs was associated with improved outcomes. BACKGROUND: The advent of angiotensin-converting enzyme inhibitors, beta-blockers, and spironolactone has revolutionized the management of heart failure. Randomized double-blind studies have demonstrated survival benefits of these drugs in heart failure patients. Nevertheless, in spite of these advances, heart failure continues to be a syndrome of poor outcomes.1,4 There is also evidence that a significant portion of heart failure patients does not receive this evidence-based therapy that reduces morbidity and mortality.5,7 Various disease-management programs have been proposed and tested to improve the quality of heart failure care. Most of these programs are specialized multidisciplinary heart failure clinics lead by cardiologists or heart failure specialists and conducted by nurses or nurse practitioners. Similar to the Department of Veterans Affairs (VA) multidisciplinary geriatric assessment clinics, these clinics also use many other services, including pharmacists, dietitians, physical therapists, and social workers. Some of these programs also have an affiliated home health service. Several observation studies, using mostly pre- and postcomparison designs, have demonstrated the effectiveness of these programs in the process of care, resource use, healthcare costs, and clinical outcomes in patients with heart failure.8 Risk of hospitalization was reduced by 50% to 85% in six of the studies.8 Subsequently, several randomized trials were conducted to determine the effectiveness of these programs. The purpose of this systematic review was to determine the effectiveness of these programs on mortality and hospitalization rates of heart failure patients. METHODS: Published articles on human randomized trials involving specialized heart failure disease-management programs in all languages were searched using Medline from 1966 to 1999 and other online databases using the following terms and Medical Subject Headings: case management (exp); comprehensive health care (exp); disease management (exp); health services research (exp); home care services (exp); clinical protocols (exp); patient care planning (exp); quality of health care (exp); nurse led clinics; special clinics; and heart failure, congestive (exp). In addition, a manual search of the bibliographies of searched articles was performed to identify articles otherwise missed in the above search. Personal communications were made with three authors to obtain further data on their studies. Using a data abstraction tool, two of the investigators separately abstracted data from the selected articles. Data from the selected studies were combined using the DerSimonian and Laird random effects model and the Mantel-Haenszel-Peto fixed effects model. Meta-Analyst 0.998 software (J. Lau, New England Medical Center, Boston, MA) was used to determine risk ratios (RRs) with 95% confidence intervals (CIs) of mortality and hospitalization for patients receiving care through these specialized programs compared with those receiving usual care. The Cochran Q test was used to test heterogeneity among the studies, and sensitivity analyses were performed to examine the effect of various covariates, such as duration of intervention, and other characteristics of the disease-management programs. RESULTS: The original search resulted in 416 published articles, of which 35 met preliminary selection criteria. Of these, 11 were randomized trials and were selected for the meta-analysis. Studies that were not randomized trials, did not involve heart failure patients or disease-management programs, or had missing outcomes were excluded. Of the 11 studies selected, nine involved specialized follow-up using multidisciplinary teams and the remaining two involved follow-up by primary care physicians and telephone. These studies involved 1,937 heart failure patients with a mean age of 74. The follow-up period ranged from no follow-up (one study) to 1 year (one study). Patients receiving care from specialized heart failure disease-management programs had a 13% lower risk of hospitalization than those receiving usual care (summary RR = 0.87; 95% CI = 0.79,0.96), but the Cochran Q test demonstrated significant heterogeneity among the studies (P = .003). Subgroup analysis of the nine studies using specialized follow-up by a multidisciplinary team showed similar results (summary RR = 0.77, 95% CI = 0.68,0.86; test of heterogeneity, P> .50). Seven of the nine studies did not show any significant association between intervention and reduced hospitalization, but the two studies that used follow up by primary care physicians and telephone failed to show any significant reduction in hospitalization (summary RR = 0.94, 95% CI = 0.75,1.19). In fact, one of the studies demonstrated a higher risk of hospitalization for patients receiving intervention (RR = 1.26, 95% CI = 1.04,1.52). Of the 11 studies, only six reported mortality as an outcome. None of these studies found any association between intervention and mortality (summary RR = 1.15, 95% CI = 0.96,1.37; test of heterogeneity, P> .15). Five of the studies used quality of life or functional status as outcomes, and, of them, only one demonstrated significant positive association. The results of the sensitivity analyses were negative for any significant association with duration of intervention or follow-up or year of study. Eight studies performed cost analyses and seven demonstrated cost-effectiveness of the intervention. CONCLUSIONS: The authors concluded that specialized disease-management programs were cost-effective, and heart failure patients cared for by these programs were more likely to undergo fewer hospitalizations, but the study did not provide any conclusive association between these programs and quality of care or mortality. The authors recommend that disease-management programs involve patient education and specialized follow-up by a multidisciplinary team including home health care. [source] Divalproex sodium vs. valproic acid: drug utilization patterns, persistence rates and predictors of hospitalization among VA patients diagnosed with bipolar disorderJOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 6 2007S. U. Iqbal MBA MPH MD Summary Objectives:, To compare divalproex sodium and valproic acid for therapeutic patterns, persistence rates and predictors of hospitalization among bipolar patients on monotherapy in the Veterans Affairs (VA) healthcare system. Methods:, Using VA administrative data bases, we conducted a retrospective inception cohort study of VA patients', 18 years of age who had at least one outpatient diagnoses of bipolar disorder and two continuous prescription records for the study drugs in the VA PBM pharmacy database during the study period of 1st April 2001 to 30th September 2003. Persistence for the comparative drugs was reported as continuous variable and compared using t -tests. Logistic regression models were used to examine the risk of hospitalization whereas Cox proportional hazard regression models were used to evaluate the time to hospitalization and time to interruption of therapy for the two drug groups. Results:, We identified 4624 bipolar patients on monotherapy with valproic acid (n = 4036) and divalproex sodium (n = 588) during the study period. The descriptive statistics included sociodemographics, disability and comorbidity status and were similar for the two groups. For the crude persistence rates there were no statistically significant differences between divalproex sodium (120 days) and valproic acid (110 days). The logistic regression model for risk of hospitalization showed no statistically significant difference between the two comparators [odds ratio = 1·06, 95% confidence interval (CI) = 0·787,1·444]. The Cox model for time to interruption of therapy showed an insignificant hazard ratio (HR) for divalproex sodium vs. valproic acid (HR = 0·928, 95% CI = 0·844,1·020) and for time to hospitalization also no statistically significant difference in the HR for the two drugs (HR = 0·984, 95% CI = 0·784,1·295). Conclusion:, The study showed a comparable profile of generic valproic acid with divalproex sodium for persistence and predictors of hospitalization for bipolar patients on monotherapy in the VA. Results have important healthcare implications for treatment and costs. [source] Use of mental health treatment among veterans filing claims for posttraumatic stress disorderJOURNAL OF TRAUMATIC STRESS, Issue 1 2007Nina A. Sayer This study examines predictors of current mental health service use in a sample of 154 veterans filing claims for Veterans Affairs (VA) disability benefits based on Posttraumatic Stress Disorder (PTSD). Our conceptual framework was the behavioral model that classifies predictors of service utilization into predisposing (background), enabling (e.g., insurance) and need (e.g., symptoms) factors. Slightly more than half of the PTSD claimants were receiving mental health treatment at the time of claim initiation. Mean symptom levels were clinically significant in both users and nonusers of mental health treatment. In a multivariate logistic regression analysis, mental health treatment use was associated with younger age, marriage, and dependence on public insurance. Implications for future research are discussed. [source] Pretreatment assessment and predictors of hepatitis C virus treatment in US veterans coinfected with HIV and hepatitis C virusJOURNAL OF VIRAL HEPATITIS, Issue 12 2006L. I. Backus Summary., The US Department of Veterans Affairs (VA) cares for many human immunodeficiency virus/hepatitis C virus (HIV/HCV)-coinfected patients. VA treatment recommendations indicate that all HIV/HCV-coinfected patients undergo evaluation for HCV treatment and list pretreatment assessment tests. We compared clinical practice with these recommendations. We identified 377 HIV/HCV-coinfected veterans who began HCV therapy with pegylated interferon and ribavirin and 4135 HIV/HCV-coinfected veterans who did not but were in VA care at the same facilities during the same period. We compared laboratory and clinical characteristics of the two groups and estimated multivariate logistic regression models of receipt of HCV treatment. Overall, patients had high rates of receipt of tests necessary for HCV pretreatment assessment. Patients starting HCV treatment had higher alanine aminotransferase (ALT), lower creatinine, higher CD4 counts and lower HIV viral loads than patients not starting HCV treatment. In the multivariate model, positive predictors of starting HCV treatment included being non-Hispanic whites, having higher ALTs, lower creatinines, higher HCV viral loads, higher CD4 counts, undetectable HIV viral loads and receiving HIV antiretrovirals. A history of chronic mental illness and a history of hard drug use were negative predictors. Most HIV/HCV-coinfected patients received the necessary HCV pretreatment assessments, although rates of screening for hepatitis A and B immunity can be improved. Having well-controlled HIV disease is by far the most important modifiable factor affecting the receipt of HCV treatment. More research is needed to determine if the observed racial differences in starting HCV treatment reflect biological differences, provider behaviour or patient preference. [source] Variation in practice of ileal intubation among diverse endoscopy settings: results from a national endoscopic databaseALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 6 2005G. C. HAREWOOD Summary Background:, Terminal ileum intubation rates at colonoscopy are variable. One of the major indications for terminal ileum intubation is to identify Crohn's disease. Signs and symptoms which raise a suspicion of Crohn's include abdominal pain/bloating, anaemia and diarrhoea. Aim:, To determine the proportion of terminal ileal intubation in patients undergoing evaluation of abdominal pain/bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy. Methods:, The Clinical Outcomes Research Initiative national endoscopic database was analysed to determine the proportion of terminal ileum intubation in patients undergoing evaluation of either abdominal pain/bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy and to characterize this population of patients. Patients with known or suspected inflammatory bowel disease were excluded from the analysis. Results:, Between January 2000 and December 2003, 21 638 patients underwent complete colonoscopy for evaluation of either abdominal pain/bloating, anaemia or diarrhoea with normal colon findings. Overall, 3858 patients (18%) underwent terminal ileum evaluation. Intubation rates differed according to procedure indication: abdominal pain (13%), anaemia (13%), diarrhoea (28%). Terminal ileum assessment declined with advancing patient age and was least frequent in Black patients (12% vs. 18% in non-Blacks, P < 0.0001). Ileal intubation rates also varied among endoscopy site types: community (17%), academic (21%), Veterans Affairs Medical Centres (17%), P < 0.0001. Multiple logistic regression identified patients with the indication of diarrhoea (OR: 2.58) as more likely to undergo terminal ileum intubation when compared with those with abdominal pain/bloating. Patients in Veterans Affairs (OR: 1.26) and academic (OR: 1.29) sites were more likely to undergo terminal ileum intubation compared with community sites. Conclusion:, Less than one-fifth of patients with either abdominal pain/bloating, anaemia or diarrhoea underwent ileal intubation in the setting of a normal colonoscopy. Significant practice variation was observed in rates of terminal ileum evaluation. Further study is required to determine whether terminal ileum examination impacts patient management or outcome. [source] Agreement between patient self-report and a Veterans Affairs national pharmacy database for identifying recent exposures to antibioticsPHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 1 2003Joshua P. Metlay MD Abstract Purpose The dramatic rise in antibiotic drug resistance among community pathogens has stimulated interest in the epidemiological relationship between antibiotic exposure and drug resistance. In assessing the strength of this relationship, studies are hampered by the lack of data on the accuracy of subject self-report of antibiotic exposure. The authors compared self-report with pharmacy dispensing data to determine the accuracy of self-reported antibiotic exposure. Methods The study design was a cross-sectional survey of veterans seen at the Philadelphia Veterans Affairs (VA) Medical Center in 1999 and 2000. Subjects reported exposures to antibiotics, antihypertensive drugs and nonsteroidal anti-inflammatory drugs through a structured telephone interview. The instrument included open-ended questions, condition-specific prompts and drug-specific prompts. Subject responses were linked to a national VA pharmacy database that served as the reference standard for evaluating self-reported exposures. Results The authors found that the sensitivity of self-report of antibiotic exposure increased with increasing use of prompts. A comprehensive assessment of antibiotic exposure identified 73% of antibiotic exposures, compared to 73% of antihypertensive drug exposures and 92% of nonsteroidal anti-inflammatory drug exposures. Conclusions Assessment of antibiotic exposure appears to be comparable to assessment of other chronic and episodic drugs. Multistep assessment of exposure improves the sensitivity of assessment. Copyright © 2002 John Wiley & Sons, Ltd. [source] Improving PTSD/Substance Abuse Treatment in the VA: A Survey of ProvidersTHE AMERICAN JOURNAL ON ADDICTIONS, Issue 3 2010Lisa M. Najavits PhD We surveyed 205 Veterans Affairs (VA) staff on treatment of posttraumatic stress disorder (PTSD), substance use disorder (SUD), and the combination (PTSD/SUD). The survey was anonymous and VA-wide. PTSD/SUD was perceived as more difficult to treat than either disorder alone; gratification in the work was stronger than difficulty (for PTSD, SUD, and PTSD/SUD); and difficulty and gratification appeared separate constructs. Respondents endorsed views that represent expert treatment for the comorbidity; however, there was also endorsement of "myths." Thus, there is a need for more training, policy clarifications, service integration, and adaptations for veterans returning from Iraq and Afghanistan. Limitations are described.,(Am J Addict 2010;19:257,263) [source] Use of Court-ordered Supervised Disulfiram Therapy at DVA Medical Centers in the United StatesTHE AMERICAN JOURNAL ON ADDICTIONS, Issue 3 2005Brandon Martin B.A. Having reported high adherence to court-mandated disulfiram treatment, we hypothesized that other Department of Veterans Affairs (DVA) medical centers would report frequent use of this modality. Telephone interviews with DVA substance abuse clinics in 48 of the 50 states matched the national DVA frequencies. Phone survey responders reported disulfiram prescription as never/rarely 63%, sometimes 32%, and often 5%, while court-ordered disulfiram was used never/rarely 95%, sometimes 3%, and often 2%. Nationally, disulfiram prescriptions covered only 0.07% of all veterans seen. These data suggest a need for a re-evaluation of disulfiram as an underused treatment for alcohol dependence. [source] Impact of Rural Residence on Survival of Male Veterans Affairs Patients After Age 65THE JOURNAL OF RURAL HEALTH, Issue 4 2010Todd A. MacKenzie PhD Abstract Objectives: More than 1 in 5 Veterans Affairs (VA) users lives in a rural setting. Rural veterans face different barriers to health care than their urban counterparts, but their risk of death relative to their urban counterparts is unknown. The objective of our study was to compare survival between rural and urban VA users. Methods: We linked the Large Health Survey of Veteran Enrollees conducted in 1999 to the Veterans Administration vital status registry. We used time-to-event regression models controlling for patient race, education, ZIP-code median income, and marital and smoking status. Findings: Of the 372,463 male veterans of age 65 or greater, 80,931 lived in rural settings. Age-adjusted mortality was 5.9% higher (95% CI, 4.5%-7.2%) in rural residents compared to urban residents. After adjusting for age, education, and ZIP-code median income, rural residents had 3.0% lower mortality (95% CI, 1.5%-4.4%). Compared to urban and suburban VA users, rural VA users' mortality at age 65 was 12% lower, but this advantage gradually diminished by age 75. Conclusion: Mortality after the age of 65 for male VA users is higher in rural dwellers than in urban dwellers. However, among veterans of the same socioeconomic characteristics, rural-dwelling veterans have up to 15% better mortality than urban-dwelling veterans until the age of 75. [source] VA telemental health: Suicide assessment,BEHAVIORAL SCIENCES & THE LAW, Issue 3 2008Linda Godleski M.D. The Department of Veterans Affairs (VA) encompasses one of the largest telemental health networks in the world, with over 45,000 videoconferencing and over 5,000 home telemental health encounters annually. Recently, the VA designated suicide prevention as a major priority, with telehealth modalities providing opportunities for remote interventions. Suicide risk assessments, using videoconferencing, are now documented in the literature, as are current studies that find telemental health to be equivalent to face-to-face treatment. Remote assessment of suicidality, however, involves complex legal issues: licensing requirements for remote delivery of care, legal procedures for involuntary detainment and commitment of potentially harmful patients, and liability questions related to the remote nature of the mental health service. VA best practices for remote suicide risk assessment include paradigms for establishing procedures in the context of legal challenges (licensing and involuntary detainment/commitment), for utilizing clinical assessment and triage decision protocols, and for contingency planning to optimize patient care and reduce liability. Published in 2008 by John Wiley & Sons, Ltd. [source] Nutrition and exercise behavior among patients with bipolar disorder,BIPOLAR DISORDERS, Issue 5 2007Amy M Kilbourne Objectives:, There have been few comprehensive studies of nutrition and exercise behaviors among patients with bipolar disorder (BPD). Based on a national sample of patients receiving care in the Veterans Affairs (VA) health care system, we compared nutrition and exercise behaviors among individuals diagnosed with BPD, others diagnosed with schizophrenia, and others who did not receive diagnoses of serious mental illness (SMI). Methods:, We conducted a cross-sectional study of patients who completed the VA's Large Health Survey of Veteran Enrollees section on health and nutrition in fiscal year (FY) 1999 and who either received a diagnosis of BPD (n = 2,032) or schizophrenia (n = 1,895), or were included in a random sample of non-SMI VA patients (n = 3,065). We compared nutrition and exercise behaviors using multivariable logistic regression, controlling for patient socio-economic and clinical factors, and adjusting for patients clustered by site using generalized estimating equations. Results:, Patients with BPD were more likely to report poor exercise habits, including infrequent walking (odds ratio, OR = 1.33, p < 0.001) or strength exercises (OR = 1.28, p < 0.001) than those with no SMI. They were also more likely to self-report suboptimal eating behaviors, including having fewer than two daily meals (OR = 1.32, p < 0.001) and having difficulty obtaining or cooking food (OR = 1.48, p < 0.001). Patients with BPD were also more likely to report having gained ,10 pounds in the past 6 months (OR = 1.59, p < 0.001) and were the least likely to report that their health care provider discussed their eating habits (OR = 0.84, p < 0.05) or physical activity (OR = 0.81, p < 0.01). Conclusions:, Greater efforts are needed to reduce the risk of poor nutrition and exercise habits among patients diagnosed with BPD. [source] Molecular markers and mortality in prostate cancerBJU INTERNATIONAL, Issue 6 2007John Concato OBJECTIVE To evaluate prognosis in prostate cancer by assessing the independent effect of selected molecular factors (e.g. markers of cell-cycle regulation), in addition to the effect of traditional clinical factors (e.g. anatomical stage, histological grade), in predicting long-term mortality among men newly diagnosed with prostate cancer. PATIENTS AND METHODS In a community-based population of 64 545 USA veterans aged ,,50 years and receiving ambulatory care during 1989,90 at nine Veterans Affairs (VA) medical centres in New England, 1274 had incident prostate cancer during 1991,95. We obtained the medical records and diagnostic tissue for these men, and then extracted demographic data and clinical information, and conducted immunohistochemical assays of molecular markers in biopsy tissue, as potential prognostic factors. In this interim analysis, data on 250 patients were analysed; the main outcome was overall mortality to 31 December 2003, providing 8,13 years of follow-up. RESULTS In 228 (91%) patients with available medical record and laboratory data, the median age was 72 years and the median prostate-specific antigen level was 10.4 ng/mL. In adjusted (multivariate) analyses that included traditional prognostic factors, bcl-2 staining (hazard ratio 2.14, 95% confidence interval 1.27,3.58, P = 0.004) and high microvessel density (1.76, 1.19,2.60; P = 0.005) had an independent effect on the outcome. CONCLUSIONS Bcl-2 and microvessel density are independent predictors of subsequent death among men with prostate cancer and might have a clinical role in assisting in deciding on treatment. [source] Local perspective of the impact of the HIPAA privacy rule on researchCANCER, Issue 2 2006M.P.H., Michael S. Wolf Ph.D. Abstract BACKGROUND The operational and economic impact of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 was evaluated. The setting was a natural experiment which involved a single-site, clinical research study that was initiated before the enactment of HIPAA and subsequently modified to be compliant with the new policy. METHODS A formative assessment was conducted of the recruitment process to a clinical trial evaluating the efficacy of an educational strategy to inform Veterans about the National Cancer Institute/Department of Veterans Affairs cosponsored Selenium and Vitamin E Cancer Prevention Trial (SELECT). Personnel time and costs were determined based on weekly accrual for study periods before and after the implementation of HIPAA. Root cause analysis was used to assess the recruitment protocol and to identify areas for improvement. RESULTS The implementation of HIPAA resulted in a 72.9% decrease in patient accrual (7.0 patients/wk vs. 1.9 patients/wk, P < 0.001), and a threefold increase in mean personnel time spent recruiting (4.1 hrs/patient vs. 14.1 hrs/patient, P < 0.001) and mean recruitment costs ($49/patient vs. $169/patient, P < 0.001). Upon review of the modified HIPAA-compliant protocol, revisions in the recruitment procedure were adopted. The revised protocol improved weekly accrual by 73% (1.9 patients/wk vs. 7.1 patients/wk, P < 0.001) and resulted in improvements in personnel time (5.4 hrs/patient) and recruitment costs ($65/patient). CONCLUSION Enactment of HIPAA initially placed a considerable burden on research time and costs. Establishing HIPAA-compliant recruitment policies can overcome some of these obstacles, although recruitment costs and time are likely to be greater than those observed before HIPAA. Cancer 2006. © 2005 American Cancer Society. [source] Fund allocation within Australian dental care: an innovative approach to output based fundingAUSTRALIAN DENTAL JOURNAL, Issue 4 2005M. Tennant Abstract Background: Over the last 15 years in Australia the process of funding government health care has changed significantly. The development of dental funding models that transparently meet both the service delivery needs for data at the treatment level and policy makers' need for health condition data is critical to the continued integration of dentistry into the wider health system. Methods: This paper presents a model of fund allocation that provides a communication construct that addresses the needs of both policy makers and service providers. Results: In this model, dental treatments (dental item numbers) have been grouped into eight broad dental health conditions. Within each dental health condition, a weighted average price is determined using the Department of Veterans Affairs' (DVA) fee schedule as the benchmark, adjusted for the mix of care. The model also adjusts for the efficiency differences between sectors providing government funded dental care. In summary, the price to be applied to a dental health condition category is determined by the weighted average DVA price adjusted by the sector efficiency. Conclusions: This model allows governments and dental service providers to develop funding agreements that both quantify and justify the treatment to be provided. Such a process facilitates the continued integration of dental care into the wider health system. [source] The experiences of non-medical health professionals undertaking community-based health assessments for people aged 75 years and overHEALTH & SOCIAL CARE IN THE COMMUNITY, Issue 2 2002Julie E. Byles BMed PhD Abstract Our objective was to explore the perceptions of allied health professionals who conducted over 3000 home-based health assessments within the general-practice-dominated Australian primary healthcare system. A series of semistructured qualitative interviews were carried out within the Department of Veterans' Affairs ,Preventive Care Trial', where health assessments are undertaken by health professionals in the homes of participating veterans and war widows. Health professionals were employed within the Preventive Care Trial to conduct assessments in 10 areas of New South Wales and Queensland. Subjects were mainly registered nurses, but also included a social worker, an occupational therapist, a physiotherapist and a psychologist. The health professionals described positive attitudes towards the health assessments, and showed that they have the broad range of necessary personal and professional skills to undertake them. Home visits were seen as an essential component and the most useful aspects included direct observation of home safety and medications. This study demonstrates that health assessments for older people can be acceptably and competently undertaken by suitably qualified allied health professionals, and that an effective collaborative approach to patient care can be achieved through such a system. [source] Risk of gastric cancer is not increased after partial gastrectomyJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 7 2000R Bassily Abstract Background: It has been suggested that there is an increased risk of gastric cancer following partial gastrectomy. This question has not been studied in an Australian population. Methods: The records of a total of 569 patients who had a partial gastrectomy for peptic ulcer disease at Repatriation General Hospital, Heidelberg, between 1957 and 1976 were reviewed. All were followed to date of death or 31 December 1996. The expected rate of gastric cancer for this population was estimated from published Australian age-and sex-specific gastric cancer mortality rates over this period, and a standardized incidence ratio was calculated. Results: The mean age at surgery was 53.5 years (range 27,83 years). There were 547 male (96.4%) and 22 female (3.6%) patients. Five hundred and seven (83.5%) had a Billroth II procedure. Thirty-eight patients (6.3%) were lost to follow up and were not included in the analysis. From the records of the Department of Veterans' Affairs, it was established that 125 (20.6%) were alive in December 1996, a mean survival after surgery of 18.8 years. The mean documented duration of follow up was 17.3 years (range 1,41 years). Nine patients developed cancer in the gastric remnant. The expected number of cancers in this population was 6.5. Assuming all survivors were free of gastric cancer, the standardized incidence ratio was 1.39 (95% confidence intervals 0.64,2.65, P = 0.313). Conclusion: The risk of gastric cancer was not increased after partial gastrectomy in this Australian population. [source] Increased risk of hip fracture in the elderly associated with prochlorperazine: is a prescribing cascade contributing?,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 9 2010Gillian E. Caughey Abstract Purpose To examine the prescribing of prochlorperazine secondary to the prescribing of a medicine which could lead to symptoms for which prochlorperazine is indicated and commonly used. Given the range of potential hypotensive, sedative, dystonic and other extra-pyramidal side effects associated with prochlorperazine, its association with hip fracture was also examined. Methods Prescription/event sequence symmetry analyses were undertaken from 1st January 2003 to 31st December 2006, using administrative claims data from the Department of Veterans' Affairs, Australia. This method assesses asymmetry in the distribution of an incident event (either prescription of another medicine or hospitalization) before and after the initiation of prochlorperazine. Crude and adjusted sequence ratios (ASR) with 95% confidence intervals (CI) were calculated. Results A total of 34,235 persons with incident use of prochlorperazine were identified during the study period. Statistically significant positive associations were found for a number of commonly used medicines, including cardiovascular medicines, NSAIDs, opioids and sedatives and the subsequent initiation of prochlorperazine that ranged from 1.07 (95%CI 1.01,1.14) for diuretics to 1.50 (95%CI 1.40,1.61) for statins. Prescription event analysis showed a 49% (95%CI 1.19,1.86) increased risk of hospitalisation for hip fracture following dispensing of prochlorperazine. Conclusions Prescribers should consider the possible contributing role of newly initiated medicines with the potential to cause of dizziness, and where possible address this through dose reduction or cessation of the medicine, rather than prescribing prochlorperazine. Copyright © 2010 John Wiley & Sons, Ltd. [source] Validity of medication-based co-morbidity indices in the Australian elderly populationAUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH, Issue 2 2009Agnes Vitry Abstract Objectives: To determine the validity of two medication-based co-morbidity indices, the Medicines Disease Burden Index (MDBI) and Rx-Risk-V in the Australian elderly population. Methods: In Phase I, the sensitivity and specificity of both indices were determined in 767 respondents from wave 6 of the Australian Longitudinal Study of Ageing (ALSA). Medication-defined index disease categories were compared to self-reported medical conditions. Correlation with self-rated health was examined and Cox proportional hazards models were used to assess the predictive validity for mortality. Phase II verified the predictive ability of Rx-Risk-V in a sample of 213,191 veterans from Australian Department of Veterans' Affairs (DVA) database. Results: MDBI and Rx-Risk-V scores could be calculated for 28% and 73% of the ALSA sample respectively. Both indices had high specificities and low to moderate sensitivities compared to self-reported medical conditions. Total weighted scores were significantly related to self-rated health (p<0.001). Both indices were predictive of mortality (Hazard Ratio (HR) =3.690 (95% CI 2.264-6.015) for MDBI and HR 1.079 (95% CI 1.045-1.114) for Rx-Risk-V. The predictive validity for mortality of Rx-Risk-V was confirmed using DVA data (HR= 1.090, 95% CI 1.088-1.092). Conclusions: Medication-based co-morbidity indices Rx-Risk-V and MDBI are valid measures of co-morbidity. However, Rx-Risk-V detects more comorbidity in the Australian elderly population and is likely to be a more suitable index to use in administrative datasets, particularly where studies include large numbers of outpatients. [source] Back to veterans affairs: We need to reconsider ADR for appeals board mattersALTERNATIVES TO THE HIGH COST OF LITIGATION, Issue 4 2009Richard M. Rosenbleeth Richard M. Rosenbleeth, of Philadelphia, updates his argument for ADR in dealing with the backlog of U.S. military veterans' disability claims. [source] Veterans Affairs Primary Care Clinicians' Attitudes toward Chronic Pain and Correlates of Opioid Prescribing RatesPAIN MEDICINE, Issue 5 2008Steven K. Dobscha MD ABSTRACT Objectives., The primary objective of this study was to identify veterans affairs (VA) primary care clinicians' attitudes regarding chronic pain treatment. A secondary objective was to explore relationships between clinician and practice characteristics and an objective measure of opioid prescribing rates. Design., Cross-sectional study of clinician survey and pharmacy data. Participants., Forty-five VA clinicians from five primary care clinics of one VA medical center. Measures., Survey of pain-related attitudes and behaviors, satisfaction with treatment resources, and job satisfaction; percentage of patients in clinicians' panels prescribed opioids (PCPO). Results., Seventy-one percent of clinicians felt moderately or strongly confident in their ability to treat chronic pain, and 77% moderately or strongly agreed that skilled pain management is a high priority. However, 73% moderately or strongly agreed that patients with chronic pain are a major source of frustration and 38% reported moderate or greater dissatisfaction with their ability to provide optimal pain treatment. Fifty-two percent moderately or strongly agreed that their management is influenced by previous experiences with patients addicted to drugs. The mean PCPO was 16.5% (SD = 6.7). In bivariate comparisons, clinician panel size, job and resource satisfaction, and professional training were associated with opioid prescribing rates. Conclusion., High clinician confidence and interest in treating chronic pain concurrent with low satisfaction with ability to provide optimal treatment suggests a need for more system support. VA primary care clinicians are frequently influenced by fears of contributing to dependence or addiction. The relationships among panel size, job satisfaction, and opioid prescribing rates merit additional investigation. [source] | ||||||||||||||||||||||||||||||||||