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Wolfe HL, Jeon A, Goulet JL, Simpson TL, Eleazer JR, Jasuja GK, Blosnich JR, Kauth MR, Shipherd JC, Littman AJ. Non-affirmation minority stress, internalized transphobia, and subjective cognitive decline among transgender and gender diverse veterans aged 45 years and older. Aging Ment Health 2024:1-7. [PMID: 38567655 DOI: 10.1080/13607863.2024.2335565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/18/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES To examine the associations of two measures of minority stress, non-affirmation minority stress and internalized transphobia, with subjective cognitive decline (SCD) among transgender and gender diverse (TGD) veterans. METHOD We administered a cross-sectional survey from September 2022 to July 2023 to TGD veterans. The final analytic sample included 3,152 TGD veterans aged ≥45 years. We used a generalized linear model with quasi-Poisson distribution to calculate prevalence ratios (PR) and 95% confidence intervals (CIs) measuring the relationship between non-affirmation minority stress and internalized transphobia and past-year SCD. RESULTS The mean age was 61.3 years (SD = 9.7) and the majority (70%) identified as trans women or women. Overall, 27.2% (n = 857) reported SCD. Adjusted models revealed that TGD veterans who reported experiencing non-affirmation minority stress or internalized transphobia had greater risk of past-year SCD compared to those who did not report either stressor (aPR: 1.09, 95% CI: 1.04-1.15; aPR: 1.19, 95% CI: 1.12-1.27). CONCLUSION Our findings demonstrate that proximal and distal processes of stigma are associated with SCD among TGD veterans and underscore the need for addressing multiple types of discrimination. Above all, these results indicate the lasting sequelae of transphobia and need for systemic changes to prioritize the safety and welfare of TGD people.
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Affiliation(s)
- Hill L Wolfe
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, Connecticut, CT, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Section of Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, CT, USA
| | - Amy Jeon
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Joseph L Goulet
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, Connecticut, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tracy L Simpson
- Center of Excellence in Substance Addiction Treatment & Education, VA Puget Sound Healthcare System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Jacob R Eleazer
- Department of Psychiatry and Psychology, Mayo Clinic Florida, Jacksonville, FL, USA
- Transgender and Intersex Specialty Care Clinic, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - John R Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Michael R Kauth
- Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Health Program, Veterans Health Administration, Washington, DC, USA
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Jillian C Shipherd
- Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Health Program, Veterans Health Administration, Washington, DC, USA
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Alyson J Littman
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, WA, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, US Department of Veterans Affairs, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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Wolfe HL, Vimalananda VG, Wong DH, Reisman JI, Rao SR, Shipherd JC, Blosnich JR, Livingston NA, Jasuja GK. Patient Characteristics Associated with Receiving Gender-Affirming Hormone Therapy in the Veterans Health Administration. Transgend Health 2024; 9:151-161. [PMID: 38694620 PMCID: PMC11059777 DOI: 10.1089/trgh.2022.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose This study aimed to examine patient characteristics associated with receipt of gender-affirming hormone therapy in the Veterans Health Administration (VHA). Methods This cross-sectional study included a national cohort of 9555 transgender and gender diverse (TGD) patients with TGD-related diagnosis codes who received care in the VHA from 2006 to 2018. Logistic regression models were used to determine the association of health conditions and documented social stressors with receipt of gender affirming hormone therapy. Results Of the 9555 TGD patients, 57.4% received gender-affirming hormone therapy in the VHA. In fully adjusted models, patients who had following characteristics were less likely to obtain gender-affirming hormones in the VHA: Black, non-Hispanic versus white (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.52-0.72), living in the Northeast versus the West (aOR: 0.72; 95% CI: 0.62-0.84), a documented drug use disorder (aOR: 0.56; 95% CI: 0.47-0.68), ≥3 versus no comorbidities (aOR: 0.44; 95% CI: 0.34-0.57), and ≥3 versus no social stressors (aOR: 0.42; 95% CI: 0.30-0.58; all p<0.001). Younger patients aged 21-29 years were almost 3 times more likely to receive gender affirming hormone therapy in the VHA than those aged ≥60 (aOR: 2.98; 95% CI: 2.55-3.47; p<0.001). Conclusion TGD individuals who were older, Black, non-Hispanic, and had more comorbidities and documented social stressors were less likely to receive gender-affirming hormone therapy in the VHA. Further understanding of patient preferences in addition to clinician- and site-level determinants that may impact access to gender-affirming hormone therapy for TGD individuals in the VHA is needed.
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Affiliation(s)
- Hill L. Wolfe
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Varsha G. Vimalananda
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Denise H. Wong
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
| | - Sowmya R. Rao
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jillian C. Shipherd
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- LGBTQ+ Health Program, Office of Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia, USA
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - John R. Blosnich
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
| | - Nicholas A. Livingston
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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Jasuja GK, Reisman JI, Miller DR, Ansara ED, Chiulli DL, Moore T, Ourth HL, Tran MH, Smith EG, Morreale AP, McCullough MM. Complexity of patients with mental healthcare needs cared for by mental health clinical pharmacist practitioners in Veterans Affairs. Am J Health Syst Pharm 2024:zxae007. [PMID: 38468398 DOI: 10.1093/ajhp/zxae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Indexed: 03/13/2024] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The complexity of patients with mental healthcare needs cared for by clinical pharmacists is not well delineated. We evaluated the complexity of patients with schizophrenia, bipolar disorder, and major depressive disorder (MDD) in Veterans Affairs (VA) cared for by mental health clinical pharmacist practitioners (MH CPPs). METHODS Patients at 42 VA sites with schizophrenia, bipolar disorder, or MDD in 2016 through 2019 were classified by MH CPP visits into those with 2 or more visits ("ongoing MH CPP care"), those with 1 visit ("consultative MH CPP care"), and those with no visits ("no MH CPP care"). Patient complexity for each condition was defined by medication regimen and service utilization. RESULTS For schizophrenia, more patients in ongoing MH CPP care were complex than those with no MH CPP care, based on all measures examined: the number of primary medications (15.3% vs 8.1%), inpatient (13.7% vs 9.1%) and outpatient (42.6% vs 29.7%) utilization, and receipt of long-acting injectable antipsychotics (36.7% vs 25.8%) and clozapine (20.5% vs 9.5%). For bipolar disorder, more patients receiving ongoing or consultative MH CPP care were complex than those with no MH CPP care based on the number of primary medications (27.9% vs 30.5% vs 17.7%) and overlapping mood stabilizers (10.1% vs 11.6% vs 6.2%). For MDD, more patients receiving ongoing or consultative MH CPP care were complex based on the number of primary medications (36.8% vs 35.5% vs 29.2%) and augmentation of antidepressants (56.1% vs 54.4% vs 47.0%) than patients without MH CPP care. All comparisons were significant (P < 0.01). CONCLUSION MH CPPs provide care for complex patients with schizophrenia, bipolar disorder, and MDD in VA.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA
| | - Joel I Reisman
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Donald R Miller
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, and Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, MA, USA
| | | | - Dana L Chiulli
- W.G. (Bill) Hefner Salisbury Department of Veterans Affairs Medical Center, Salisbury, NC, USA
| | - Tera Moore
- VA Pharmacy Benefits Management Services, Clinical Pharmacy Practice Office, Washington, DC, USA
| | - Heather L Ourth
- VA Pharmacy Benefits Management Services, Clinical Pharmacy Practice Office, Washington, DC, USA
| | - Michael H Tran
- VA Pharmacy Benefits Management Services, Clinical Pharmacy Practice Office, Washington, DC, USA
| | - Eric G Smith
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, Departmentof Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, and Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Anthony P Morreale
- VA Pharmacy Benefits Management Services, Clinical Pharmacy Practice Office, Washington, DC, USA
| | - Megan M McCullough
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, and Department of Public Health, Zuckerberg School of Health Sciences, University of Massachusetts, Lowell, MA, USA
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Jackson GL, Fix GM, White BS, Cutrona SL, Reardon CM, Damschroder LJ, Burns M, DeLaughter K, Opra Widerquist MA, Arasim M, Lindquist J, Gifford AL, King HA, Kaitz J, Jasuja GK, Hogan TP, Lopez JCF, Henderson B, Fitzgerald BA, Goetschius A, Hagan D, McCoy C, Seelig A, Nevedal A. Diffusion of excellence: evaluating a system to identify, replicate, and spread promising innovative practices across the Veterans health administration. Front Health Serv 2024; 3:1223277. [PMID: 38420338 PMCID: PMC10900518 DOI: 10.3389/frhs.2023.1223277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/20/2023] [Indexed: 03/02/2024]
Abstract
Introduction The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program provides a system to identify, replicate, and spread promising practices across the largest integrated healthcare system in the United States. DoE identifies innovations that have been successfully implemented in the VHA through a Shark Tank style competition. VHA facility and regional directors bid resources needed to replicate promising practices. Winning facilities/regions receive external facilitation to aid in replication/implementation over the course of a year. DoE staff then support diffusion of successful practices across the nationwide VHA. Methods Organized around the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, we summarize results of an ongoing long-term mixed-methods implementation evaluation of DoE. Data sources include: Shark Tank application and bid details, tracking practice adoptions through a Diffusion Marketplace, characteristics of VHA facilities, focus groups with Shark Tank bidders, structured observations of DoE events, surveys of DoE program participants, and semi-structured interviews of national VHA program office leaders, VHA healthcare system/facility executives, practice developers, implementation teams and facilitators. Results In the first eight Shark Tanks (2016-2022), 3,280 Shark Tank applications were submitted; 88 were designated DoE Promising Practices (i.e., practices receive facilitated replication). DoE has effectively spread practices across the VHA, with 1,440 documented instances of adoption/replication of practices across the VHA. This includes 180 adoptions/replications in facilities located in rural areas. Leadership decisions to adopt innovations are often based on big picture considerations such as constituency support and linkage to organizational goals. DoE Promising Practices that have the greatest national spread have been successfully replicated at new sites during the facilitated replication process, have close partnerships with VHA national program offices, and tend to be less expensive to implement. Two indicators of sustainment indicate that 56 of the 88 Promising Practices are still being diffused across the VHA; 56% of facilities originally replicating the practices have sustained them, even up to 6 years after the first Shark Tank. Conclusion DoE has developed a sustainable process for the identification, replication, and spread of promising practices as part of a learning health system committed to providing equitable access to high quality care.
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Affiliation(s)
- George L. Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Advancing Implementation and Improvement Science Program, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Gemmae M. Fix
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Brandolyn S. White
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Sarah L. Cutrona
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Caitlin M. Reardon
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Laura J. Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Madison Burns
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | | | - Maria Arasim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Jennifer Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Allen L. Gifford
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Heather A. King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Department of Population Health Sciences, Duke University, Durham, NC, United States
- Division of General Internal Medicine, Duke University, Durham, NC, United States
| | - Jenesse Kaitz
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | - Guneet K. Jasuja
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Timothy P. Hogan
- Advancing Implementation and Improvement Science Program, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | - Jaifred Christian F. Lopez
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Department of Population Health Sciences, Duke University, Durham, NC, United States
| | - Blake Henderson
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Blaine A. Fitzgerald
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Amber Goetschius
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Danielle Hagan
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Carl McCoy
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Alex Seelig
- Agile Six Applications, Inc., San Diego, CA, United States
| | - Andrea Nevedal
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
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Rose AJ, Greenspan SL, Jasuja GK. Gaps in evidence on treatment of male osteoporosis: a Research Agenda. Aging Male 2023; 26:2223699. [PMID: 37314290 DOI: 10.1080/13685538.2023.2223699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
OBJECTIVE To identify key research gaps regarding medication therapy to prevent osteoporotic fractures in men. DATA SOURCES Articles from the peer-reviewed literature containing empirical studies of the use of medication therapy for fracture prevention in men, either in clinical trials or observational studies. STUDY SELECTION AND DATA EXTRACTION We searched PubMed with search terms including "osteoporosis AND medication therapy management". We read all articles to ensure that they were indeed empirical studies of our topic. For each included study, we searched for all articles in the bibliography, all articles that cited the article, and all related articles, using these functions in PubMed. DATA SYNTHESIS We have identified six research gaps that could inform the more rational, evidence-based treatment of male osteoporosis. Specifically, among men, we lack key information about: (1) whether treatment can prevent clinical fractures, (2) rates of side effects and complications of therapy, (3) the role of testosterone in treatment, (4) the comparative effectiveness of different therapeutic regimens, (5) role of drug holidays for those receiving bisphosphonates and sequential therapies, and (6) effectiveness of therapy for secondary prevention. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Addressing these six topics should be key goal for the next decade of research on male osteoporosis.
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Affiliation(s)
- Adam J Rose
- School of Public Health, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Susan L Greenspan
- Osteoporosis Prevention and Treatment Center, Division of Geriatrics and Gerontology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Guneet K Jasuja
- Edith Nourse Rogers Memorial Veterans' Hospital, Bedford, Massachusetts, USA
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
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Wolfe HL, Boyer TL, Shipherd JC, Kauth MR, Jasuja GK, Blosnich JR. Barriers and Facilitators to Gender-affirming Hormone Therapy in the Veterans Health Administration. Ann Behav Med 2023; 57:1014-1023. [PMID: 37436725 DOI: 10.1093/abm/kaad035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND In 2011, the Veterans Health Administration (VHA) established a policy for the delivery of transition-related services, including gender-affirming hormone therapy (GAHT), for transgender and gender diverse (TGD) patients. In the decade since this policy's implementation, limited research has investigated barriers and facilitators of VHA's provision of this evidence-based therapy that can improve life satisfaction among TGD patients. PURPOSE This study provides a qualitative summary of barriers and facilitators to GAHT at the individual (e.g., knowledge, coping mechanisms), interpersonal (e.g., interactions with other individuals or groups), and structural (e.g., gender norms, policies) levels. METHODS Transgender and gender diverse patients (n = 30) and VHA healthcare providers (n = 22) completed semi-structured, in-depth interviews in 2019 regarding barriers and facilitators to GAHT access and recommendations for overcoming perceived barriers. Two analysts used content analysis to code and analyze transcribed interview data and employed the Sexual and Gender Minority Health Disparities Research Framework to organize themes into multiple levels. RESULTS Facilitators included having GAHT offered through primary care or TGD specialty clinics and knowledgeable providers, with patients adding supportive social networks and self-advocacy. Several barriers were identified, including a lack of providers trained or willing to prescribe GAHT, patient dissatisfaction with prescribing practices, and anticipated or enacted stigma. To overcome barriers, participants recommended increasing provider capacity, providing opportunities for continual education, and enhancing communication around VHA policy and training. CONCLUSIONS Multi-level system improvements within and outside the VHA are needed to ensure equitable and efficient access to GAHT.
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Affiliation(s)
- Hill L Wolfe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT, USA
| | - Taylor L Boyer
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jillian C Shipherd
- Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Health Program, Veterans Health Administration, Washington D.C., USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
| | - Michael R Kauth
- Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Health Program, Veterans Health Administration, Washington D.C., USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA 02118, USA
| | - John R Blosnich
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
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7
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Dinesh D, Shao Q, Palnati M, McDannold S, Zhang Q, Monfared AAT, Jasuja GK, Davila H, Xia W, Moo LR, Miller DR, Palacios N. The epidemiology of mild cognitive impairment, Alzheimer's disease and related dementia in U.S. veterans. Alzheimers Dement 2023; 19:3977-3984. [PMID: 37114952 DOI: 10.1002/alz.13071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/25/2022] [Accepted: 11/10/2022] [Indexed: 04/29/2023]
Abstract
INTRODUCTION US veterans have a unique dementia risk profile that may be evolving over time. METHODS Age-standardized incidence and prevalence of Alzheimer's disease (AD), AD and related dementias (ADRD), and mild cognitive impairment (MCI) was estimated from electronic health records (EHR) data for all veterans aged 50 years and older receiving Veterans Health Administration (VHA) care from 2000 to 2019. RESULTS The annual prevalence and incidence of AD declined, as did ADRD incidence. ADRD prevalence increased from 1.07% in 2000 to 1.50% in 2019, primarily due to an increase in the prevalence of dementia not otherwise specified. The prevalence and incidence of MCI increased sharply, especially after 2010. The prevalence and incidence of AD, ADRD, and MCI were highest in the oldest veterans, in female veterans, and in African American and Hispanic veterans. DISCUSSION We observed 20-year trends of declining prevalence and incidence of AD, increasing prevalence of ADRD, and sharply increasing prevalence and incidence of MCI.
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Affiliation(s)
- Deepika Dinesh
- Department of Public Health, University of Massachusetts at Lowell, Zuckerberg College of Health Sciences, Lowell, Massachusetts, USA
- Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, Massachusetts, USA
| | - Qing Shao
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
| | - Madhuri Palnati
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
| | - Sarah McDannold
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
| | - Quanwu Zhang
- Easai Inc., Neurology Business Group, Woodcliff Lake, New Jersey, USA
| | - Amir Abbas Tahami Monfared
- Easai Inc., Neurology Business Group, Woodcliff Lake, New Jersey, USA
- McGill University, Epidemiology, Biostatistics, and Occupational Health, Montreal, Quebec, Canada
| | - Guneet K Jasuja
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Heather Davila
- Center for Access & Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa, USA
- General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Weiming Xia
- Bedford VA Healthcare System, Geriatric Research and Education Clinical Center, Bedford, Massachusetts, USA
- Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lauren R Moo
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
- Bedford VA Healthcare System, Geriatric Research and Education Clinical Center, Bedford, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Donald R Miller
- Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, Massachusetts, USA
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
| | - Natalia Palacios
- Department of Public Health, University of Massachusetts at Lowell, Zuckerberg College of Health Sciences, Lowell, Massachusetts, USA
- Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, Massachusetts, USA
- Bedford VA Healthcare System, Geriatric Research and Education Clinical Center, Bedford, Massachusetts, USA
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8
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Borzecki AM, Conti J, Reisman JI, Vimalananda V, Nagy MW, Paluri R, Linsky AM, McCullough M, Bhasin S, Matsumoto AM, Jasuja GK. Development and Validation of Quality Measures for Testosterone Prescribing. J Endocr Soc 2023; 7:bvad075. [PMID: 37362384 PMCID: PMC10289518 DOI: 10.1210/jendso/bvad075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Indexed: 06/28/2023] Open
Abstract
Context Accurate measures to assess appropriateness of testosterone prescribing are needed to improve prescribing practices. Objective This work aimed to develop and validate quality measures around the initiation and monitoring of testosterone prescribing. Methods This retrospective cohort study comprised a national cohort of male patients receiving care in the Veterans Health Administration who initiated testosterone during January or February 2020. Using laboratory data and diagnostic codes, we developed 9 initiation and 7 monitoring measures. These were based on the current Endocrine Society guidelines supplemented by expert opinion and prior work. We chose measures that could be operationalized using national VA electronic health record (EHR) data. We assessed criterion validity for these 16 measures by manual review of 142 charts. Main outcome measures included positive and negative predictive values (PPVs, NPVs), overall accuracy (OA), and Matthews Correlation Coefficients (MCCs). Results We found high PPVs (>78%), NPVs (>98%), OA (≥94%), and MCCs (>0.85) for the 10 measures based on laboratory data (5 initiation and 5 monitoring). For the 6 measures relying on diagnostic codes, we similarly found high NPVs (100%) and OAs (≥98%). However, PPVs for measures of acute conditions occurring before testosterone initiation (ie, acute myocardial infarction or stroke) or new conditions occurring after initiation (ie, prostate or breast cancer) PPVs were much lower (0% to 50%) due to few or no cases. Conclusion We developed several valid EHR-based quality measures for assessing testosterone-prescribing practices. Deployment of these measures in health care systems can facilitate identification of quality gaps in testosterone-prescribing and improve care of men with hypogonadism.
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Affiliation(s)
- Ann M Borzecki
- Correspondence: Ann M. Borzecki, MD, MPH, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Rd, Bedford, MA 01730, USA.
| | - Jennifer Conti
- Center for Healthcare Organization & Implementation Research, Bedford Site, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Joel I Reisman
- Center for Healthcare Organization & Implementation Research, Bedford Site, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Varsha Vimalananda
- Center for Healthcare Organization & Implementation Research, Bedford Site, VA Bedford Healthcare System, Bedford, MA 01730, USA
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University School of Medicine, Boston, MA 02118, USA
| | - Michael W Nagy
- Clinical Sciences Department, Medical College of Wisconsin, School of Pharmacy, Milwaukee, WI 53226, USA
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI 53295, USA
| | | | - Amy M Linsky
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
- Center for Healthcare Organization & Implementation Research, Boston Site, VA Boston Healthcare System, Boston, MA 02130, USA
| | - Megan McCullough
- Center for Healthcare Organization & Implementation Research, Bedford Site, VA Bedford Healthcare System, Bedford, MA 01730, USA
- Department of Public Health, University of Massachusetts Lowell, Lowell, MA 01854, USA
| | - Shalender Bhasin
- Research Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Alvin M Matsumoto
- Geriatric Research, Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA 98108, USA
- Division of Gerontology & Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization & Implementation Research, Bedford Site, VA Bedford Healthcare System, Bedford, MA 01730, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA 02118, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
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9
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Streed CG, King D, Grasso C, Reisner SL, Mayer KH, Jasuja GK, Poteat T, Mukherjee M, Shapira-Daniels A, Cabral H, Tangpricha V, Paasche-Orlow MK, Benjamin EJ. Validation of an administrative algorithm for transgender and gender diverse persons against self-report data in electronic health records. J Am Med Inform Assoc 2023; 30:1047-1055. [PMID: 36921287 PMCID: PMC10198536 DOI: 10.1093/jamia/ocad039] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 02/19/2023] [Accepted: 02/25/2023] [Indexed: 03/17/2023] Open
Abstract
OBJECTIVE To adapt and validate an algorithm to ascertain transgender and gender diverse (TGD) patients within electronic health record (EHR) data. METHODS Using a previously unvalidated algorithm of identifying TGD persons within administrative claims data in a multistep, hierarchical process, we validated this algorithm in an EHR data set with self-reported gender identity. RESULTS Within an EHR data set of 52 746 adults with self-reported gender identity (gold standard) a previously unvalidated algorithm to identify TGD persons via TGD-related diagnosis and procedure codes, and gender-affirming hormone therapy prescription data had a sensitivity of 87.3% (95% confidence interval [CI] 86.4-88.2), specificity of 98.7% (95% CI 98.6-98.8), positive predictive value (PPV) of 88.7% (95% CI 87.9-89.4), and negative predictive value (NPV) of 98.5% (95% CI 98.4-98.6). The area under the curve (AUC) was 0.930 (95% CI 0.925-0.935). Steps to further categorize patients as presumably TGD men versus women based on prescription data performed well: sensitivity of 97.6%, specificity of 92.7%, PPV of 93.2%, and NPV of 97.4%. The AUC was 0.95 (95% CI 0.94-0.96). CONCLUSIONS In the absence of self-reported gender identity data, an algorithm to identify TGD patients in administrative data using TGD-related diagnosis and procedure codes, and gender-affirming hormone prescriptions performs well.
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Affiliation(s)
- Carl G Streed
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
- Center for Transgender Medicine and Surgery, Boston Medical Center, Boston, Massachusetts, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Dana King
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Chris Grasso
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Sari L Reisner
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Guneet K Jasuja
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Howard Cabral
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Emelia J Benjamin
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
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10
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Rose AJ, Hughto JM, Dunbar MS, Quinn EK, Deutsch M, Feldman J, Radix A, Safer JD, Shipherd JC, Thompson J, Jasuja GK. Trends in Feminizing Hormone Therapy for Transgender Patients, 2006-2017. Transgend Health 2023; 8:188-194. [PMID: 37013092 PMCID: PMC10066771 DOI: 10.1089/trgh.2021.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Combination therapy with estrogen and spironolactone may help some transgender women achieve desired results. We used two databases, OptumLabs® Data Warehouse (OLDW) and Veterans Health Administration (VHA), to examine trends in feminizing therapy. We included 3368 transgender patients from OLDW and 3527 from VHA, all of whom received estrogen, spironolactone, or both between 2006 and 2017. In OLDW, the proportion receiving combination therapy increased from 47% to 75% during this period. Similarly, in VHA, the proportion increased from 39% to 69% during this period. We conclude that the use of combination hormone therapy has become much more common over the past decade.
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Affiliation(s)
- Adam J. Rose
- Hebrew University School of Public Health, Jerusalem, Israel
| | - Jaclyn M.W. Hughto
- Brown University School of Public Health, Providence, Rhode Island, USA
- Fenway Health, Boston, Massachusetts, USA
| | | | - Emily K. Quinn
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Madeline Deutsch
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Jamie Feldman
- University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Asa Radix
- Callen-Lorde Community Health Center, New York, New York, USA
| | - Joshua D. Safer
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jillian C. Shipherd
- Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning (LGBTQ+) Health Program, Veterans Health Administration, Washington, District of Columbia, USA
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Guneet K. Jasuja
- Boston University School of Medicine, Boston, Massachusetts, USA
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Memorial Veterans Hospital, Bedford VA Medical Center, Bedford, Massachusetts, USA
- OptumLabs Visiting Scholar, OptumLabs, Eden Prairie, Minnesota, USA
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11
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LoBrutto LR, Elwy AR, Miano D, Ann Petrakis B, Kyrish A, Javier S, Erhardt T, Midboe AM, Carbonaro R, Jasuja GK, McInnes DK, Maguire EM, Asch SM, Gifford AL, Clayman ML. Antecedents to COVID-19 vaccine uptake among patients and employees in the Veterans Health Administration. Transl Behav Med 2023; 13:73-84. [PMID: 36448882 DOI: 10.1093/tbm/ibac085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The present study sought to understand the antecedents to COVID-19 vaccination among those reporting a change in vaccine intention in order to improve COVID-19 vaccine uptake in the United States. We employed semi-structured interviews and one focus group discussion with vaccinated and unvaccinated Veterans Health Administration (VHA) employees and Veterans at three Veterans' Affairs medical centers between January and June 2021. A subset of these participants (n=21) self-reported a change in COVID-19 vaccine intention and were selected for additional analysis. We combined thematic analysis using the 5C scale (confidence, collective responsibility, complacency, calculation, constraints) as our theoretical framework with a constant comparative method from codes based on the SAGE Working Group on Vaccine Hesitancy. We generated 13 themes distributed across the 5C constructs that appeared to be associated with a change in COVID-19 vaccine intention. Themes included a trusted family member, friend or colleague in a healthcare field, a trusted healthcare professional, distrust of government or politics (confidence); duty to family and protection of others (collective responsibility); perceived health status and normative beliefs (complacency); perceived vaccine safety, perceived risk-benefit, and orientation towards deliberation (calculation); and ease of process (constraints). Key factors in promoting vaccine uptake included a desire to protect family; and conversations with as key factors in promoting vaccine uptake. Constructs from the 5C scale are useful in understanding intrapersonal changes in vaccine intentions over time, which may help public health practitioners improve future vaccine uptake.
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Affiliation(s)
- Lara R LoBrutto
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, MA 02130, USA
| | - A Rani Elwy
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA.,Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI 02912, USA
| | - Danielle Miano
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Beth Ann Petrakis
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Angela Kyrish
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Sarah Javier
- Bridge QUERI Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA.,Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Taryn Erhardt
- Bridge QUERI Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
| | - Amanda M Midboe
- Bridge QUERI Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA.,Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Richard Carbonaro
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Guneet K Jasuja
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - D Keith McInnes
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA 02118, USA
| | - Elizabeth M Maguire
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Steven M Asch
- Bridge QUERI Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA.,Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Allen L Gifford
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, MA 02130, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA 02118, USA
| | - Marla L Clayman
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Chan School of Medicine, Worcester, MA 01655, USA
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12
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Jasuja GK, Reisman JI, Rao SR, Wolfe HL, Hughto JMW, Reisner SL, Shipherd JC. Social Stressors and Health Among Older Transgender and Gender Diverse Veterans. LGBT Health 2023; 10:148-157. [PMID: 36454239 PMCID: PMC10081710 DOI: 10.1089/lgbt.2022.0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Purpose: Health disparities in transgender and gender diverse (TGD) veterans compared with cisgender veterans have been documented. However, there is a paucity of literature focused on older TGD veterans. We assessed health conditions and social stressors in older TGD veterans compared with matched cisgender veterans. Methods: Using gender identity disorder diagnosis codes, we identified 1244 TGD veterans (65+ years of age) receiving care in the Veterans Health Administration (VHA) from 2006 to 2018. These TGD veterans were then matched to 3732 cisgender veterans based on age, VHA site, and date of care in VHA. Results: In adjusted models, TGD veterans compared with cisgender veterans were less likely to have alcohol use disorder (adjusted odds ratio [AOR; 95% confidence interval]: [0.70; 0.58-0.85]), drug use disorder (0.59; 0.47-0.74), tobacco use (0.75; 0.65-0.86), and anxiety (0.74; 0.62-0.90). However, compared with cisgender veterans, TGD veterans were more likely to experience depression (1.63; 1.39-1.93), Alzheimer's disease (8.95; 4.25-18.83), cancer (1.83; 1.56-2.14), violence (1.82; 1.14-2.91), social/familial problems (2.45; 1.99-3.02), lack of access to care/transportation (2.23; 1.48-3.37), and military sexual trauma (2.59; 1.93-3.46). Furthermore, compared with cisgender veterans, TGD veterans were more likely to have documentation of a higher count of social stressors: 1 or more stressors (1.64; 1.38-1.95) and 2 or more stressors (1.22; 1.01-1.49). Conclusion: Despite significant disparities in social stressors and health conditions compared with cisgender veterans, TGD veterans had a lower likelihood of substance use and anxiety. Interventions are needed to mitigate social stressors and improve health among the older TGD veteran population.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Joel I Reisman
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
| | - Sowmya R Rao
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Hill L Wolfe
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jaclyn M W Hughto
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Health Promotion and Health Equity, Brown University, Providence, Rhode Island, USA.,The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Sari L Reisner
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA.,General Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jillian C Shipherd
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA.,LGBTQ+ Health Program, Office of Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
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13
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Engle RL, Bokhour BG, Rose AJ, Reisman JI, Jasuja GK. Characterizing patient attitudes and beliefs towards testosterone therapy in Veterans Affairs: A qualitative study. Patient Educ Couns 2023; 106:201-207. [PMID: 36253229 DOI: 10.1016/j.pec.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/28/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE We examined patient attitudes and beliefs and provider perspectives on patients' attitudes and beliefs towards testosterone therapy in Veterans Affairs (VA). METHODS We used a thematic analysis approach to understand variation in patient attitudes and beliefs towards testosterone at six VA sites with high and low levels of testosterone prescribing in VA. Semi-structured phone interviews with 18 patients and 22 providers at these sites were transcribed and coded using a priori theoretical constructs and emergent themes. A cross-case matrix of coded data was used to evaluate themes related to patient-level factors. RESULTS Patients' beliefs toward testosterone did not differ across sites. Patients, not providers, generally initiated conversations about testosterone. We identified five key domains related to patient beliefs and provider perceived patient beliefs towards testosterone: reasons for initiating testosterone, patient information sources and expectations about testosterone, receptivity towards discontinuation of testosterone, patient/provider engagement in information sharing, and self-advocacy by the patients in decision-making. CONCLUSIONS Patient factors play an important role in testosterone prescribing decisions. PRACTICE IMPLICATIONS By considering these patient factors, providers can potentially help create a partnership with patients and foster shared decision-making for testosterone and other, similar medications.
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Affiliation(s)
- Ryann L Engle
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA; Department of Population and Quantitative Health Sciences, University of Massachusetts Chan School of Medicine, Worcester, MA, USA.
| | - Adam J Rose
- Hebrew University School of Public Health, Jerusalem, Israel.
| | - Joel I Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA.
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA; Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
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14
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Dolsen EA, Byers AL, Flentje A, Goulet JL, Jasuja GK, Lynch KE, Maguen S, Neylan TC. Sleep disturbance and suicide risk among sexual and gender minority people. Neurobiol Stress 2022; 21:100488. [PMID: 36164391 PMCID: PMC9508603 DOI: 10.1016/j.ynstr.2022.100488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/01/2022] Open
Abstract
Sleep disturbance has emerged as an independent, mechanistic, and modifiable risk factor for suicide. Sexual and gender minority (SGM) people disproportionately experience sleep disturbance and are at higher risk of death by suicide relative to cisgender and/or heterosexual individuals. The present narrative review evaluates nascent research related to sleep disturbance and suicide-related thoughts and behaviors (STBs) among SGM populations, and discusses how experiences of minority stress may explain heightened risk among SGM people. Although there is a growing understanding of the link between sleep disturbance and STBs, most research has not been conducted in SGM populations or has not examined suicide as an outcome. Research is needed to examine whether and how aspects of sleep disturbances relate to STBs among SGM people in order to better tailor sleep treatments for SGM populations.
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Affiliation(s)
- Emily A Dolsen
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.,Mental Illness Research Education and Clinical Centers, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Amy L Byers
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.,Research Service, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,Department of Medicine, Division of Geriatrics, University of California, San Francisco, CA, USA
| | - Annesa Flentje
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, CA, USA.,Alliance Health Project, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of California, San Francisco, USA
| | - Joseph L Goulet
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, West Haven, CT, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Kristine E Lynch
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, Salt Lake City, UT, USA
| | - Shira Maguen
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.,Mental Illness Research Education and Clinical Centers, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Thomas C Neylan
- Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.,Mental Illness Research Education and Clinical Centers, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
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15
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Gibson CJ, Li Y, Jasuja GK, Keyhani S, Byers AL. Long-term Psychoactive Medications, Polypharmacy, and Risk of Suicide and Unintended Overdose Death Among Midlife and Older Women Veterans. J Gen Intern Med 2022; 37:770-777. [PMID: 36042093 PMCID: PMC9481785 DOI: 10.1007/s11606-022-07592-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rates of suicide and unintended overdose death are high among midlife and older women, yet there is paucity of data identifying women at greatest risk. Psychoactive medications, commonly prescribed and co-prescribed in this population, may serve as salient indicators of risk for these outcomes. OBJECTIVE To determine whether long-term psychoactive medications and psychoactive polypharmacy predict risk of suicide and unintended overdose death among midlife and older women Veterans above and beyond other recognized factors. DESIGN Longitudinal cohort study PARTICIPANTS: Women Veterans aged ≥ 50 with at least one Veterans Health Administration (VHA) clinical encounter in FY2012-2013. MAIN MEASURES Long-term psychoactive medications (opioids, benzodiazepines, sedative-hypnotics, antidepressants, antipsychotics, and antiepileptics, prescribed for ≥ 90/180 days) and psychoactive polypharmacy (overlapping for ≥ 1 day) from VHA pharmacy records; suicide and unintended overdose death through December 31, 2018. KEY RESULTS In this national sample of 154,558 midlife and older women Veterans (mean age 63.4, SD 9.3 years), 130 died by suicide and 175 died from unintentional overdose over an average of 5.6 years. In fully adjusted models, long-term opioids (hazard ratio (HR) 2.01, 95% CI 1.21-3.35) and benzodiazepines (HR 2.99, 95% CI 1.82-4.91) were associated with death by suicide; opioids (HR 3.62, 95% CI 2.46-5.34), benzodiazepines (HR 2.77, 95% CI 1.73-4.42), sedative-hypnotics (HR 1.87, 95% CI 1.06-3.29), antidepressants (HR 1.47, 95% CI 1.03-2.12), antipsychotics (HR 1.81, 95% CI 1.02-3.22), and antiepileptics (HR 2.17, 95% CI 1.48-3.19) were associated with unintended overdose death. Women who were co-prescribed ≥ 3 psychoactive medications had over 2-fold increased risk of suicide (HR 2.83, 95% CI 1.65-4.84) and unintended overdose death (HR 2.60, 95% CI 1.72-3.94). CONCLUSIONS Long-term psychoactive medications and psychoactive medication polypharmacy were important indicators of risk for death by suicide and death by unintended overdose among midlife and older women Veterans, even after accounting for psychiatric and substance use disorders.
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Affiliation(s)
- Carolyn J Gibson
- San Francisco VA Health Care System, 4150 Clement Street, 116P, San Francisco, CA, 94121, USA.
- University of California, San Francisco, San Francisco, USA.
| | - Yixia Li
- NCIRE-The Veterans Health Research Institute, San Francisco, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford, USA
- Boston University School of Medicine, Boston, USA
| | - Salomeh Keyhani
- San Francisco VA Health Care System, 4150 Clement Street, 116P, San Francisco, CA, 94121, USA
- University of California, San Francisco, San Francisco, USA
| | - Amy L Byers
- San Francisco VA Health Care System, 4150 Clement Street, 116P, San Francisco, CA, 94121, USA
- University of California, San Francisco, San Francisco, USA
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16
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Dunbar MS, Hughto JMW, Jasuja GK, Quinn EK, Deutsch M, Radix A, Feldman J, Abbott J, Safer JD, Thompson J, Rose AJ. Considering Quality Measures for the Care of Transgender Patients: Preliminary Findings from a Technical Expert Panel. LGBT Health 2022; 9:264-275. [PMID: 35363052 DOI: 10.1089/lgbt.2021.0279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Transgender (TG) individuals are a historically understudied and underserved patient population. Although clinical guidelines for the care of TG patients exist, quality measures (QMs) specific to this population are lacking. The goal of this study was to obtain expert input on aspects of care for which quality measurement may be appropriate and describe feedback on candidate QMs. Methods: We convened a virtual technical expert panel in September 2020 with six experts in TG medical care. Experts participated in a guided discussion and provided numeric ratings on dimensions of measure suitability (importance, validity/reliability, feasibility, and ease of understanding) for eight candidate QMs spanning multiple care domains (e.g., laboratory testing/monitoring, cancer screening, and sexually transmitted infection screening). Results: Panelists acknowledged high importance and potential to improve care for some candidate QMs, particularly those related to laboratory testing before initiating and during hormone therapy. Numeric ratings of QMs varied but tended to be higher for testing-focused QMs. Experts raised concerns about overly prescriptive language for some QMs and emphasized the importance of considering more flexible specifications to accommodate diverse care scenarios-including care provided to nonbinary individuals-and align with the individualized nature of gender-affirming care. Conclusion: These preliminary findings support a potential role for QMs in improving quality of care for TG patients. Measures related to laboratory testing/monitoring for patients who receive or plan to initiate hormone therapy may be feasible and promising to explore in the future. Additional larger-scale efforts are needed to develop and test QMs for the care of TG individuals.
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Affiliation(s)
- Michael S Dunbar
- Health Care Division, RAND Corporation, Pittsburgh, Pennsylvania, USA
| | - Jaclyn M W Hughto
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Health Promotion and Health Equity, Brown University, Providence, Rhode Island, USA.,The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Memorial Veterans Hospital, Bedford VA Medical Center, Bedford, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Emily K Quinn
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Madeline Deutsch
- UCSF Transgender Care, University of California, San Francisco, San Francisco, California, USA.,Department of Family & Community Medicine, UCSF School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Asa Radix
- Callen-Lorde Community Health Center, New York, New York, USA
| | - Jamie Feldman
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer Abbott
- Western North Carolina Community Health Services, Asheville, North Carolina, USA
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Adam J Rose
- Department of Health Policy, School of Public Health, Hebrew University, Jerusalem, Israel.,OptumLabs, Eden Prairie, Minnesota, USA
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17
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Elwy A, Clayman ML, LoBrutto L, Miano D, Ann Petrakis B, Javier S, Erhardt T, Midboe AM, Carbonaro R, Jasuja GK, Maguire EM, Kyrish A, Asch SM, Gifford AL, McInnes DK. Vaccine hesitancy as an opportunity for engagement: A rapid qualitative study of patients and employees in the U.S. Veterans Affairs healthcare system. Vaccine X 2021; 9:100116. [PMID: 34580652 PMCID: PMC8457639 DOI: 10.1016/j.jvacx.2021.100116] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/06/2021] [Accepted: 09/19/2021] [Indexed: 12/01/2022] Open
Abstract
Although COVID-19 vaccines have been available to many U.S. Veterans Affairs (VA) healthcare system employees and Veteran patients since early 2021, vaccine receipt data indicates some groups are not receiving them. Our objective was to conduct a rapid qualitative assessment of Veterans' and VA employees' views on COVID-19 vaccination to inform clinical leaders' ongoing efforts to increase vaccine uptake across the VA. We employed semi-structured interviews and a focus group involving employees and Veterans as part of a quality improvement project between January and June 2021 at three VA medical centers. Thirty-one employees and 27 Veterans participated in semi-structured interviews; 5 Veterans from a national stakeholder organization participated in a focus group. Data were analyzed using directed content analysis, involving an a priori coding framework comprised of four domains with subcodes under each: contextual influences, barriers and facilitators, vaccine-specific issues, and VA/military experiences. We then classified initial codes into five categories of hesitancy: vaccine deliberation, dissent, distrust, indifference and skepticism. A subset of Veterans (n = 14) and employees (n = 8) identified as vaccine hesitant. Vaccine hesitancy categories were represented by subcodes of religion, culture, gender or socio-economic factors, perceptions of politics and policies, role of healthcare providers, and historical influences; (contextual influences); knowledge or awareness of vaccines, perceived susceptibility to COVID-19, and beliefs and attitudes about health and illness (barriers and facilitators); vaccine development process (vaccine-specific issues) and military experiences (VA/military factors). Facilitators involved talking with trusted others, ease of vaccine access, and perceptions of family and societal benefits of vaccines. Vaccine hesitancy is multi-faceted and likely requires multiple strategies for engaging in conversations to address Veteran and VA employee concerns. Messages should involve patient-centered communication strategies delivered by trusted healthcare providers and peers and should focus on addressing expected benefits for family, friends, and society.
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Affiliation(s)
- A.Rani Elwy
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI 02912, USA
| | - Marla L. Clayman
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Lara LoBrutto
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, MA 02130, USA
| | - Danielle Miano
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Beth Ann Petrakis
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Sarah Javier
- Bridge QUERI Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Taryn Erhardt
- Bridge QUERI Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
| | - Amanda M. Midboe
- Bridge QUERI Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Richard Carbonaro
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Guneet K. Jasuja
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Elizabeth M. Maguire
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Angela Kyrish
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
| | - Steven M. Asch
- Bridge QUERI Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Allen L. Gifford
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, MA 02130, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA 02118, USA
| | - D. Keith McInnes
- Bridge QUERI Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA 01730, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA 02118, USA
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18
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Jasuja GK, Meterko M, Bradshaw LD, Carbonaro R, Clayman ML, LoBrutto L, Miano D, Maguire EM, Midboe AM, Asch SM, Gifford AL, McInnes DK, Elwy AR. Attitudes and Intentions of US Veterans Regarding COVID-19 Vaccination. JAMA Netw Open 2021; 4:e2132548. [PMID: 34730819 PMCID: PMC8567110 DOI: 10.1001/jamanetworkopen.2021.32548] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/02/2021] [Indexed: 12/11/2022] Open
Abstract
Importance Compared with the general population, veterans are at high risk for COVID-19 and have a complex relationship with the government. This potentially affects their attitudes toward receiving COVID-19 vaccines. Objective To assess veterans' attitudes toward and intentions to receive COVID-19 vaccines. Design, Setting, and Participants This cross-sectional web-based survey study used data from the Department of Veterans Affairs (VA) Survey of Healthcare Experiences of Patients' Veterans Insight Panel, fielded between March 12 and 28, 2021. Of 3420 veterans who were sent a link to complete a 58-item web-based survey, 1178 veterans (34%) completed the survey. Data were analyzed from April 1 to August 25, 2021. Exposures Veterans eligible for COVID-19 vaccines. Main Outcomes and Measures The outcomes of interest were veterans' experiences with COVID-19, vaccination status and intention groups, reasons for receiving or not receiving a vaccine, self-reported health status, and trusted and preferred sources of information about COVID-19 vaccines. Reasons for not getting vaccinated were classified into categories of vaccine deliberation, dissent, distrust, indifference, skepticism, and policy and processes. Results Among 1178 respondents, 974 (83%) were men, 130 (11%) were women, and 141 (12%) were transgender or nonbinary; 58 respondents (5%) were Black, 54 veterans (5%) were Hispanic or Latino, and 987 veterans (84%) were non-Hispanic White. The mean (SD) age of respondents was 66.7 (10.1) years. A total of 817 respondents (71%) self-reported being vaccinated against COVID-19. Of 339 respondents (29%) who were not vaccinated, those unsure of getting vaccinated were more likely to report fair or poor overall health (32 respondents [43%]) and mental health (33 respondents [44%]) than other nonvaccinated groups (overall health: range, 20%-32%; mental health: range, 18%-40%). Top reasons for not being vaccinated were skepticism (120 respondents [36%] were concerned about side effects; 65 respondents [20%] preferred using few medications; 63 respondents [19%] preferred gaining natural immunity), deliberation (74 respondents [22%] preferred to wait because vaccine is new), and distrust (61 respondents [18%] did not trust the health care system). Among respondents who were vaccinated, preventing oneself from getting sick (462 respondents [57%]) and contributing to the end of the COVID-19 pandemic (453 respondents [56%]) were top reasons for getting vaccinated. All veterans reported the VA as 1 of their top trusted sources of information. The proportion of respondents trusting their VA health care practitioner as a source of vaccine information was higher among those unsure about vaccination compared with those who indicated they would definitely not or probably not get vaccinated (18 respondents [26%] vs 15 respondents [15%]). There were no significant associations between vaccine intention groups and age (χ24 = 5.90; P = .21) or gender (χ22 = 3.99; P = .14). Conclusions and Relevance These findings provide information needed to develop trusted messages used in conversations between VA health care practitioners and veterans addressing specific vaccine hesitancy reasons, as well as those in worse health. Conversations need to emphasize societal reasons for getting vaccinated and benefits to one's own health.
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Affiliation(s)
- Guneet K. Jasuja
- Bridge Quality Enhancement Research Initiative Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Mark Meterko
- Office of Analytics and Performance Integration, Survey of Healthcare Experiences of Patients, Veterans Health Administration, Washington, District of Columbia
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Ledjona D. Bradshaw
- Office of Analytics and Performance Integration, Survey of Healthcare Experiences of Patients, Veterans Health Administration, Washington, District of Columbia
| | - Richard Carbonaro
- Bridge Quality Enhancement Research Initiative Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Marla L. Clayman
- Bridge Quality Enhancement Research Initiative Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Lara LoBrutto
- Bridge Quality Enhancement Research Initiative Program, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
| | - Danielle Miano
- Bridge Quality Enhancement Research Initiative Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Elizabeth M. Maguire
- Bridge Quality Enhancement Research Initiative Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Amanda M. Midboe
- Bridge Quality Enhancement Research Initiative Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
| | - Steven M. Asch
- Bridge Quality Enhancement Research Initiative Program, Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Allen L. Gifford
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- Bridge Quality Enhancement Research Initiative Program, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
| | - D. Keith McInnes
- Bridge Quality Enhancement Research Initiative Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - A. Rani Elwy
- Bridge Quality Enhancement Research Initiative Program, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, Rhode Island
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19
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Hashemi L, Zhang Q, Getahun D, Jasuja GK, McCracken C, Pisegna J, Roblin D, Silverberg MJ, Tangpricha V, Vupputuri S, Goodman M. Longitudinal Changes in Liver Enzyme Levels Among Transgender People Receiving Gender Affirming Hormone Therapy. J Sex Med 2021; 18:1662-1675. [PMID: 37057433 PMCID: PMC8444147 DOI: 10.1016/j.jsxm.2021.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/10/2021] [Accepted: 06/18/2021] [Indexed: 01/12/2023]
Abstract
Background: The effect of gender affirming hormone therapy (GAHT) on clinical laboratory parameters, including levels of liver enzymes alanine aminotransferase (ALT) and aspartate transaminase (AST), is an area of uncertainty in transgender health. Aim: We sought to estimate the distribution parameters of liver enzyme levels among transmasculine (TM) and transfeminine (TF) persons receiving GAHT relative to the corresponding measures in cisgender reference groups, and to evaluate longitudinal changes in these laboratory measures following GAHT initiation. Methods: The data for this longitudinal study included 624 TF and 438 transmasculine (TM) people as well as 4,090 cisgender males and 4,797 cisgender females enrolled in 3 integrated health systems. Time under observation was divided into 2 intervals: from the first blood test to the date of the first filled GAHT prescription and from GAHT initiation to the most recent ALT or AST measurement. Linear mixed models were used to compare changes in log-transformed ALT and AST values among transgender cohort members before and after GAHT initiation, and relative to the reference groups. The results were expressed as relative differences (in %) and the ratios of these differences (ratios-of-ratios) along with the 95% confidence intervals (CIs). Outcomes: Changes in ALT and AST levels among transgender people over time and relative to the corresponding changes in cisgender referents. Results: Among TM study participants, the post GAHT ratios-of-ratios for AST were 1.61 (95% CI: 1.13, 2.31) and 1.57 (95% CI: 1.06, 2.31) relative to cisgender males and females respectively. For ALT, the corresponding comparisons yielded the ratios-of-ratios (95% CIs) of 2.06 (1.67, 2.54) and 1.90 (1.50, 2.40). No statistically significant changes were observed among TF participants. Other factors associated with higher liver enzyme levels included alcohol use/abuse and obesity. Clinical Implications: TM persons may experience modest increases in ALT and AST concentrations following testosterone initiation; however, clinical significance of the observed association remains unclear and requires further investigation. By contrast, feminizing GAHT is unlikely to induce appreciable changes in liver enzyme levels. Strength and Limitations: The strengths of this study are the longitudinal design and the ability to assemble an unselected cohort nested within large health systems. The main limitations include the lack of information on hormone levels and the inability to take into account GAHT doses and routes of administration. Conclusion: The influence of long-term GAHT on ALT and AST levels appears modest and not likely to reflect clinically meaningful changes in liver function.
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Affiliation(s)
- Leila Hashemi
- VA Greater Los Angeles Healthcare System, Department of General Internal Medicine, Los Angeles, CA, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Qi Zhang
- Rollins School of Public Health, Emory University, Atlanta GA, USA
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Memorial Veterans Hospital, Bedford VA Medical Center, Bedford, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Courtney McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Joseph Pisegna
- VA Greater Los Angeles Healthcare System, Department of General Internal Medicine, Los Angeles, CA, USA; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlanta States, Rockville, MD, USA
| | | | - Vin Tangpricha
- Department of Endocrinology, Emory University, School of Medicine, Atlanta, GA, USA; The Atlanta VA Medical Center, Atlanta, GA, USA
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlanta States, Rockville, MD, USA
| | - Michael Goodman
- Rollins School of Public Health, Emory University, Atlanta GA, USA
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20
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Wong DH, Vimalananda VG, Reisman JI, Rao SR, Shipherd JC, Wolfe HL, Blosnich JR, Livingston NA, Jasuja GK. Patient Characteristics Associated With the Receipt of Hormone Therapy Among Transgender Patients in the Veterans Health Administration. J Endocr Soc 2021. [PMCID: PMC8265843 DOI: 10.1210/jendso/bvab048.1615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: Many transgender patients experience gender dysphoria as a result of an incongruence between their gender identity and sex assigned at birth. Gender-affirming hormone therapy improves the quality of life for transgender patients seeking to increase alignment of their secondary sex characteristics and gender identity. However, little is known about the patient factors that are associated with receipt of this therapy which is critical to identifying areas for improvement in care for transgender patients. Objective: To evaluate patient characteristics associated with transgender patients’ receipt of hormone therapy from the Veterans Health Administration (VHA). Methods: Inpatient and outpatient data were reviewed for transgender patients, identified through ICD-9/ICD-10 diagnosis codes for gender identity disorder (GID), receiving VHA health care from January 2006 to December 2018. We evaluated receipt of hormone therapy (testosterone or estrogen +/- spironolactone) from the VHA, socio-demographics, comorbidities, social stressors, military sexual trauma, and documented suicide attempts. Adjusted Odds Ratios (aOR) and 95% Confidence Intervals (CI) were obtained from a multivariable logistic regression model used to ascertain the relationship between patient characteristics and hormone therapy. Results: Of 9,406 patients with documented GID, 5,487 (58.3%) received hormone therapy from the VHA. Compared to patients not receiving hormone therapy, a higher proportion of patients receiving hormone therapy were younger (21-29 years: 18.1% vs. 11.6%; 30-39 years: 20.0% vs. 14.6%; 40-49 years: 16.2% vs. 13.6%), had documentation of a positive military sexual trauma screening (22.2% vs. 16.2%; p<0.0001), and a suicide attempt (11.4% vs. 9.9%; p=0.0067). There were significant associations between receipt of hormone therapy and: 1) younger age (aOR: 1.33; 95% CI: 1.29-1.36; p<0.0001); 2) Black non-Hispanic patients (aOR: 0.58; 95% CI: 050-0.68; p<0.0001); 3) increasing number of comorbidities (aOR: 0.86; 95% CI: 0.84-0.88; p<0.0001); and 4) increasing number of social stressors (aOR: 0.86; 95% CI: 0.83-0.90; p<0.0001). Conclusions: Age, race/ethnicity, comorbidities, and social stressors among other factors are associated with receipt of hormone therapy among transgender patients in the VHA. Subsequent efforts should focus on understanding clinician- and site-level determinants to facilitate the design of effective quality improvement measures that optimize gender affirming hormone therapy through VHA for transgender patients.
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Affiliation(s)
- Denise H Wong
- Boston University School of Medicine, Boston, MA, USA
| | | | | | - Sowmya R Rao
- Boston University School of Public Health, Boston, MA, USA
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21
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Wolfe HL, Reisman JI, Yoon SS, Blosnich JR, Shipherd JC, Vimalananda VG, Rao SR, Hashemi L, Berlowitz D, Goodman M, Livingston NA, Reece SG, Jasuja GK. Validating Data-driven Methods to Identify Transgender Individuals in the Veterans Affairs. Am J Epidemiol 2021; 190:1928-1934. [PMID: 33843970 DOI: 10.1093/aje/kwab102] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 12/28/2022] Open
Abstract
We sought to operationalize and validate data-driven approaches to identify transgender individuals in the U.S. Department of Veteran Affairs (VA) health care system through a retrospective analysis using VA administrative data from 2006 to 2018. Besides gender identity disorder (GID) diagnoses, a combination of non-GID data elements were used to identify potential transgender veterans, including: 1) endocrine disorder, unspecified or not otherwise specified codes, 2) receipt of sex hormones not associated with the sex documented in the veteran's records (gender-affirming hormone therapy), and 3) change in the administratively recorded sex. Both GID and non-GID data elements were applied to a sample of 13,233,529 veterans utilizing the VA healthcare system between January 2006 and December 2018. We identified 10,769 potential transgender veterans. Based on a high positive predictive value of GID (83%, 95% Confidence Interval (CI)=77-89%) versus non-GID-coded veterans (2%, 95% CI=1-11%) from chart review validation, the final analytical sample comprised of only veterans with a GID diagnosis code (n=9,608). In the absence of self-identified gender identity, findings suggest that relying entirely on GID diagnosis codes are the most reliable approach to identify transgender individuals in the VA.
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22
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Jasuja GK, Bettano A, Smelson D, Bernson D, Rose AJ, Byrne T, Berlowitz DR, McCullough MB, Miller DR. Homelessness and Veteran Status in Relation to Nonfatal and Fatal Opioid Overdose in Massachusetts. Med Care 2021; 59:S165-S169. [PMID: 33710090 DOI: 10.1097/mlr.0000000000001437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Compared with non-Veterans, Veterans are at higher risk of experiencing homelessness, which is associated with opioid overdose. OBJECTIVE To understand how homelessness and Veteran status are related to risks of nonfatal and fatal opioid overdose in Massachusetts. DESIGN A cross-sectional study. PARTICIPANTS All residents aged 18 years and older during 2011-2015 in the Massachusetts Department of Public Health's Data Warehouse (Veterans: n=144,263; non-Veterans: n=6,112,340). A total of 40,036 individuals had a record of homelessness, including 1307 Veterans and 38,729 non-Veterans. MAIN MEASURES The main independent variables were homelessness and Veteran status. Outcomes included nonfatal and fatal opioid overdose. RESULTS A higher proportion of Veterans with a record of homelessness were older than 45 years (77% vs. 48%), male (80% vs. 62%), or receiving high-dose opioid therapy (23% vs. 15%) compared with non-Veterans. The rates of nonfatal and fatal opioid overdose in Massachusetts were 85 and 16 per 100,000 residents, respectively. Among individuals with a record of homelessness, these rates increased 31-fold to 2609 and 19-fold to 300 per 100,000 residents. Homelessness and Veteran status were independently associated with higher odds of nonfatal and fatal opioid overdose. There was a significant interaction between homelessness and Veteran status in their effects on risk of fatal overdose. CONCLUSIONS Both homelessness and Veteran status were associated with a higher risk of fatal opioid overdoses. An understanding of health care utilization patterns can help identify treatment access points to improve patient safety among vulnerable individuals both in the Veteran population and among those experiencing homelessness.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Health Law, Policy and Management, Boston University School of Public Health
| | - Amy Bettano
- Office of Population Health, Department of Public Health, The Commonwealth of Massachusetts, Boston
| | - David Smelson
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Psychiatry, University of Massachusetts Medical School, Worcester
| | - Dana Bernson
- Office of Population Health, Department of Public Health, The Commonwealth of Massachusetts, Boston
| | - Adam J Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine
| | - Thomas Byrne
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Boston University School of Social Work, Boston
| | - Dan R Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Public Health
| | - Megan B McCullough
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Department of Public Health
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford
- Center for Population Health, University of Massachusetts, Lowell, MA
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23
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Rose AJ, Dunbar MS, Hughto JMW, Jasuja GK. Conceptual approach to developing quality measures for transgender patients. BMC Health Serv Res 2021; 21:152. [PMID: 33593361 PMCID: PMC7885225 DOI: 10.1186/s12913-021-06161-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/01/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Valid and reliable quality measures can help catalyze improvements in health care. The care of transgender patients is ripe for quality measurement, as there is increasing awareness of the increasing prevalence of this population and the urgency of improving the health care they receive. While best practices may not exist for some aspects of transgender health care, other aspects are characterized by well-developed and highly evidence-based recommendations. Our objective was to create a list of potential quality measures for transgender care. METHODS AND RESULTS In consultation with our advisory panel, which consisted of clinical and academic experts in transgender medicine, we selected eight prominent clinical practice guidelines of transgender health care for review. Our four team investigators carefully reviewed all eight clinical practice guidelines. Through the course of multiple consensus-building meetings, we iteratively refined items until we had agreed upon a list of forty potential quality measures, all of which met the criteria for quality measures set forth in the Center for Medicare and Medicaid Services Blueprint for developing quality measures. CONCLUSIONS This manuscript explains the origin of the quality measures we developed, and also provides a useful roadmap to any group hoping to develop quality measures for a field that has not previously had any.
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Affiliation(s)
- Adam J Rose
- Hebrew University School of Public Health, Jerusalem, Israel.
| | - Michael S Dunbar
- RAND Corporation, 4750 Fifth Avenue, Suite, Pittsburgh, PA, 600, USA
| | | | - Guneet K Jasuja
- Bedford VA Medical Center, Bedford, MA, USA
- Boston University School of Public Health, Boston, MA, USA
- OptumLabs Visiting Scholar, OptumLabs, Eden Prairie, MN, USA
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Boyer TL, Youk AO, Haas AP, Brown GR, Shipherd JC, Kauth MR, Jasuja GK, Blosnich JR. Suicide, Homicide, and All-Cause Mortality Among Transgender and Cisgender Patients in the Veterans Health Administration. LGBT Health 2021; 8:173-180. [PMID: 33544021 DOI: 10.1089/lgbt.2020.0235] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: This study examines the differences in suicide, homicide, and all-cause mortality between transgender and cisgender Veterans Health Administration (VHA) patients. Methods: VHA electronic medical record data from October 1, 1999 to December 31, 2016 were used to create a sample of transgender and cisgender patients (n = 32,441). Cox proportional hazard regression was used to evaluate differences in survival time (date of birth to death date/study end). Death data were from the National Death Index. Results: Transgender patients had more than twofold greater hazard of suicide than cisgender patients (adjusted hazard ratio [aHR] = 2.77, 95% confidence interval [CI] = 1.88-4.09), especially among younger (18-39 years) (aHR = 3.35, 95% CI = 1.30-8.60) and older (≥65 years) patients (aHR = 9.48, 95% CI = 3.88-23.19). Alternatively, transgender patients had an overall lower hazard of all-cause mortality (aHR = 0.90, 95% CI = 0.84-0.97) compared with cisgender patients, which was driven by patients 40-64 years old (aHR = 0.78, 95% CI = 0.72-0.86) and reversed by those 65 years and older (aHR = 1.17, 95% CI = 1.03-1.33). Conclusion: Transgender patients' hazard of suicide mortality was significantly greater than that of cisgender VHA patients.
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Affiliation(s)
- Taylor L Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ann P Haas
- Department of Health Sciences, Lehman College, City University of New York, Bronx, New York, USA
| | - George R Brown
- Mountain Home VA Medical Center, Johnson City, Tennessee, USA.,Department of Psychiatry and Behavioral Sciences, East Tennessee State University, Johnson City, Tennessee, USA
| | - Jillian C Shipherd
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia, USA.,National Center for Post-traumatic Stress Disorder, VA Boston Healthcare System, Boston, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michael R Kauth
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia, USA.,South Central Mental Illness Research, Education and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Department of Psychiatry, Baylor College of Medicine, Houston, Texas, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers VA Medical Center, Bedford, Massachusetts, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - John R Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
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Abstract
BACKGROUND Among midlife and older women, menopause symptoms and menopausal hormone therapy have been linked to mental health disorders and other comorbidities related to suicide. However, the role of hormone therapy as a prognostic factor of suicide risk is largely unknown. OBJECTIVES To examine associations between menopausal hormone therapy, suicide attempts, and suicide among midlife and older women Veterans. RESEARCH DESIGN In this longitudinal analysis of national Veterans Health Administration data from women Veterans aged 50 years and above, we used Fine-Gray proportional hazards models to examine associations between menopausal hormone therapy (prescribed in 2012-2013) and incident suicide attempts and suicide (index date-2016). MEASURES Menopausal hormone therapy and psychoactive medications from pharmacy records; suicide attempts and suicide from national suicide data repositories; demographic variables, medical and psychiatric diagnoses, and substance use disorders from electronic medical record data and International Classification Diagnoses-9-CM codes. RESULTS In this national sample of 291,709 women Veterans (mean age 60.47, SD 9.81), 6% were prescribed menopausal hormone therapy at baseline. Over an average of 4.5 years, 2673 had an incident suicide attempt (93%) or death by suicide (7%). Adjusting for age, race, and medical diagnoses, menopausal hormone therapy was associated with increased risk of suicide attempt (hazard ratio 1.41; 95% confidence interval, 1.22-1.64) and over 2-fold increased risk of death by suicide (hazard ratio 2.47; 95% confidence interval, 1.58-3.87). Associations with death by suicide remained significant after accounting for psychiatric comorbidity and psychoactive medications. CONCLUSIONS Menopausal hormone therapy may be an important indicator of suicide risk among midlife and older women.
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Affiliation(s)
- Carolyn J. Gibson
- San Francisco VA Health Care System
- Department of Psychiatry, University of California
| | - Yixia Li
- San Francisco VA Health Care System
- NCIRE—The Veterans Health Research Institute, San Francisco, CA
| | - Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center, Bedford
- Boston University School of Public Health, Boston, MA
| | - Kyle J. Self
- San Francisco VA Health Care System
- Department of Psychiatry, University of California
| | - Karen H. Seal
- San Francisco VA Health Care System
- Departments of Medicine and Psychiatry, University of California, San Francisco, CA
| | - Amy L. Byers
- San Francisco VA Health Care System
- Department of Psychiatry, University of California
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Hughto JMW, Quinn EK, Dunbar MS, Rose AJ, Shireman TI, Jasuja GK. Prevalence and Co-occurrence of Alcohol, Nicotine, and Other Substance Use Disorder Diagnoses Among US Transgender and Cisgender Adults. JAMA Netw Open 2021; 4:e2036512. [PMID: 33538824 PMCID: PMC7862992 DOI: 10.1001/jamanetworkopen.2020.36512] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Substance use disorders are a major source of morbidity and mortality in the United States. National data comparing the prevalence of substance use disorder diagnoses (SUDDs) among transgender and cisgender individuals are lacking in the United States. OBJECTIVES To investigate the prevalence of SUDDs among transgender and cisgender adults and to identify within-group and between-group differences by age, gender, and geographic location. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the OptumLabs Data Warehouse to analyze deidentified claims from approximately 74 million adults aged 18 years or older enrolled in commercial or Medicare Advantage insurance plans in 2017. A total of 15 637 transgender adults were identified based on a previously developed algorithm using a combination of International Classification of Diseases, Tenth Revision (ICD-10) transgender-related diagnosis and procedure codes and sex-discordant hormone prescriptions. A cohort of 46 911 cisgender adults was matched to the transgender cohort in a 3:1 ratio based on age and geographic location. MAIN OUTCOMES AND MEASURES SUDDs, based on ICD-10 codes, were assessed overall and compared between transgender and cisgender cohorts and by geographic region (ie, Northeast, Midwest, South, and West); age groups (eg, 18-25, 26-30, 31-35 years), and gender (ie, transfeminine [TF; assigned male sex at birth, identify along feminine gender spectrum], transmasculine [TM; assigned female sex at birth, identify along masculine gender spectrum], male, and female). RESULTS In this study of 15 637 transgender adults (4955 [31.7%] TM) and 46 911 cisgender adults (23 247 [50.4%] men), most (8627 transgender adults [55.2%]; 51 762 cisgender adults [55.2%]) were aged between 18 and 40 years, and 6482 transgender adults (41.5%) and 19 446 cisgender adults (41.5%) lived in the South. Comparing transgender to cisgender groups, significant differences were found in the prevalence of a nicotine (2594 [16.6%] vs 2551 [5.4%]; P < .001), alcohol (401 [2.6%] vs 438 [0.9%]; P < .001), and drug (678 [4.3%] vs 549 [1.2%]; P < .001) SUDDs. Among transgender adults, cannabis was the most prevalent drug SUDD (321 [2.1%]), followed by opioid SUDD (205 [1.3%]) and cocaine SUDD (81 [0.5%]), whereas among cisgender adults, cannabis and opioid SUDDs were equally prevalent (cannabis, 186 [0.4%]; opioid, 207 [0.4%]), followed by cocaine SUDD (59 [0.1%]). CONCLUSIONS AND RELEVANCE In this study, the prevalence of SUDDs was significantly elevated among transgender adults relative to their cisgender peers. These findings underscore the need for culturally tailored clinical interventions to treat substance use disorder in transgender populations.
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Affiliation(s)
- Jaclyn M. W. Hughto
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
- Center for Health Promotion and Health Equity, Brown School of Public Health, Brown University, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Emily K. Quinn
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | | | - Adam J. Rose
- School of Public Health, Hebrew University, Jerusalem, Israel
| | - Theresa I. Shireman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Bedford, Massachusetts
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
- OptumLabs, Eden Prairie, Minnesota
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Jasuja GK, Ameli O, Reisman JI, Rose AJ, Miller DR, Berlowitz DR, Bhasin S. Health Outcomes Among Long-term Opioid Users With Testosterone Prescription in the Veterans Health Administration. JAMA Netw Open 2019; 2:e1917141. [PMID: 31825502 PMCID: PMC6991198 DOI: 10.1001/jamanetworkopen.2019.17141] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Androgen deficiency is common among male opioid users, and opioid use has emerged as a common antecedent of testosterone treatment. The long-term health outcomes associated with testosterone therapy remain unknown, however. OBJECTIVE To compare health outcomes between long-term opioid users with testosterone deficiency who filled testosterone prescriptions and those with the same condition but who did not receive testosterone treatment. DESIGN, SETTING, AND PARTICIPANTS This cohort study focused on men in the care of the Veterans Health Administration (VHA) facilities throughout the United States from October 1, 2008, to September 30, 2014. It included male veterans who were long-term opioid users, had low testosterone levels (<300 ng/dL), and received either a testosterone prescription or any other prescription. It excluded male patients with HIV infection, gender dysphoria, or prostate cancer and those who received testosterone in fiscal year 2008. Data were analyzed from April 1, 2017, to April 30, 2019. EXPOSURE Prescription for testosterone. MAIN OUTCOMES AND MEASURES All-cause mortality and incidence of major adverse cardiovascular events (MACE), vertebral or femoral fractures, and anemia during the 6-year follow-up through September 30, 2015. RESULTS After exclusions, 21 272 long-term opioid users (mean [SD] age, 53 [10] years; n = 16 689 [78.5%] white) with low total or free testosterone levels were included for analysis, of whom 14 121 (66.4%) received testosterone and 7151 (33.6%) did not. At baseline, compared with opioid users who did not receive testosterone, long-term opioid users who received testosterone treatment were more likely to have obesity (43.7% vs 49.0%; P < .001), hyperlipidemia (43.0% vs 48.8%; P < .001), and hypertension (53.9% vs 55.2%; P = .07) but had lower prevalence of coronary artery disease (15.9% vs 12.9%; P < .001) and stroke (2.4% vs 1.3%; P < .001). After adjusting for covariates, opioid users who received testosterone had significantly lower all-cause mortality (hazard ratio [HR] = 0.51; 95% CI, 0.42-0.61) and lower incidence of MACE (HR = 0.58; 95% CI, 0.51-0.67), femoral or hip fractures (HR = 0.68; 95% CI, 0.48-0.96), and anemia (HR = 0.73; 95% CI, 0.68-0.79) during the follow-up period of up to 6 years, compared with their counterparts without a testosterone prescription. In covariate-adjusted models, men who received opioids plus testosterone were more likely to have resolved anemia compared with those who received opioids only during the 6-year follow-up (HR = 1.16; 95% CI, 1.02-1.31). Similar results were obtained in propensity score-matched models and when analyses were restricted to opioid users with noncancer pain or those who did not receive glucocorticoids. CONCLUSIONS AND RELEVANCE This study found that, in the VHA system, male long-term opioid users with testosterone deficiency who were treated with opioid and testosterone medications had significantly lower all-cause mortality and significantly lower incidence of MACE, femoral or hip fractures, and anemia after a multiyear follow-up. These results warrant confirmation through a randomized clinical trial to ascertain the efficacy of testosterone in improving health outcomes for opioid users with androgen deficiency.
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Affiliation(s)
- Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Administration Medical Center, Bedford, Massachusetts
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Omid Ameli
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- OptumLabs, Cambridge, Massachusetts
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Administration Medical Center, Bedford, Massachusetts
| | - Adam J. Rose
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Administration Medical Center, Bedford, Massachusetts
| | - Dan R. Berlowitz
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Administration Medical Center, Bedford, Massachusetts
| | - Shalender Bhasin
- Research Program in Men’s Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Jasuja GK, Engle RL, Skolnik A, Rose AJ, Male A, Reisman JI, Bokhour BG. Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study. J Gen Intern Med 2019; 34:2467-2474. [PMID: 31512188 PMCID: PMC6848590 DOI: 10.1007/s11606-019-05270-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/21/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines. OBJECTIVE We examined system and clinician factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA. DESIGN Qualitative study using a positive deviance approach to understand practice variation in high- and low-testosterone prescribing sites. PARTICIPANTS Twenty-two interview participants included primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high- and 3 low-testosterone prescribing sites. APPROACH Semi-structured phone interviews were conducted, transcribed, and coded using a priori theoretical constructs and emergent themes. Case studies were developed for each site and a cross-case matrix was created to evaluate variation across high- and low-prescribing sites. KEY RESULTS We identified four system-level domains related to variation in testosterone prescribing: organizational structures and processes specific to testosterone prescribing, availability of local guidance on testosterone prescribing, well-defined dissemination process for local testosterone polices, and engagement in best practices related to testosterone prescribing. Two clinician-level domains were also identified, specifically, structured initial testosterone prescribing process and specified follow-up testosterone prescribing process. High- and low-testosterone prescribing sites systematically varied in the four system-level domains, while the clinician-level domains looked similar across all sites. The third high-prescribing site was unusual in that it exhibited the four domains similar to the 3 low-prescribing sites at the time of our visit. This site had greatly reduced its prescribing of testosterone in the interim. CONCLUSIONS Findings suggest that local organizational factors play an important role in influencing prescribing. Sites have the potential to transform their utilization patterns by providing access to specialty care expertise, an electronic health record-based system to facilitate guideline-concordant prescribing, well-defined dissemination processes for information, guidance from multiple sources, and clarity regarding best practices for prescribing.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, Bedford, MA, USA. .,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Ryann L Engle
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Avy Skolnik
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, Bedford, MA, USA
| | - Adam J Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Alexandra Male
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Joel I Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, Bedford, MA, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, Bedford, MA, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Jasuja GK, Reisman JI, Weiner RS, Christopher ML, Rose AJ. Gender differences in prescribing of zolpidem in the Veterans Health Administration. Am J Manag Care 2019; 25:e58-e65. [PMID: 30875172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Use of nonbenzodiazepine sedative hypnotics, especially zolpidem, has grown substantially, raising concerns about safety. Here, we evaluated prescribing patterns of zolpidem in the Veterans Health Administration. STUDY DESIGN A cross-sectional study of veterans receiving zolpidem in the outpatient setting from October 1, 2011, to September 30, 2016. METHODS The study population consisted of 500,332 zolpidem users (58,598 women and 441,734 men) and a random 10% sample (n = 631,449) of nonusers. We examined 2 outcomes related to inappropriate prescribing: high-dose zolpidem prescribing and overlap with benzodiazepines. We generated interrupted time series and logistic regression models to analyze these outcomes in men and women separately. RESULTS In 2016, 29.7% of female veterans received an inappropriately high guideline-discordant dosage compared with 0.1% of male veterans (P <.001 for all reported comparisons). Furthermore, more women than men had overlapping benzodiazepine and zolpidem prescriptions (18.8% vs 14.3%). In fully adjusted models, inappropriately high doses were more commonly received by younger women (adjusted odds ratios [AORs]: 2.75 for 21-39 years and 2.97 for 40-49 years compared with ≥80 years) and women with substance use disorder (AOR, 1.48). In the second inappropriateness outcome models, women with anxiety (AOR, 2.28) or schizophrenia (AOR, 2.05) and men with cancer (AOR, 1.42), anxiety (AOR, 2.66), or schizophrenia (AOR, 2.46) were more likely to receive an overlapping prescription of zolpidem and benzodiazepines. CONCLUSIONS We found evidence of inappropriate zolpidem prescribing among veterans, particularly women. Greater understanding of the drivers of this inappropriate prescribing is necessary to develop interventions to promote safer, more guideline-concordant prescribing.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, 200 Springs Rd, Bedford, MA 01730.
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Jasuja GK, Ameli O, Miller DR, Land T, Bernson D, Rose AJ, Berlowitz DR, Smelson DA. Overdose risk for veterans receiving opioids from multiple sources. Am J Manag Care 2018; 24:536-540. [PMID: 30452210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate whether veterans in Massachusetts receiving opioids and/or benzodiazepines from both Veterans Health Administration (VHA) and non-VHA pharmacies are at higher risk of adverse events compared with those receiving opioids at VHA pharmacies only. STUDY DESIGN A cohort study of veterans who filled a prescription for any Schedule II through V substance at a Massachusetts VHA pharmacy. Prescriptions were recorded in the Massachusetts Department of Public Health Chapter 55 data set. METHODS The study sample included 16,866 veterans residing in Massachusetts, of whom 9238 (54.8%) received controlled substances from VHA pharmacies only and 7628 (45.2%) had filled prescriptions at both VHA and non-VHA pharmacies ("dual care users") between October 1, 2013, and December 31, 2015. Our primary outcomes were nonfatal opioid overdose, fatal opioid overdose, and all-cause mortality. RESULTS Compared with VHA-only users, more dual care users resided in rural areas (12.6% vs 10.6%), received high-dose opioid therapy (26.3% vs 7.3%), had concurrent prescriptions of opioids and benzodiazepines (34.8% vs 8.2%), and had opioid use disorder (6.8% vs 1.6%) (P <.0001 for all). In adjusted models, dual care users had higher odds of nonfatal opioid overdose (odds ratio [OR], 1.29; 95% CI, 0.98-1.71) and all-cause mortality (OR, 1.66; 95% CI, 1.43-1.93) compared with VHA-only users. Dual care use was not associated with fatal opioid overdoses. CONCLUSIONS Among veterans in Massachusetts, receipt of opioids from multiple sources was associated with worse outcomes, specifically nonfatal opioid overdose and mortality. Better information sharing between VHA and non-VHA pharmacies and prescribers has the potential to improve patient safety.
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Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, 200 Springs Rd, Bedford, MA 01730.
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Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Skolnik A, Berlowitz DR, Gifford AL. Use of testosterone in men infected with human immunodeficiency virus in the veterans healthcare system. AIDS Care 2018; 30:1207-1214. [PMID: 29557189 DOI: 10.1080/09540121.2018.1447080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Testosterone supplementation has been widely used in those infected with human immunodeficiency virus (HIV) for hypogonadism, and wasting. But with effective antiretroviral therapy and increasing recognition of atherosclerotic disease and adults infected with HIV, the risks of inappropriate testosterone use in HIV-infected patients are far better recognized than previously. Testosterone use has expanded among U.S. males, but few studies have examined prescribing in those infected with HIV. In a national cohort of males with at least one outpatient prescription in the Veterans Health Administration (VHA), we examined 9475 HIV-infected males, including 2484 who had received testosterone and a randomly selected 6991 who had not. For comparison, we identified 1,387,241 uninfected males (189,369 had received testosterone and a randomly selected 1,197,872 had not). We determined rates of new and prevalent testosterone use, and also examined the adequacy of the diagnostic evaluation that had preceded testosterone initiation among our HIV-infected and uninfected testosterone groups. Our main results were as follows. HIV-infected men had higher rates of initiation (0.8% vs. 0.4% in FY09; p < 0.001) and prevalence of testosterone use (2.2% vs. 0.8% in FY08; p < 0.001) compared to the uninfected men across the entire period. Trends of prescribing for both groups followed a similar pattern, rising from FY08, reaching a peak in FY13, and then dipping in FY 14. Only 1.1% of HIV-infected patients had a fully guideline-concordant workup before starting testosterone therapy, compared to 3.5% of uninfected patients (p < 0.001). In conclusion, testosterone use among HIV-infected patients in the VHA system rose to a peak in FY13 and has decreased somewhat since. Only a small minority of HIV-infected patients who receive testosterone therapy from VHA have undergone an appropriate workup before starting therapy, suggesting an opportunity for improvement.
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Affiliation(s)
- Guneet K Jasuja
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA
| | - Shalender Bhasin
- d Research Program in Men's Health, Aging and Metabolism; Boston Claude D. Pepper Older Americans Independence Center , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
| | - Adam J Rose
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,e Department of Medicine , Section of General Internal Medicine, Boston University School of Medicine , Boston , MA , USA
| | - Joel I Reisman
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA
| | - Avy Skolnik
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA
| | - Dan R Berlowitz
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA
| | - Allen L Gifford
- a Center for Healthcare Organization and Implementation Research (CHOIR) , ENRM VAMC , Bedford , MA , USA.,b VA Boston Healthcare System , Boston , MA , USA.,c Department of Health Law, Policy and Management , Boston University School of Public Health , Boston , MA , USA.,e Department of Medicine , Section of General Internal Medicine, Boston University School of Medicine , Boston , MA , USA
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Rose AJ, McCullough MB, Jasuja GK. A three-step health services research approach to improve prescribing. Healthc (Amst) 2017; 6:135-138. [PMID: 29126852 DOI: 10.1016/j.hjdsi.2017.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 07/27/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
Abstract
Medications are often prescribed suboptimally; some effective medications are underused, some ineffective medications are overused, and some medications that should be received by a few are instead given to many. The underlying causes of suboptimal prescribing likely differ for each medication, and therefore must be understood anew, although previous studies can help generate hypotheses. This perspective sets forth a 3-step research agenda, which has worked well for us in several recently completed and ongoing projects. The three steps are to 1) demonstrate variation in suboptimal prescribing for the targeted medication; 2a) use mixed methods to understand the patient-, provider-, and system-level causes of suboptimal prescribing for this medication; 2b) develop a justification for improving the use of this medication, often involving a business case analysis; and 3) develop and implement interventions to improve prescribing of the targeted medication, informed by what has been learned in Steps 1 and 2 and relying on the principles of implementation science. Previous efforts have focused disproportionately on Step 1, or documenting gaps in practice, and Step 3, or deploying and evaluating efforts to improve practice. Our contention is that addressing all three steps sequentially, while effort-intensive, will maximize the chances of deploying a more effective intervention that will impact population health. We commend this three-step approach to health services researchers who wish to maximize impact by basing their research on a natural progression from documenting problems, to understanding their causes, to formulating and deploying a solution.
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Affiliation(s)
- Adam J Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA.
| | - Megan B McCullough
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA; Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA; Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Jasuja GK, Rose AJ. Who Gets Testosterone? Patient Characteristics Associated with Testosterone Prescribing in the Veteran Affairs System: A Cross-Sectional Study. J Gen Intern Med 2017; 32:1075. [PMID: 28699059 PMCID: PMC5602764 DOI: 10.1007/s11606-017-4113-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford VA Medical Center, 200 Springs Road, Bedford, MA, 01730, USA. .,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Adam J Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
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Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Hanlon JT, Miller DR, Morreale AP, Pogach LM, Cunningham FE, Park A, Wiener RS, Gifford AL, Berlowitz DR. Provider and Site-Level Determinants of Testosterone Prescribing in the Veterans Healthcare System. J Clin Endocrinol Metab 2017; 102:3226-3233. [PMID: 28911150 PMCID: PMC5587071 DOI: 10.1210/jc.2017-00468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023]
Abstract
CONTEXT Testosterone prescribing rates have increased substantially in the past decade. However, little is known about the context within which such prescriptions occur. OBJECTIVE We evaluated provider- and site-level determinants of receipt of testosterone and of guideline-concordant testosterone prescribing. DESIGN This study was cross-sectional in design. SETTING This study was conducted at the Veterans Health Administration (VA). PARTICIPANTS Study participants were a national cohort of male patients who had received at least one outpatient prescription within the VA during fiscal year (FY) 2008 to FY 2012. A total of 38,648 providers and 130 stations were associated with these patients. MAIN OUTCOME MEASURE This study measured receipt of testosterone and guideline-concordant testosterone prescribing. RESULTS Providers ranging in age from 31 to 60 years, with less experience in the VA [all adjusted odds ratio (AOR), <2; P < 0.01] and credentialed as medical doctors in endocrinology (AOR, 3.88; P < 0.01) and urology (AOR, 1.48; P < 0.01) were more likely to prescribe testosterone compared with older providers, providers of longer VA tenure, and primary care providers, respectively. Sites located in the West compared with the Northeast [AOR, 1.75; 95% confidence interval (CI), 1.45-2.11] and care received at a community-based outpatient clinic compared with a medical center (AOR, 1.22; 95% CI, 1.20-1.24) also predicted testosterone use. Although they were more likely to prescribe testosterone, endocrinologists were also more likely to obtain an appropriate workup before prescribing compared with primary care providers (AOR, 2.14; 95% CI, 1.54-2.97). CONCLUSIONS Our results highlight the opportunity to intervene at both the provider and the site levels to improve testosterone prescribing. This study also provides a useful example of how to examine contributions to prescribing variation at different levels of the health care system.
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Affiliation(s)
- Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
| | - Shalender Bhasin
- Research Program in Men’s Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School Boston, Boston, Massachusetts 02115
| | - Adam J. Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Joseph T. Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15213
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Anthony P. Morreale
- Clinical Pharmacy Services and Healthcare Services Research, VA Pharmacy Benefits Management Services VACO, San Diego, California 92161
| | - Leonard M. Pogach
- Department of Veterans Affairs, New Jersey Healthcare System, East Orange, New Jersey 07018
| | | | - Angela Park
- New England Veterans Engineering Resource Center, Boston, Massachusetts 02130
| | - Renda S. Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Medicine, The Pulmonary Center, Boston University, Boston, Massachusetts 02118
| | - Allen L. Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Dan R. Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
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Abstract
PURPOSE OF REVIEW There has been an increase in the prescribing of testosterone therapy in the past decade. There is concern that at least part of this increase is driven by advertising rather than sound medical practice. The purpose of this review is to summarize the recent trends in testosterone prescribing, and to examine whether testosterone is being appropriately prescribed as per guidelines. RECENT FINDINGS Both global and U.S. data reflect an overall increase in the use of testosterone in the last decade, although there are early signs of a decline in testosterone sales since 2014. This increased prescribing has been accompanied with an overall increase in testing for testosterone levels, prescription of testosterone without the appropriate diagnostic evaluation recommended by clinical practice guidelines, and apparent use of this therapy for unproven medical conditions. SUMMARY Research to date suggests that there is room to improve our prescribing of testosterone. Greater understanding of the potential provider-level and system-level factors that contribute to the current prescribing practices may help accomplish such improvement.
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Affiliation(s)
- Guneet K Jasuja
- aCenter for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford. bDepartment of Health Law, Policy and Management, Boston University School of Public Health, Boston cResearch Program in Men's Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School, Boston dRAND Corporation, Boston, MA eDepartment of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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Kim EJ, Ozonoff A, Hylek EM, Berlowitz DR, Ash AS, Miller DR, Zhao S, Reisman JI, Jasuja GK, Rose AJ. Predicting outcomes among patients with atrial fibrillation and heart failure receiving anticoagulation with warfarin. Thromb Haemost 2015; 114:70-7. [PMID: 25948532 DOI: 10.1160/th14-09-0754] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 02/20/2015] [Indexed: 01/07/2023]
Abstract
Among patients receiving oral anticoagulation for atrial fibrillation (AF), heart failure (HF) is associated with poor anticoagulation control. However, it is not known which patients with heart failure are at greatest risk of adverse outcomes. We evaluated 62,156 Veterans Health Administration (VA) patients receiving warfarin for AF between 10/1/06-9/30/08 using merged VA-Medicare dataset. We predicted time in therapeutic range (TTR) and rates of adverse events by categorising patients into those with 0, 1, 2, or 3+ of five putative markers of HF severity such as aspartate aminotransferase (AST)> 80 U/l, alkaline phosphatase> 150 U/l, serum sodium< 130 mEq/l, any receipt of metolazone, and any inpatient admission for HF exacerbation. These risk categories predicted TTR: patients without HF (referent) had a mean TTR of 65.0 %, while HF patients with 0, 1, 2, 3 or more markers had mean TTRs of 62.2 %, 57.2 %, 53.5 %, and 50.7 %, respectively (p< 0.001). These categories also discriminated for major haemorrhage well; compared to patients without HF, HF patients with increasing severity had hazard ratios of 1.84, 3.06, 3.52 and 5.14 respectively (p< 0.001). However, although patients with HF had an elevated hazard for bleeding compared to those without HF, these categories did not effectively discriminate risk of ischaemic stroke across HF. In conclusion, we developed a HF severity model using easily available clinical characteristics that performed well to risk-stratify patients with HF who are receiving anticoagulation for AF with regard to major haemorrhage.
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Affiliation(s)
- Eun-Jeong Kim
- Eun-Jeong Kim, MD, Hospital Medicine Group, Division of General Internal Medicine, Massachusetts General Hospital, 55 Fruit Street Bulfinch 015, Boston, MA 02114, USA, Tel.: +1 617 724 3874, Fax: +1 617 643 1384, E-mail:
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Affiliation(s)
- Zayd Razouki
- From the Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA (Z.R., A.O., S.Z., G.K.J., A.J.R.); Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA (Z.R., A.J.R.); and Biostatistics Section, Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, MA (A.O.)
| | - Al Ozonoff
- From the Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA (Z.R., A.O., S.Z., G.K.J., A.J.R.); Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA (Z.R., A.J.R.); and Biostatistics Section, Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, MA (A.O.)
| | - Shibei Zhao
- From the Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA (Z.R., A.O., S.Z., G.K.J., A.J.R.); Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA (Z.R., A.J.R.); and Biostatistics Section, Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, MA (A.O.)
| | - Guneet K. Jasuja
- From the Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA (Z.R., A.O., S.Z., G.K.J., A.J.R.); Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA (Z.R., A.J.R.); and Biostatistics Section, Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, MA (A.O.)
| | - Adam J. Rose
- From the Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA (Z.R., A.O., S.Z., G.K.J., A.J.R.); Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA (Z.R., A.J.R.); and Biostatistics Section, Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, MA (A.O.)
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Paradise HT, Berlowitz DR, Ozonoff A, Miller DR, Hylek EM, Ash AS, Jasuja GK, Zhao S, Reisman JI, Rose AJ. Outcomes of anticoagulation therapy in patients with mental health conditions. J Gen Intern Med 2014; 29:855-61. [PMID: 24549520 PMCID: PMC4026501 DOI: 10.1007/s11606-014-2784-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 12/03/2013] [Accepted: 01/12/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients with mental health conditions (MHCs) experience poor anticoagulation control when using warfarin, but we have limited knowledge of the association between specific mental illness and warfarin treatment outcomes. OBJECTIVE To examine the relationship between the severity of MHCs and outcomes of anticoagulation therapy. DESIGN Retrospective cohort analysis. PARTICIPANTS We studied 103,897 patients on warfarin for 6 or more months cared for by the Veterans Health Administration during fiscal years 2007-2008. We identified 28,216 patients with MHCs using ICD-9 codes: anxiety disorders, bipolar disorder, depression, post-traumatic stress disorder, schizophrenia, and other psychotic disorders. MAIN MEASURES Outcomes included anticoagulation control, as measured by percent time in the therapeutic range (TTR), as well as major hemorrhage. Predictors included different categories of MHC, Global Assessment of Functioning (GAF) scores, and psychiatric hospitalizations. KEY RESULTS Patients with bipolar disorder, depression, and other psychotic disorders experienced TTR decreases of 2.63 %, 2.26 %, and 2.92 %, respectively (p < 0.001), after controlling for covariates. Patients with psychotic disorders other than schizophrenia experienced increased hemorrhage after controlling for covariates [hazard ratio (HR) 1.24, p = 0.03]. Having any MHC was associated with a slightly increased hazard for hemorrhage (HR 1.19, p < 0.001) after controlling for covariates. CONCLUSION Patients with specific MHCs (bipolar disorder, depression, and other psychotic disorders) experienced slightly worse anticoagulation control. Patients with any MHC had a slightly increased hazard for major hemorrhage, but the magnitude of this difference is unlikely to be clinically significant. Overall, our results suggest that appropriately selected patients with MHCs can safely receive therapy with warfarin.
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Affiliation(s)
- Helen T Paradise
- Department of Community Based Clinics, University of Texas Medical Branch (UTMB), 6465 South Shore Blvd. Suite 500, League City, TX, 77573, USA,
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Efird LM, Mishkin DS, Berlowitz DR, Ash AS, Hylek EM, Ozonoff A, Reisman JI, Zhao S, Jasuja GK, Rose AJ. Stratifying the Risks of Oral Anticoagulation in Patients With Liver Disease. Circ Cardiovasc Qual Outcomes 2014; 7:461-7. [DOI: 10.1161/circoutcomes.113.000817] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Lydia M. Efird
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Daniel S. Mishkin
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Dan R. Berlowitz
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Arlene S. Ash
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Elaine M. Hylek
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Al Ozonoff
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Joel I. Reisman
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Shibei Zhao
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Guneet K. Jasuja
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
| | - Adam J. Rose
- From the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA (D.R.B., A.S.A., E.M.H., A.O., J.I.R., S.Z., G.K.J., A.J.R.); Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, MA (L.M.E., D.R.B., A.S.A., E.M.H., A.J.R.); Section of Gastroenterology, Granite Medical Group, Boston University Medical Center, MA (D.S.M.); Department of Health Policy and Management, Boston University
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Efird LM, Miller DR, Ash AS, Berlowitz DR, Ozonoff A, Zhao S, Reisman JI, Jasuja GK, Rose AJ. Identifying the risks of anticoagulation in patients with substance abuse. J Gen Intern Med 2013; 28:1333-9. [PMID: 23620189 PMCID: PMC3785645 DOI: 10.1007/s11606-013-2453-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 02/25/2013] [Accepted: 04/03/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Warfarin is effective in preventing thromboembolic events, but concerns exist regarding its use in patients with substance abuse. OBJECTIVE Identify which patients with substance abuse who receive warfarin are at risk for poor outcomes. DESIGN Retrospective cohort study. Diagnostic codes, lab values, and other factors were examined to identify risk of adverse outcomes. PATIENTS Veterans AffaiRs Study to Improve Anticoagulation (VARIA) database of 103,897 patients receiving warfarin across 100 sites. MAIN MEASURES Outcomes included percent time in therapeutic range (TTR), a measure of anticoagulation control, and major hemorrhagic events by ICD-9 codes. RESULTS Nonusers had a higher mean TTR (62 %) than those abusing alcohol (53 %), drugs (50 %), or both (44 %, p < 0.001). Among alcohol abusers, an increasing ratio of the serum hepatic transaminases aspartate aminotransferase/alanine aminotransferase (AST:ALT) correlated with inferior anticoagulation control; normal AST:ALT ≤ 1.5 predicted relatively modest decline in TTR (54 %, p < 0.001), while elevated ratios (AST:ALT 1.50-2.0 and > 2.0) predicted progressively poorer anticoagulation control (49 % and 44 %, p < 0.001 compared to nonusers). Age-adjusted hazard ratio for major hemorrhage was 1.93 in drug and 1.37 in alcohol abuse (p < 0.001 compared to nonusers), and remained significant after also controlling for anticoagulation control and other bleeding risk factors (1.69 p < 0.001 and 1.22 p = 0.003). Among alcohol abusers, elevated AST:ALT >2.0 corresponded to more than three times the hemorrhages (HR 3.02, p < 0.001 compared to nonusers), while a normal ratio AST:ALT ≤ 1.5 predicted a rate similar to nonusers (HR 1.19, p < 0.05). CONCLUSIONS Anticoagulation control is particularly poor in patients with substance abuse. Major hemorrhages are more common in both alcohol and drug users. Among alcohol abusers, the ratio of AST/ALT holds promise for identifying those at highest risk for adverse events.
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Affiliation(s)
- Lydia M Efird
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, 72 East Concord Street, Evans 124, Boston, MA, 02118, USA,
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Jasuja GK, Reisman JI, Miller DR, Berlowitz DR, Hylek EM, Ash AS, Ozonoff A, Zhao S, Rose AJ. Identifying major hemorrhage with automated data: results of the Veterans Affairs study to improve anticoagulation (VARIA). Thromb Res 2012; 131:31-6. [PMID: 23158402 DOI: 10.1016/j.thromres.2012.10.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/29/2012] [Accepted: 10/22/2012] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Identifying major bleeding is fundamental to assessing the outcomes of anticoagulation therapy. This drives the need for a credible implementation in automated data for the International Society of Thrombosis and Haemostasis (ISTH) definition of major bleeding. MATERIALS AND METHODS We studied 102,395 patients who received 158,511 person-years of warfarin treatment from the Veterans Health Administration (VA) between 10/1/06-9/30/08. We constructed a list of ICD-9-CM codes of "candidate" bleeding events. Each candidate event was identified as a major hemorrhage if it fulfilled one of four criteria: 1) associated with death within 30days; 2) bleeding in a critical anatomic site; 3) associated with a transfusion; or 4) was coded as the event that precipitated or was responsible for the majority of an inpatient hospitalization. RESULTS This definition classified 11,240 (15.8%) of 71, 338 candidate events as major hemorrhage. Typically, events more likely to be severe were retained at higher rates than those less likely to be severe. For example, Diverticula of Colon with Hemorrhage (562.12) and Hematuria (599.7) were retained 46% and 4% of the time, respectively. Major, intracranial, and fatal hemorrhage were identified at rates comparable to those found in randomized clinical trials however, higher than those reported in observational studies: 4.73, 1.29, and 0.41 per 100 patient years, respectively. CONCLUSIONS We describe here a workable definition for identifying major hemorrhagic events from large automated datasets. This method of identifying major bleeding may have applications for quality measurement, quality improvement, and comparative effectiveness research.
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Affiliation(s)
- Guneet K Jasuja
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA, USA.
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Kimokoti RW, Newby PK, Gona P, Zhu L, Jasuja GK, Pencina MJ, McKeon-O'Malley C, Fox CS, D'Agostino RB, Millen BE. Diet quality, physical activity, smoking status, and weight fluctuation are associated with weight change in women and men. J Nutr 2010; 140:1287-93. [PMID: 20484553 PMCID: PMC2884329 DOI: 10.3945/jn.109.120808] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 01/28/2010] [Accepted: 05/01/2010] [Indexed: 12/20/2022] Open
Abstract
The effect of diet quality on weight change, relative to other body weight determinants, is insufficiently understood. Furthermore, research on long-term weight change in U.S. adults is limited. We evaluated prospectively patterns and predictors of weight change in Framingham Offspring/Spouse (FOS) women and men (n = 1515) aged > or =30 y with BMI > or = 18.5 kg/m2 and without cardiovascular disease, diabetes, and cancer at baseline over a 16-y period. Diet quality was assessed using the validated Framingham Nutritional Risk Score. In women, older age (P < 0.0001) and physical activity (P < 0.05) were associated with lower weight gain. Diet quality interacted with former smoking status (P-interaction = 0.02); former smokers with lower diet quality gained an additional 5.2 kg compared with those with higher diet quality (multivariable-adjusted P-trend = 0.06). Among men, older age (P < 0.0001) and current smoking (P < 0.01) were associated with lower weight gain, and weight fluctuation (P < 0.01) and former smoking status (P < 0.0001) were associated with greater weight gain. Age was the strongest predictor of weight change in both women (partial R(2) = 11%) and men (partial R(2) = 8.6%). Normal- and overweight women gained more than obese women (P < 0.05) and younger adults gained more weight than older adults (P < 0.0001). Patterns and predictors of weight change differ by sex. Age in both sexes and physical activity among women as well as weight fluctuation and smoking status in men were stronger predictors of weight change than diet quality among FOS adults. Women who stopped smoking over follow-up and had poor diet quality gained the most weight. Preventive interventions need to be sex-specific and consider lifestyle factors.
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Affiliation(s)
- Ruth W Kimokoti
- Department of Family Medicine, Boston University School of Medicine, Boston, MA 02118, USA.
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Krasnoff JB, Basaria S, Pencina MJ, Jasuja GK, Vasan RS, Ulloor J, Zhang A, Coviello A, Kelly-Hayes M, D'Agostino RB, Wolf PA, Bhasin S, Murabito JM. Free testosterone levels are associated with mobility limitation and physical performance in community-dwelling men: the Framingham Offspring Study. J Clin Endocrinol Metab 2010; 95:2790-9. [PMID: 20382680 PMCID: PMC2902069 DOI: 10.1210/jc.2009-2680] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Mobility limitation is associated with increased morbidity and mortality. The relationship between circulating testosterone and mobility limitation and physical performance is incompletely understood. OBJECTIVE Our objective was to examine cross-sectional and prospective relations between baseline sex hormones and mobility limitations and physical performance in community-dwelling older men. DESIGN, SETTING, AND PARTICIPANTS We conducted cross-sectional and longitudinal analyses of 1445 men (mean age 61.0 +/- 9.5 yr) who attended Framingham Offspring Study examinations 7 and 8 (mean 6.6 yr apart). Total testosterone (TT) was measured by liquid chromatography tandem mass spectrometry at examination 7. Cross-sectional and longitudinal analyses of mobility limitation and physical performance were performed with continuous (per SD) and dichotomized [low TT and free testosterone (FT) and high SHBG vs. normal] hormone levels. MAIN OUTCOME MEASURES Self-reported mobility limitation, subjective health, usual walking speed, and grip strength were assessed at examinations 7 and 8. Short physical performance battery was performed at examination 7. RESULTS Higher continuous FT was positively associated with short physical performance battery score (beta = 0.13; P = 0.008), usual walking speed (beta = 0.02; P = 0.048), and lower risk of poor subjective health [odds ratio (OR) = 0.72; P = 0.01]. In prospective analysis, 1 SD increase in baseline FT was associated with lower risk of developing mobility limitation (OR = 0.78; 95% confidence interval = 0.62-0.97) and progression of mobility limitation (OR = 0.75; 95% confidence interval = 0.60-0.93). Men with low baseline FT had 57% higher odds of reporting incident mobility limitation (P = 0.03) and 68% higher odds of worsening of mobility limitation (P = 0.007). CONCLUSIONS Lower levels of baseline FT are associated with a greater risk of incident or worsening mobility limitation in community-dwelling older men. Whether this risk can be reduced with testosterone therapy needs to be determined by randomized trials.
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Affiliation(s)
- Joanne B Krasnoff
- Boston University School of Medicine, Section of Endocrinology, Diabetes, and Nutrition, 670 Albany Street, Second Floor, Boston, Massachusetts 02118-2393, USA
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