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Zakrzewski JJ, Doran N, Mayes TL, Twamley EW, Ayers CR. Rates of diagnosis and service utilization in veterans with hoarding disorder. Psychiatry Res 2024; 336:115888. [PMID: 38608540 DOI: 10.1016/j.psychres.2024.115888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/20/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024]
Abstract
Hoarding Disorder (HD) is a prominent and disabling neuropsychiatric condition defined by the inability to discard objects resulting in impairing levels of clutter. The prevalence rate is 2-6 % and increases with age. The aging Veteran population is a high risk group for impairment associated with HD. Medical and psychiatric comorbidities as well as associated rates of disability and poor quality of life are very common in both HD and the related disorder of OCD. We examined rates of HD and OCD diagnoses at the VA San Diego Healthcare System. Data were obtained from medical records for all Veterans with these diagnoses over 8-years and included information on medical and psychiatric care, homelessness services, and Care Assessment Needs (CAN) scores. Rates of diagnosis for both HD and OCD were well below epidemiological estimates. Veterans with HD were older, had higher rates of medical hospital admissions with longer stays; had more cardiac, neurological, and acquired medical conditions; had more psychiatric comorbidities; had more interactions with the suicide prevent team and homelessness services; and had higher CAN scores than Veterans with OCD. The low rate of diagnosis and high services utilization of Veterans with HD demonstrates an area of unmet need.
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Affiliation(s)
- Jessica J Zakrzewski
- Research Service, VA San Diego Healthcare System, La Jolla, CA, United States; Department of Psychiatry, UC San Diego, La Jolla, CA, United States.
| | - Neal Doran
- Research Service, VA San Diego Healthcare System, La Jolla, CA, United States; Department of Psychiatry, UC San Diego, La Jolla, CA, United States; Psychology Service, VA San Diego Healthcare System, La Jolla, CA, United States
| | - Tina L Mayes
- Department of Psychiatry, UC San Diego, La Jolla, CA, United States; Psychology Service, VA San Diego Healthcare System, La Jolla, CA, United States
| | - Elizabeth W Twamley
- Research Service, VA San Diego Healthcare System, La Jolla, CA, United States; Department of Psychiatry, UC San Diego, La Jolla, CA, United States; Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, United States
| | - Catherine R Ayers
- Research Service, VA San Diego Healthcare System, La Jolla, CA, United States; Department of Psychiatry, UC San Diego, La Jolla, CA, United States; Psychology Service, VA San Diego Healthcare System, La Jolla, CA, United States.
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Young AS, Skela J, Chang ET, Oberman R, Siddarth P. Variation in benefit among patients with serious mental illness who receive integrated psychiatric and primary care. PLoS One 2024; 19:e0304312. [PMID: 38781176 PMCID: PMC11115296 DOI: 10.1371/journal.pone.0304312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE The population with serious mental illness has high risk for hospitalization or death due to unhealthy behaviors and inadequate medical care, though the level of risk varies substantially. Programs that integrate medical and psychiatric services improve outcomes but are challenging to implement and access is limited. It would be useful to know whether benefits are confined to patients with specific levels of risk. METHODS In a population with serious mental illness and increased risk for hospitalization or death, a specialized medical home integrated services and improved treatment and outcomes. Treatment quality, chronic illness care, care experience, symptoms, and quality of life were assessed for a median of 385 days. Analyses examine whether improvements varied by baseline level of patient risk. RESULTS Patients with greater risk were more likely to be older, more cognitively impaired, and have worse mental health. Integrated services increased appropriate screening for body mass index, lipids, and glucose, but increases did not differ significantly by level of risk. Integrated services also improved chronic illness care, care experience, mental health-related quality of life, and psychotic symptoms. There were also no significant differences by risk level. CONCLUSIONS There were benefits from integration of primary care and psychiatric care at all levels of increased risk, including those with extremely high risk above the 95th percentile. When developing integrated care programs, patients should be considered at all levels of risk, not only those who are the healthiest.
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Affiliation(s)
- Alexander S. Young
- Desert Pacific Mental Illness Research Education and Clinical Center, Greater Los Angeles Veterans Healthcare System, Los Angeles, California, United States of America
- Department of Psychiatry, School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles Veterans Healthcare System, Los Angeles, California, United States of America
| | - Jessica Skela
- Department of Psychiatry, School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Evelyn T. Chang
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles Veterans Healthcare System, Los Angeles, California, United States of America
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Rebecca Oberman
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, Greater Los Angeles Veterans Healthcare System, Los Angeles, California, United States of America
| | - Prabha Siddarth
- Department of Psychiatry, School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
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Young AS, Skela J, Siddarth P. The Characteristics of People with Serious Mental Illness Who are at High Risk for Hospitalization or Death. Community Ment Health J 2024:10.1007/s10597-024-01281-8. [PMID: 38653869 DOI: 10.1007/s10597-024-01281-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
Many individuals with serious mental illness are at high risk for hospitalization or death due to inadequate treatment of medical conditions or unhealthy behaviors. The authors describe demographic and clinical characteristics associated with increased risk in this population. Electronic data were obtained for individuals in treatment at a large Veterans' healthcare system who were at high risk according to a validated model. A random sample of these individuals was assessed in person. Multivariable regressions estimated the effect of numerous demographic, health, and clinical characteristics on risk. Emergency visits and hospitalizations were common. Greater risk was associated with being male, not married, and having more diagnoses. While risk varied by race, this effect was no longer significant after controlling for other factors. Health-related quality of life worsened with increasing risk. Routine data identify a large population of high-risk individuals who may benefit from outreach to provide healthcare services.
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Affiliation(s)
- Alexander S Young
- Desert Pacific Mental Illness Research Education and Clinical Center, Greater Los Angeles Veterans Healthcare System, 11301 Wilshire Blvd., 210A, Los Angeles, CA, USA.
- Department of Psychiatry, School of Medicine, University of California, 300 UCLA Medical Plaza, Los Angeles, CA, USA.
| | - Jessica Skela
- Department of Psychiatry, School of Medicine, University of California, 300 UCLA Medical Plaza, Los Angeles, CA, USA
| | - Prabha Siddarth
- Desert Pacific Mental Illness Research Education and Clinical Center, Greater Los Angeles Veterans Healthcare System, 11301 Wilshire Blvd., 210A, Los Angeles, CA, USA
- Department of Psychiatry, School of Medicine, University of California, 300 UCLA Medical Plaza, Los Angeles, CA, USA
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Giannitrapani KF, Sasnal M, McCaa M, Wu A, Morris AM, Connell NB, Aslakson RA, Schenker Y, Shreve S, Lorenz KA. Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans. J Pain Symptom Manage 2023; 66:621-629.e5. [PMID: 37643653 DOI: 10.1016/j.jpainsymman.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively. OBJECTIVES To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons. METHODS We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8). RESULTS Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care. CONCLUSION The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.
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Affiliation(s)
- Karleen F Giannitrapani
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California.
| | - Marzena Sasnal
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | - Matthew McCaa
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California
| | - Adela Wu
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Department of Neurosurgery (A.W.), Stanford School of Medicine, Stanford, California
| | - Arden M Morris
- Department of Surgery (M.S., A.M.M.), S-SPIRE Center, Stanford School of Medicine, Stanford, California
| | | | - Rebecca A Aslakson
- Department of Anesthesiology (R.A.A.), University of Vermont, Burlington, Vermont
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics (Y.S.), Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott Shreve
- Department of Veterans Affairs (S.S.), VA Palliative Care, Lebanon, Pennsylvania
| | - Karl A Lorenz
- Department of Veterans Affairs (K.F.G., M.S., M.M., A.W., K.A.L.), Menlo Park, California; Primary Care and Population Health (K.F.G., K.A.L.), Stanford School of Medicine, Stanford, California
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List JM, Palevsky P, Tamang S, Crowley S, Au D, Yarbrough WC, Navathe AS, Kreisler C, Parikh RB, Wang-Rodriguez J, Klutts JS, Conlin P, Pogach L, Meerwijk E, Moy E. Eliminating Algorithmic Racial Bias in Clinical Decision Support Algorithms: Use Cases from the Veterans Health Administration. Health Equity 2023; 7:809-816. [PMID: 38076213 PMCID: PMC10698768 DOI: 10.1089/heq.2023.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 01/29/2024] Open
Abstract
The Veterans Health Administration uses equity- and evidence-based principles to examine, correct, and eliminate use of potentially biased clinical equations and predictive models. We discuss the processes, successes, challenges, and next steps in four examples. We detail elimination of the race modifier for estimated kidney function and discuss steps to achieve more equitable pulmonary function testing measurement. We detail the use of equity lenses in two predictive clinical modeling tools: Stratification Tool for Opioid Risk Mitigation (STORM) and Care Assessment Need (CAN) predictive models. We conclude with consideration of ways to advance racial health equity in clinical decision support algorithms.
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Affiliation(s)
- Justin M. List
- VA Office of Health Equity, Washington, District of Columbia, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Paul Palevsky
- Kidney Medicine Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Suzanne Tamang
- Department of Veterans Affairs, Palo Alto, California, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Susan Crowley
- Nephrology Section, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - David Au
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - William C. Yarbrough
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
- VA North Texas Health Care System, Dallas, Texas, USA
| | - Amol S. Navathe
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Craig Kreisler
- Analytics and Performance Integration (API), Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Ravi B. Parikh
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jessica Wang-Rodriguez
- VA National Pathology and Laboratory Medicine Service, Washington, District of Columbia, USA
- Department of Pathology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - J. Stacey Klutts
- National VHA Diagnostics Office, Washington, District of Columbia, USA
- Iowa City VA Healthcare System, Iowa City, Iowa, USA
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Paul Conlin
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Leonard Pogach
- Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey, USA
| | | | - Ernest Moy
- VA Office of Health Equity, Washington, District of Columbia, USA
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Alowais SA, Alghamdi SS, Alsuhebany N, Alqahtani T, Alshaya AI, Almohareb SN, Aldairem A, Alrashed M, Bin Saleh K, Badreldin HA, Al Yami MS, Al Harbi S, Albekairy AM. Revolutionizing healthcare: the role of artificial intelligence in clinical practice. BMC MEDICAL EDUCATION 2023; 23:689. [PMID: 37740191 PMCID: PMC10517477 DOI: 10.1186/s12909-023-04698-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/19/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Healthcare systems are complex and challenging for all stakeholders, but artificial intelligence (AI) has transformed various fields, including healthcare, with the potential to improve patient care and quality of life. Rapid AI advancements can revolutionize healthcare by integrating it into clinical practice. Reporting AI's role in clinical practice is crucial for successful implementation by equipping healthcare providers with essential knowledge and tools. RESEARCH SIGNIFICANCE This review article provides a comprehensive and up-to-date overview of the current state of AI in clinical practice, including its potential applications in disease diagnosis, treatment recommendations, and patient engagement. It also discusses the associated challenges, covering ethical and legal considerations and the need for human expertise. By doing so, it enhances understanding of AI's significance in healthcare and supports healthcare organizations in effectively adopting AI technologies. MATERIALS AND METHODS The current investigation analyzed the use of AI in the healthcare system with a comprehensive review of relevant indexed literature, such as PubMed/Medline, Scopus, and EMBASE, with no time constraints but limited to articles published in English. The focused question explores the impact of applying AI in healthcare settings and the potential outcomes of this application. RESULTS Integrating AI into healthcare holds excellent potential for improving disease diagnosis, treatment selection, and clinical laboratory testing. AI tools can leverage large datasets and identify patterns to surpass human performance in several healthcare aspects. AI offers increased accuracy, reduced costs, and time savings while minimizing human errors. It can revolutionize personalized medicine, optimize medication dosages, enhance population health management, establish guidelines, provide virtual health assistants, support mental health care, improve patient education, and influence patient-physician trust. CONCLUSION AI can be used to diagnose diseases, develop personalized treatment plans, and assist clinicians with decision-making. Rather than simply automating tasks, AI is about developing technologies that can enhance patient care across healthcare settings. However, challenges related to data privacy, bias, and the need for human expertise must be addressed for the responsible and effective implementation of AI in healthcare.
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Affiliation(s)
- Shuroug A Alowais
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia.
| | - Sahar S Alghamdi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Pharmaceutical Sciences, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nada Alsuhebany
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Tariq Alqahtani
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Pharmaceutical Sciences, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman I Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Sumaya N Almohareb
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Atheer Aldairem
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Alrashed
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Khalid Bin Saleh
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hisham A Badreldin
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Majed S Al Yami
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Shmeylan Al Harbi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulkareem M Albekairy
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Riyadh, 14611, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
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Trivedi RB, Rossi FS, Javier SJ, Greene L, Singer SJ, Vanneman ME, Goldstein M, Zulman DM. Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans. J Gen Intern Med 2022; 37:4071-4079. [PMID: 35869316 PMCID: PMC9708986 DOI: 10.1007/s11606-022-07705-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/16/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. OBJECTIVE To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. DESIGN Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. PARTICIPANTS 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. MAIN OUTCOME AND MEASURES The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. KEY RESULTS In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30). CONCLUSIONS Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.
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Affiliation(s)
- Ranak B Trivedi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA.
- Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
| | - Fernanda S Rossi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah J Javier
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Liberty Greene
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara J Singer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mary Goldstein
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
- Office of Geriatrics and Extended Care, Department of Veterans Affairs, Washington, DC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Haderlein TP, Wong MS, Jones KT, Moy EM, Yuan AH, Washington DL. Racial/Ethnic Variation in Veterans Health Administration COVID-19 Vaccine Uptake. Am J Prev Med 2022; 62:596-601. [PMID: 34782188 PMCID: PMC8529259 DOI: 10.1016/j.amepre.2021.08.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/03/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Equitable COVID-19 vaccine access is imperative to mitigating negative COVID-19 impacts among racial/ethnic minorities. U.S. racial/ethnic minorities have lower COVID-19 vaccination rates than Whites despite higher COVID-19 death/case rates. The Veterans Health Administration provides the unique context of a managed care system with few access barriers. This study evaluates race/ethnicity as a predictor of Veterans Health Administration COVID-19 vaccination. METHODS The cohort was composed of Veterans Health Administration outpatient users aged ≥65 years (N=3,474,874). COVID-19 vaccination was assessed between December 14, 2020 and February 23, 2021. Multivariable logistic regressions were conducted, controlling for demographics, medical comorbidity, and influenza vaccination history. Proximity to Indian Health Service Contract Health Service Delivery Areas was tested as a moderator. Data analyses were conducted during 2021. RESULTS Blacks (OR=1.28, 95% CI=1.17, 1.40), Hispanics (OR=1.15, 95% CI=1.05, 1.25), and Asians (OR=1.21, 95% CI=1.02, 1.43) were more likely than Whites to receive Veterans Health Administration COVID-19 vaccinations. American Indian/Alaska Natives were less likely than Whites to receive Veterans Health Administration COVID-19 vaccinations, but only those residing in Contract Health Service Delivery Area counties (OR= 0.58, 95% CI= 0.47, 0.72). Influenza vaccine history positively predicted COVID-19 vaccine uptake (OR= 2.28, 95% CI=2.22, 2.34). CONCLUSIONS In the Veterans Health Administration, compared with the general U.S. population, COVID-19 vaccine receipt is higher among most racial/ethnic minority groups than Whites, suggesting reduced vaccination barriers . The Indian Health Service may provide a safety net for American Indian/Alaska Native populations. Addressing vaccination access barriers in non-Veterans Health Administration settings can potentially reduce racial/ethnic disparities.
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Affiliation(s)
- Taona P Haderlein
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michelle S Wong
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Kenneth T Jones
- VA Office of Health Equity, Washington, District of Columbia
| | - Ernest M Moy
- VA Office of Health Equity, Washington, District of Columbia
| | - Anita H Yuan
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Donna L Washington
- VA HSR&D Center for the Study of Health Care Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.
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9
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Röösli E, Bozkurt S, Hernandez-Boussard T. Peeking into a black box, the fairness and generalizability of a MIMIC-III benchmarking model. Sci Data 2022; 9:24. [PMID: 35075160 PMCID: PMC8786878 DOI: 10.1038/s41597-021-01110-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Abstract
As artificial intelligence (AI) makes continuous progress to improve quality of care for some patients by leveraging ever increasing amounts of digital health data, others are left behind. Empirical evaluation studies are required to keep biased AI models from reinforcing systemic health disparities faced by minority populations through dangerous feedback loops. The aim of this study is to raise broad awareness of the pervasive challenges around bias and fairness in risk prediction models. We performed a case study on a MIMIC-trained benchmarking model using a broadly applicable fairness and generalizability assessment framework. While open-science benchmarks are crucial to overcome many study limitations today, this case study revealed a strong class imbalance problem as well as fairness concerns for Black and publicly insured ICU patients. Therefore, we advocate for the widespread use of comprehensive fairness and performance assessment frameworks to effectively monitor and validate benchmark pipelines built on open data resources.
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Affiliation(s)
- Eliane Röösli
- School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
- Department of Medicine (Biomedical Informatics), Stanford University, Stanford, CA, USA
| | - Selen Bozkurt
- Department of Medicine (Biomedical Informatics), Stanford University, Stanford, CA, USA
| | - Tina Hernandez-Boussard
- Department of Medicine (Biomedical Informatics), Stanford University, Stanford, CA, USA.
- Department of Biomedical Data Sciences, Stanford University, Stanford, CA, USA.
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10
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Soerensen SJC, Thomas IC, Schmidt B, Daskivich TJ, Skolarus TA, Jackson C, Osborne TF, Chertow GM, Brooks JD, Rehkopf DH, Leppert JT. Using an Automated Electronic Health Record Score To Estimate Life Expectancy In Men Diagnosed With Prostate Cancer In The Veterans Health Administration. Urology 2021; 155:70-76. [PMID: 34139251 DOI: 10.1016/j.urology.2021.05.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/11/2021] [Accepted: 05/09/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine if an automatically calculated electronic health record score can estimate intermediate-term life expectancy in men with prostate cancer to provide guideline concordant care. METHODS We identified all men (n = 36,591) diagnosed with prostate cancer in 2013-2015 in the VHA. Of the 36,591, 35,364 (96.6%) had an available Care Assessment Needs (CAN) score (range: 0-99) automatically calculated in the 30 days prior to the date of diagnosis. It was designed to estimate short-term risks of hospitalization and mortality. We fit unadjusted and multivariable Cox proportional hazards regression models to determine the association between the CAN score and overall survival among men with prostate cancer. We compared CAN score performance to two established comorbidity measures: The Charlson Comorbidity Index and Prostate Cancer Comorbidity Index (PCCI). RESULTS Among 35,364 men, the CAN score correlated with overall stage, with mean scores of 46.5 ( ± 22.4), 58.0 ( ± 24.4), and 68.1 ( ± 24.3) in localized, locally advanced, and metastatic disease, respectively. In both unadjusted and adjusted models for prostate cancer risk, the CAN score was independently associated with survival (HR = 1.23 95%CI 1.22-1.24 & adjusted HR = 1.17 95%CI 1.16-1.18 per 5-unit change, respectively). The CAN score (overall C-Index 0.74) yielded better discrimination (AUC = 0.76) than PCCI (AUC = 0.65) or Charlson Comorbidity Index (AUC = 0.66) for 5-year survival. CONCLUSION The CAN score is strongly associated with intermediate-term survival following a prostate cancer diagnosis. The CAN score is an example of how learning health care systems can implement multi-dimensional tools to provide fully automated life expectancy estimates to facilitate patient-centered cancer care.
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Affiliation(s)
- Simon John Christoph Soerensen
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Department of Urology, Aarhus University Hospital, Aarhus, Denmark
| | - I-Chun Thomas
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Bogdana Schmidt
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | | | - Ted A Skolarus
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Ann Arbor, MI
| | - Christian Jackson
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Thomas F Osborne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Glenn M Chertow
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - James D Brooks
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - David H Rehkopf
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - John T Leppert
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA.
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11
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Schalet BD, Reise SP, Zulman DM, Lewis ET, Kimerling R. Psychometric evaluation of a patient-reported item bank for healthcare engagement. Qual Life Res 2021; 30:2363-2374. [PMID: 33835412 DOI: 10.1007/s11136-021-02824-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Healthcare engagement is a core measurement target for efforts to improve healthcare systems. This construct is broadly defined as the extent to which healthcare services represent collaborative partnerships with patients. Previous qualitative work operationalized healthcare engagement as generalized self-efficacy in four related subdomains: self-management, collaborative communication, health information use, and healthcare navigation. Building on this work, our objective was to establish a healthcare engagement instrument that is sufficiently unidimensional to yield a single score. METHOD We conducted cognitive interviews followed by a nation-wide mail survey of US Veteran Administration (VA) healthcare users. Data were collected on 49 candidate healthcare engagement items, as well as measures of self-efficacy for managing symptoms, provider communication, and perceived access. Items were subjected to exploratory bifactor, statistical learning, and IRT analyses. RESULTS Cognitive interviews were completed by 56 patients and 9552 VA healthcare users with chronic conditions completed the mail survey. Participants were mostly white and male but with sizable minority participation. Psychometric analyses and content considerations reduced the item pool to 23 items, which demonstrated a strong general factor (OmegaH of .89). IRT analyses revealed a high level of reliability across the trait range and little DIF across groups. Most health information use items were removed during analyses, suggesting a more independent role for this domain. CONCLUSION We provide quantitative evidence for a relatively unidimensional measure of healthcare engagement. Despite developed with VA healthcare users, the measure is intended for general use. Future work includes short-form development and validation with other patient groups.
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Affiliation(s)
- Benjamin D Schalet
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, USA.
| | - Steven P Reise
- Department of Psychology, University of California, San Diego, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, USA
| | - Eleanor T Lewis
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, USA
| | - Rachel Kimerling
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, USA
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12
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Scott IA. Demystifying machine learning: a primer for physicians. Intern Med J 2021; 51:1388-1400. [PMID: 33462882 DOI: 10.1111/imj.15200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/16/2021] [Accepted: 01/16/2021] [Indexed: 01/17/2023]
Abstract
Machine learning is a tool for analysing digitised data sets and formulating predictions that can optimise clinical decision-making. It aims to identify complex patterns in large data sets and encode them into models that can then classify new unseen cases or make predictions on new data. Machine learning methods take several forms and individual models can be of many different types. More than 50 models have been approved for use in routine healthcare, and the numbers continue to grow exponentially. The reliability and robustness of any model depends on multiple factors, including the quality and quantity of the data used to develop the models, and the selection of features in the data considered most important to maximising accuracy. In ensuring models are safe, effective and reproducible in routine care, physicians need to have some understanding of how these models are developed and evaluated, and to collaborate with data and computer scientists in their design and validation. This narrative review introduces principles, methods and examples of machine learning in a way that does not require mastery of highly complex statistical and computational concepts.
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Affiliation(s)
- Ian A Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia
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13
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Osborne TF, Veigulis ZP, Arreola DM, Röösli E, Curtin CM. Automated EHR score to predict COVID-19 outcomes at US Department of Veterans Affairs. PLoS One 2020; 15:e0236554. [PMID: 32716922 PMCID: PMC7384633 DOI: 10.1371/journal.pone.0236554] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/08/2020] [Indexed: 01/20/2023] Open
Abstract
The sudden emergence of COVID-19 has brought significant challenges to the care of Veterans. An improved ability to predict a patient's clinical course would facilitate optimal care decisions, resource allocation, family counseling, and strategies for safely easing distancing restrictions. The Care Assessment Need (CAN) score is an existing risk assessment tool within the Veterans Health Administration (VA), and produces a score from 0 to 99, with a higher score correlating to a greater risk. The model was originally designed for the nonacute outpatient setting and is automatically calculated from structured data variables in the electronic health record. This multisite retrospective study of 6591 Veterans diagnosed with COVID-19 from March 2, 2020 to May 26, 2020 was designed to assess the utility of repurposing the CAN score as objective and automated risk assessment tool to promptly enhance clinical decision making for Veterans diagnosed with COVID-19. We performed bivariate analyses on the dichotomized CAN 1-year mortality score (high vs. low risk) and each patient outcome using Chi-square tests of independence. Logistic regression models using the continuous CAN score were fit to assess its predictive power for outcomes of interest. Results demonstrated that a CAN score greater than 50 was significantly associated with the following outcomes after positive COVID-19 test: hospital admission (OR 4.6), prolonged hospital stay (OR 4.5), ICU admission (3.1), prolonged ICU stay (OR 2.9), mechanical ventilation (OR 2.6), and mortality (OR 7.2). Repurposing the CAN score offers an efficient way to risk-stratify COVID-19 Veterans. As a result of the compelling statistical results, and automation, this tool is well positioned for broad use across the VA to enhance clinical decision-making.
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Affiliation(s)
- Thomas F. Osborne
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
- Department of Radiology, Stanford University School of Medicine, Stanford, California, United States of America
| | - Zachary P. Veigulis
- US Department of Veterans Affairs, Central Iowa Health Care System, Des Moines, Iowa, United States of America
| | - David M. Arreola
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Eliane Röösli
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Catherine M. Curtin
- US Department of Veterans Affairs, Palo Alto Healthcare System, Palo Alto, California, United States of America
- Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
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