1
|
Hung A, Wilson L, Smith VA, Pavon JM, Sloan CE, Hastings SN, Farley J, Maciejewski ML. Comprehensive Medication Review Completion Rates and Disparities After Medicare Star Rating Measure. JAMA Health Forum 2024; 5:e240807. [PMID: 38700854 DOI: 10.1001/jamahealthforum.2024.0807] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024] Open
Abstract
Importance Comprehensive medication reviews (CMRs) are offered to qualifying US Medicare beneficiaries annually to optimize medication regimens and therapeutic outcomes. In 2016, Medicare adopted CMR completion as a Star Rating quality measure to encourage the use of CMRs. Objective To examine trends in CMR completion rates before and after 2016 and whether racial, ethnic, and socioeconomic disparities in CMR completion changed. Design, Setting, and Participants This observational study using interrupted time-series analysis examined 2013 to 2020 annual cohorts of community-dwelling Medicare beneficiaries aged 66 years and older eligible for a CMR as determined by Part D plans and by objective minimum eligibility criteria. Data analysis was conducted from September 2022 to February 2024. Exposure Adoption of CMR completion as a Star Rating quality measure in 2016. Main Outcome and Measures CMR completion modeled via generalized estimating equations. Results The study included a total of 561 950 eligible beneficiaries, with 253 561 in the 2013 to 2015 cohort (median [IQR] age, 75.8 [70.7-82.1] years; 90 778 male [35.8%]; 6795 Asian [2.7%]; 24 425 Black [9.6%]; 7674 Hispanic [3.0%]; 208 621 White [82.3%]) and 308 389 in the 2016 to 2020 cohort (median [IQR] age, 75.1 [70.4-80.9] years; 126 730 male [41.1%]; 8922 Asian [2.9%]; 27 915 Black [9.1%]; 7635 Hispanic [2.5%]; 252 781 White [82.0%]). The unadjusted CMR completion rate increased from 10.2% (7379 of 72 225 individuals) in 2013 to 15.6% (14 185 of 90 847 individuals) in 2015 and increased further to 35.8% (18 376 of 51 386 individuals) in 2020, in part because the population deemed by Part D plans to be MTM-eligible decreased by nearly half after 2015 (90 487 individuals in 2015 to 51 386 individuals in 2020). Among a simulated cohort based on Medicare minimum eligibility thresholds, the unadjusted CMR completion rate increased but to a lesser extent, from 4.4% in 2013 to 12.6% in 2020. Compared with White beneficiaries, Asian and Hispanic beneficiaries experienced greater increases in likelihood of CMR completion after 2016 but remained less likely to complete a CMR. Dual-Medicaid enrollees also experienced greater increases in likelihood of CMR completion as compared with those without either designation, but still remained less likely to complete CMR. Conclusion and Relevance This study found that adoption of CMR completion as a Star Rating quality measure was associated with higher CMR completion rates. The increase in CMR completion rates was achieved partly because Part D plans used stricter eligibility criteria to define eligible patients. Reductions in disparities for eligible Asian, Hispanic, and dual-Medicaid enrollees were seen, but not eliminated. These findings suggest that quality measures can inform plan behavior and could be used to help address disparities.
Collapse
Affiliation(s)
- Anna Hung
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
| | - Lauren Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Valerie A Smith
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Juliessa M Pavon
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
- Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Caroline E Sloan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Susan N Hastings
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
- Geriatrics Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Joel Farley
- Department of Pharmaceutical Care & Health Systems, University of Minnesota College of Pharmacy, Minneapolis
| | - Matthew L Maciejewski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
2
|
Chen JI, Bui D, Iwashyna TJ, Shahoumian TA, Hickok A, Shepherd-Banigan M, Hawkins EJ, Naylor J, Govier DJ, Osborne TF, Smith VA, Bowling CB, Boyko EJ, Ioannou GN, Maciejewski ML, O'Hare AM, Viglianti EM, Bohnert ASB, Hynes DM. Impact of SARS-CoV-2 Infection on Long-Term Depression Symptoms among Veterans. J Gen Intern Med 2024:10.1007/s11606-024-08630-z. [PMID: 38625482 DOI: 10.1007/s11606-024-08630-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/11/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Prior research demonstrates that SARS-COV-2 infection can be associated with a broad range of mental health outcomes including depression symptoms. Veterans, in particular, may be at elevated risk of increased depression following SARS-COV-2 infection given their high rates of pre-existing mental and physical health comorbidities. However, few studies have tried to isolate SARS-COV-2 infection associations with long term, patient-reported depression symptoms from other factors (e.g., physical health comorbidities, pandemic-related stress). OBJECTIVE To evaluate the association between SARS-COV-2 infection and subsequent depression symptoms among United States Military Veterans. DESIGN Survey-based non-randomized cohort study with matched comparators. PARTICIPANTS A matched-dyadic sample from a larger, stratified random sample of participants with and without known to SARS-COV-2 infection were invited to participate in a survey evaluating mental health and wellness 18-months after their index infection date. Sampled participants were stratified by infection severity of the participant infected with SARS-COV-2 (hospitalized or not) and by month of index date. A total of 186 participants in each group agreed to participate in the survey and had sufficient data for inclusion in analyses. Those in the uninfected group who were later infected were excluded from analyses. MAIN MEASURES Participants were administered the Patient Health Questionnaire-9 as part of a phone interview survey. Demographics, physical and mental health comorbidities were extracted from VHA administrative data. KEY RESULTS Veterans infected with SARS-COV-2 had significantly higher depression symptoms scores compared with those uninfected. In particular, psychological symptoms (e.g., low mood, suicidal ideation) scores were elevated relative to the comparator group (MInfected = 3.16, 95%CI: 2.5, 3.8; MUninfected = 1.96, 95%CI: 1.4, 2.5). Findings were similar regardless of history of depression. CONCLUSION SARS-COV-2 infection was associated with more depression symptoms among Veterans at 18-months post-infection. Routine evaluation of depression symptoms over time following SARS-COV-2 infection is important to facilitate adequate assessment and treatment.
Collapse
Affiliation(s)
- Jason I Chen
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA.
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.
| | - David Bui
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Theodore J Iwashyna
- Departments of Medicine and Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
| | | | - Alex Hickok
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Eric J Hawkins
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound HCS, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Jennifer Naylor
- School of Medicine, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- VISN 6 Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Durham VA HCS, Durham, NC, USA
| | - Diana J Govier
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- OHSU-Portland State University School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Thomas F Osborne
- VA Palo Alto HCS, Palo Alto, CA, USA
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham VA HCS, Durham, NC, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research Information Center, VA Puget Sound HCS, Seattle, WA, USA
| | - George N Ioannou
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Ann M O'Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Hospital and Specialty Medicine Service, VA Puget Sound HCS, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Elizabeth M Viglianti
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amy S-B Bohnert
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- College of Public Health and Human Sciences, and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
- School of Nursing, Oregon Health & Science University (OHSU), Portland, OR, USA
| |
Collapse
|
3
|
Govier DJ, Niederhausen M, Takata Y, Hickok A, Rowneki M, McCready H, Smith VA, Osborne TF, Boyko EJ, Ioannou GN, Maciejewski ML, Viglianti EM, Bohnert ASB, O’Hare AM, Iwashyna TJ, Hynes DM. Risk of Potentially Preventable Hospitalizations After SARS-CoV-2 Infection. JAMA Netw Open 2024; 7:e245786. [PMID: 38598237 PMCID: PMC11007577 DOI: 10.1001/jamanetworkopen.2024.5786] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/11/2024] [Indexed: 04/11/2024] Open
Abstract
Importance Research demonstrates that SARS-CoV-2 infection is associated with increased risk of all-cause hospitalization. However, no prior studies have assessed the association between SARS-CoV-2 and potentially preventable hospitalizations-that is, hospitalizations for conditions that can usually be effectively managed in ambulatory care settings. Objective To examine whether SARS-CoV-2 is associated with potentially preventable hospitalization in a nationwide cohort of US veterans. Design, Setting, and Participants This cohort study used an emulated target randomized trial design with monthly sequential trials to compare risk of a potentially preventable hospitalization among veterans with SARS-CoV-2 and matched comparators without SARS-CoV-2. A total of 189 136 US veterans enrolled in the Veterans Health Administration (VHA) who were diagnosed with SARS-CoV-2 between March 1, 2020, and April 30, 2021, and 943 084 matched comparators were included in the analysis. Data were analyzed from May 10, 2023, to January 26, 2024. Exposure SARS-CoV-2 infection. Main Outcomes and Measures The primary outcome was a first potentially preventable hospitalization in VHA facilities, VHA-purchased community care, or Medicare fee-for-service care. Extended Cox models were used to examine adjusted hazard ratios (AHRs) of potentially preventable hospitalization among veterans with SARS-CoV-2 and comparators during follow-up periods of 0 to 30, 0 to 90, 0 to 180, and 0 to 365 days. The start of follow-up was defined as the date of each veteran's first positive SARS-CoV-2 diagnosis, with the same index date applied to their matched comparators. Results The 1 132 220 participants were predominantly men (89.06%), with a mean (SD) age of 60.3 (16.4) years. Most veterans were of Black (23.44%) or White (69.37%) race. Veterans with SARS-CoV-2 and comparators were well-balanced (standardized mean differences, all <0.100) on observable baseline clinical and sociodemographic characteristics. Overall, 3.10% of veterans (3.81% of those with SARS-CoV-2 and 2.96% of comparators) had a potentially preventable hospitalization during 1-year follow-up. Risk of a potentially preventable hospitalization was greater among veterans with SARS-CoV-2 than comparators in 4 follow-up periods: 0- to 30-day AHR of 3.26 (95% CI, 3.06-3.46); 0- to 90-day AHR of 2.12 (95% CI, 2.03-2.21); 0- to 180-day AHR of 1.69 (95% CI, 1.63-1.75); and 0- to 365-day AHR of 1.44 (95% CI, 1.40-1.48). Conclusions and Relevance In this cohort study, an increased risk of preventable hospitalization in veterans with SARS-CoV-2, which persisted for at least 1 year after initial infection, highlights the need for research on ways in which SARS-CoV-2 shapes postinfection care needs and engagement with the health system. Solutions are needed to mitigate preventable hospitalization after SARS-CoV-2.
Collapse
Affiliation(s)
- Diana J. Govier
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
- Oregon Health & Science University–Portland State University School of Public Health, Portland
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
- Oregon Health & Science University–Portland State University School of Public Health, Portland
| | - Yumie Takata
- College of Health, Oregon State University, Corvallis
| | - Alex Hickok
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
| | - Mazhgan Rowneki
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
| | - Holly McCready
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, VA Durham Health Care System, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Thomas F. Osborne
- VA Palo Alto Health Care System, Palo Alto, California
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington
| | - George N. Ioannou
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, VA Durham Health Care System, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth M. Viglianti
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Amy S. B. Bohnert
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Ann M. O’Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Washington
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Theodore J. Iwashyna
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Denise M. Hynes
- Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
- College of Health, Oregon State University, Corvallis
- Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon
- School of Nursing, Oregon Health & Science University, Portland
| |
Collapse
|
4
|
Van Houtven CH, Smith VA, Miller KEM, Berkowitz TSZ, Shepherd-Banigan M, Hein T, Penney LS, Allen KD, Kabat M, Jobin T, Hastings SN. Comprehensive Caregiver Supports and Ascertainment and Treatment of Veteran Pain. Med Care Res Rev 2024; 81:107-121. [PMID: 38062735 DOI: 10.1177/10775587231210026] [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] [Indexed: 03/09/2024]
Abstract
Disabled Veterans commonly experience pain. The Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides training, a stipend, and services to family caregivers of eligible Veterans to support their caregiving role. We compared ascertainment of veteran pain and pain treatment through health care encounters and medications (pain indicators) of participants (treated group) and non-participants (comparison group) using inverse probability treatment weights. Modeled results show that the proportion of Veterans with a pain indicator in the first year post-application was higher than that pre-application for both groups. However, the proportion of Veterans with a pain indicator was substantially higher in the treatment group: 76.1% versus 63.9% in the comparison group (p < .001). Over time, the proportion of Veterans with any pain indicator fell and group differences lessened. However, differences persisted through 8 years post-application (p < .001). PCAFC caregivers appear to help Veterans engage in pain treatment at higher rates than caregivers not in PCAFC.
Collapse
Affiliation(s)
- Courtney H Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Duke Margolis Center for Health Policy, Duke University
| | - Valerie A Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Department of General Internal Medicine, Duke University
| | - Katherine E M Miller
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Medical Ethics and Health Policy, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Theodore S Z Berkowitz
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Megan Shepherd-Banigan
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
| | - Tyler Hein
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs
| | - Lauren S Penney
- The Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System
- Department of Medicine, Division of Hospital Medicine, University of Texas Health San Antonio
| | - Kelli D Allen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Margaret Kabat
- Office of the Secretary US Department of Veterans Affairs
| | - Timothy Jobin
- Caregiver Support Program, Veterans Health Administration, US Department of Veterans Affairs
| | - S Nicole Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
- Department of Population Health Sciences, Duke University School of Medicine
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine
- Center for the Study of Aging and Human Development, Duke University School of Medicine
- Geriatrics Research, Education and Clinical Center, Durham VA Health Care System
| |
Collapse
|
5
|
Smith VA, Stechuchak KM, Wong ES, Hung A, Dennis PA, Hoerster KD, Blalock DV, Raffa SD, Maciejewski ML. Association Between a National Behavioral Weight Management Program and Veterans Affairs Health Expenditures. Med Care 2024; 62:235-242. [PMID: 38458985 DOI: 10.1097/mlr.0000000000001981] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
OBJECTIVE The association between participation in a behavioral weight intervention and health expenditures has not been well characterized. We compared Veterans Affairs (VA) expenditures of individuals participating in MOVE!, a VA behavioral weight loss program, and matched comparators 2 years before and 2 years after MOVE! initiation. METHODS Retrospective cohort study of Veterans who had one or more MOVE! visits in 2008-2017 who were matched contemporaneously to up to 3 comparators with overweight or obesity through sequential stratification on an array of patient characteristics, including sex. Baseline patient characteristics were compared between the two cohorts through standardized mean differences. VA expenditures in the 2 years before MOVE! initiation and 2 years after initiation were modeled using generalized estimating equations with a log link and distribution with variance proportional to the standard deviation (gamma). RESULTS MOVE! participants (n=499,696) and comparators (n=1,336,172) were well-matched, with an average age of 56, average body mass index of 35, and similar total VA expenditures in the fiscal year before MOVE! initiation ($9662 for MOVE! participants and $10,072 for comparators, standardized mean difference=-0.019). MOVE! participants had total expenditures that were statistically lower than matched comparators in the 6 months after initiation but modestly higher in the 6 months to 2 years after initiation, though differences were small in magnitude (1.0%-1.6% differences). CONCLUSIONS The VA's system-wide behavioral weight intervention did not realize meaningful short-term health care cost savings for participants.
Collapse
Affiliation(s)
- Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Department of Medicine, Division of General Internal Medicine, School of Medicine, Duke University, Durham, NC
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
| | - Edwin S Wong
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA
| | - Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC
| | - Paul A Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Katherine D Hoerster
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC
| | - Susan D Raffa
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Department of Medicine, Division of General Internal Medicine, School of Medicine, Duke University, Durham, NC
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC
| |
Collapse
|
6
|
Wong ES, Stechuchak KM, Smith VA, Hung A, Dennis PA, Hoerster KD, Maciejewski ML. Differences in healthcare costs over 10 years following discharge from military service by weight trajectory. Obes Res Clin Pract 2024:S1871-403X(24)00038-3. [PMID: 38565463 DOI: 10.1016/j.orcp.2024.03.008] [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: 12/08/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024]
Abstract
The prevalence of overweight and obesity among military personnel has increased substantially in the past two decades. Following military discharge many personnel can receive integrated health care from the Veterans Health Administration. Prior research related to the economic impacts of obesity has not examined health care costs following the transition into civilian life following military discharge. To address this evidence gap, this study sought to compare longitudinal costs over 10 years across weight categories among VA enrollees recently discharged from the military.
Collapse
Affiliation(s)
- Edwin S Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, MS-152, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington, 3980 15th Ave. NE, Seattle, WA 98195, USA.
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC 27701, USA; Division of General Internal Medicine, Department of Medicine, Duke University, 200 Morris St., Durham, NC 27701, USA
| | - Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC 27701, USA
| | - Paul A Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC 27701, USA
| | - Katherine D Hoerster
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, MS-152, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington, 3980 15th Ave. NE, Seattle, WA 98195, USA; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC 27701, USA; Division of General Internal Medicine, Department of Medicine, Duke University, 200 Morris St., Durham, NC 27701, USA; Duke-Margolis Center for Health Policy, Duke University, 100 Fuqua Drive, Box 90120, Durham, NC 27708, USA
| |
Collapse
|
7
|
Longenecker CT, Jones KA, Hileman CO, Okeke NL, Gripshover BM, Aifah A, Bloomfield GS, Muiruri C, Smith VA, Vedanthan R, Webel AR, Bosworth HB. Nurse-Led Strategy to Improve Blood Pressure and Cholesterol Level Among People With HIV: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2356445. [PMID: 38441897 PMCID: PMC10915684 DOI: 10.1001/jamanetworkopen.2023.56445] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/22/2023] [Indexed: 03/07/2024] Open
Abstract
Importance Despite higher atherosclerotic cardiovascular disease (ASCVD) risk, people with HIV (PWH) experience unique barriers to ASCVD prevention, such as changing models of HIV primary care. Objective To test whether a multicomponent nurse-led strategy would improve systolic blood pressure (SBP) and non-high-density lipoprotein (HDL) cholesterol level in a diverse population of PWH receiving antiretroviral therapy (ART). Design, Setting, and Participants This randomized clinical trial enrolled PWH at 3 academic HIV clinics in the US from September 2019 to January 2022 and conducted follow-up for 12 months until January 2023. Included patients were 18 years or older and had a confirmed HIV diagnosis, an HIV-1 viral load less than 200 copies/mL, and both hypertension and hypercholesterolemia. Participants were stratified by trial site and randomized 1:1 to either the multicomponent EXTRA-CVD (A Nurse-Led Intervention to Extend the HIV Treatment Cascade for Cardiovascular Disease Prevention) intervention group or the control group. Primary analyses were conducted according to the intention-to-treat principle. Intervention The EXTRA-CVD group received home BP monitoring guidance and BP and cholesterol management from a dedicated prevention nurse at 4 in-person visits (baseline and 4, 8, and 12 months) and frequent telephone check-ins up to every 2 weeks as needed. The control group received general prevention education sessions from the prevention nurse at each of the 4 in-person visits. Main Outcomes and Measures Study-measured SBP was the primary outcome, and non-HDL cholesterol level was the secondary outcome. Measurements were taken over 12 months and assessed by linear mixed models. Prespecified moderators tested were sex at birth, baseline ASCVD risk, and trial site. Results A total of 297 PWH were randomized to the EXTRA-CVD arm (n = 149) or control arm (n = 148). Participants had a median (IQR) age of 59.0 (53.0-65.0) years and included 234 males (78.8%). Baseline mean (SD) SBP was 135.0 (18.8) mm Hg and non-HDL cholesterol level was 139.9 (44.6) mg/dL. At 12 months, participants in the EXTRA-CVD arm had a clinically significant 4.2-mm Hg (95% CI, 0.3-8.2 mm Hg; P = .04) lower SBP and 16.9-mg/dL (95% CI, 8.6-25.2 mg/dL; P < .001) lower non-HDL cholesterol level compared with participants in the control arm. There was a clinically meaningful but not statistically significant difference in SBP effect in females compared with males (11.8-mm Hg greater difference at 4 months, 9.6 mm Hg at 8 months, and 5.9 mm Hg at 12 months; overall joint test P = .06). Conclusions and Relevance Results of this trial indicate that the EXTRA-CVD strategy effectively reduced BP and cholesterol level over 12 months and should inform future implementation of multifaceted ASCVD prevention programs for PWH. Trial Registration ClinicalTrials.gov Identifier: NCT03643705.
Collapse
Affiliation(s)
| | | | - Corrilynn O. Hileman
- MetroHealth Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Barbara M. Gripshover
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Angela Aifah
- New York University Grossman School of Medicine, New York
| | | | | | - Valerie A. Smith
- Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | | | | | - Hayden B. Bosworth
- Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| |
Collapse
|
8
|
Iwashyna TJ, Smith VA, Seelye S, Bohnert ASB, Boyko EJ, Hynes DM, Ioannou GN, Maciejewski ML, O'Hare AM, Viglianti EM, Berkowitz TS, Pura J, Womer J, Kamphuis LA, Monahan ML, Bowling CB. Self-Reported Everyday Functioning After COVID-19 Infection. JAMA Netw Open 2024; 7:e240869. [PMID: 38427352 PMCID: PMC10907923 DOI: 10.1001/jamanetworkopen.2024.0869] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Importance Changes in everyday functioning are crucial to assessing the long-term impact of COVID-19 infection. Objective To examine the impact of COVID-19 infection on everyday functioning 18 months after infection among veterans with and without histories of COVID-19 infection. Design, Setting, and Participants This cohort study used data from the US Veterans Affairs (VA) and included 186 veterans who had COVID-19 between October 2020 and April 2021 (ie, COVID-19 cohort) and 186 matched comparators who did not have documented COVID-19 infections (ie, control cohort). This match balanced the risk of COVID-19 based on 39 variables measured in the 24 months before infection or match, using principles of target trial emulation. Data were analyzed from December 2022 to December 2023. Exposure First documented COVID-19. Main Outcome and Measures The differences in self-reported everyday functioning 18 months after COVID-19 infection were estimated and compared with their matched comparators. Within-matched pair logistic and linear regressions assessed differences in outcomes and were weighted to account for sampling and nonresponse. Results Among the 186 matched pairs of participants, their weighted mean age was 60.4 (95% CI, 57.5 to 63.2) years among veterans in the COVID-19 cohort (weighted sample, 91 459 of 101 133 [90.4%] male; 30 611 [30.3%] Black or African American veterans; 65 196 [64.4%] White veterans) and 61.1 (95% CI, 57.8 to 64.4) years among their comparators in the control cohort (91 459 [90.4%] male; 24 576 [24.3%] Black or African American veterans; 70 157 [69.4%] White veterans). A high proportion of veterans in the COVID-19 cohort (weighted percentage, 44.9% [95% CI, 34.2% to 56.2%]) reported that they could do less than what they felt they could do at the beginning of 2020 compared with the control cohort (weighted percentage, 35.3%; [95% CI, 25.6% to 46.4%]; within-matched pair adjusted odds ratio [OR], 1.52 [95% CI, 0.79 to 2.91]). There was no association of documented COVID-19 infection with fatigue, substantial pain, limitations in either activities of daily living and instrumental activities of daily living, severely curtailed life-space mobility, employment, or mean health-related quality of life on a utility scale. Conclusions and Relevance In this cohort study of veterans with and without documented COVID-19, many reported a substantial loss of everyday functioning during the pandemic regardless of whether or not they had a documented infection with COVID-19. Future work with larger samples is needed to validate the estimated associations.
Collapse
Affiliation(s)
- Theodore J Iwashyna
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
| | - Amy S B Bohnert
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Departments of Anesthesiology, Epidemiology, and Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, Washington
- University of Washington, Seattle
| | - Denise M Hynes
- VA Portland Healthcare System, Center to Improve Veteran Involvement in Care, Portland, Oregon
- College of Health, and Center for Quantitative Life Sciences, Oregon State University, Corvallis
- School of Nursing, Oregon Health and Science University, Portland
| | - George N Ioannou
- University of Washington, Seattle
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- School of Nursing, Oregon Health and Science University, Portland
| | - Ann M O'Hare
- University of Washington, Seattle
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
| | - Elizabeth M Viglianti
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Theodore S Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - John Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - James Womer
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lee A Kamphuis
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
| | - Max L Monahan
- VA Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| |
Collapse
|
9
|
Hynes DM, Niederhausen M, Chen JI, Shahoumian TA, Rowneki M, Hickok A, Shepherd-Banigan M, Hawkins EJ, Naylor J, Teo A, Govier DJ, Berry K, McCready H, Osborne TF, Wong E, Hebert PL, Smith VA, Bowling CB, Boyko EJ, Ioannou GN, Iwashyna TJ, Maciejewski ML, O'Hare AM, Viglianti EM, Bohnert ASB. Risk of Suicide-Related Outcomes After SARS-COV-2 Infection: Results from a Nationwide Observational Matched Cohort of US Veterans. J Gen Intern Med 2024; 39:626-635. [PMID: 37884839 DOI: 10.1007/s11606-023-08440-9] [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: 06/05/2023] [Accepted: 09/18/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Negative mental health-related effects of SARS-COV-2 infection are increasingly evident. However, the impact on suicide-related outcomes is poorly understood, especially among populations at elevated risk. OBJECTIVE To determine risk of suicide attempts and other self-directed violence (SDV) after SARS-COV-2 infection in a high-risk population. DESIGN We employed an observational design supported by comprehensive electronic health records from the Veterans Health Administration (VHA) to examine the association of SARS-COV-2 infection with suicide attempts and other SDV within one year of infection. Veterans with SARS-COV-2 infections were matched 1:5 with non-infected comparators each month. Three periods after index were evaluated: days 1-30, days 31-365, and days 1-365. PARTICIPANTS VHA patients infected with SARS-COV-2 between March 1, 2020 and March 31, 2021 and matched non-infected Veteran comparators. MAIN MEASURES Suicide attempt and other SDV events for the COVID-19 and non-infected comparator groups were analyzed using incidence rates per 100,000 person years and hazard ratios from Cox regressions modeling time from matched index date to first event. Subgroups were also examined. KEY RESULTS 198,938 veterans with SARS-COV-2 (COVID-19 group) and 992,036 comparators were included. Unadjusted one-year incidence per 100,000 for suicide attempt and other SDV was higher among the COVID-19 group: 355 vs 250 and 327 vs 235, respectively. The COVID-19 group had higher risk than comparators for suicide attempts: days 1-30 hazard ratio (HR) = 2.54 (CI:2.05, 3.15), days 31-365 HR = 1.30 (CI:1.19, 1.43) and days 1-365 HR = 1.41 (CI:1.30, 1.54), and for other SDV: days 1-30 HR = 1.94 (CI:1.51, 2.49), days 31-365 HR = 1.32 (CI:1.20, 1.45) and days 1-365 HR = 1.38 (CI:1.26, 1.51). CONCLUSIONS COVID-19 patients had higher risks of both suicide attempts and other forms of SDV compared to uninfected comparators, which persisted for at least one year after infection. Results support suicide risk screening of those infected with SARS-COV-2 to identify opportunities to prevent self-harm.
Collapse
Affiliation(s)
- Denise M Hynes
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA.
- College of Health, and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA.
- School of Nursing, Oregon Health & Science University (OHSU), Portland, OR, USA.
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- OHSU-Portland State University School of Public Health, OHSU, Portland, OR, USA
| | - Jason I Chen
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- Department of Psychiatry, OHSU, Portland, OR, USA
| | | | - Mazhgan Rowneki
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Alex Hickok
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Eric J Hawkins
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound HCS, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Jennifer Naylor
- School of Medicine, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Education and Clinical Center, VISN 6 Mental Illness Research, Durham, NC, USA
- Durham VA HCS, Durham, NC, USA
| | - Alan Teo
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- Department of Psychiatry, OHSU, Portland, OR, USA
| | - Diana J Govier
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- OHSU-Portland State University School of Public Health, OHSU, Portland, OR, USA
| | - Kristin Berry
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
| | - Holly McCready
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA
- Department of Psychiatry, OHSU, Portland, OR, USA
| | - Thomas F Osborne
- VA Palo Alto HCS, Palo Alto, CA, USA
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Edwin Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
| | - Paul L Hebert
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham VA HCS, Durham, NC, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research Information Center, VA Puget Sound HCS, Seattle, WA, USA
| | - George N Ioannou
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Theodore J Iwashyna
- Departments of Medicine and Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Ann M O'Hare
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA
- Hospital and Specialty Medicine Service, VA Puget Sound HCS, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Elizabeth M Viglianti
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amy S-B Bohnert
- Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
10
|
Hung A, Wong ES, Dennis PA, Stechuchak KM, Blalock DV, Smith VA, Hoerster K, Vimalananda VG, Raffa SD, Maciejewski ML. Real World Use of Anti-Obesity Medications and Weight Change in Veterans. J Gen Intern Med 2024; 39:519-528. [PMID: 37962730 PMCID: PMC10973309 DOI: 10.1007/s11606-023-08501-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Anti-obesity medications (AOMs) can be initiated in conjunction with participation in the VA national behavioral weight management program, MOVE!, to help achieve clinically meaningful weight loss. OBJECTIVE To compare weight change between Veterans who used AOM + MOVE! versus MOVE! alone and examine AOM use, duration, and characteristics associated with longer duration of use. DESIGN Retrospective cohort study using VA electronic health records. PARTICIPANTS Veterans with overweight or obesity who participated in MOVE! from 2008-2017. MAIN MEASURES Weight change from baseline was estimated using marginal structural models up to 24 months after MOVE! initiation. The probability of longer duration of AOM use (≥ 180 days) was estimated via a generalized linear mixed model. RESULTS Among MOVE! participants, 8,517 (1.6%) used an AOM within 24 months after MOVE! initiation with a median of 90 days of cumulative supply. AOM + MOVE! users achieved greater weight loss than MOVE! alone users at 6 (3.2% vs. 1.6%, p < 0.001), 12 (3.4% vs. 1.4%, p < 0.001), and 24 months (2.7% vs. 1.5%, p < 0.001), and had a greater probability of achieving ≥ 5% weight loss at 6 (38.8% vs. 26.0%, p < 0.001), 12 (43.1% vs. 28.4%, p < 0.001), and 24 months (40.4% vs. 33.3%, p < 0.001). Veterans were more likely to have ≥ 180 days of supply if they were older, exempt from medication copays, used other medications with significant weight-gain, significant weight-loss, or modest weight-loss side effects, or resided in the West North Central or Pacific regions. Veterans were less likely to have ≥ 180 days of AOM supply if they had diabetes or initiated MOVE! later in the study period. CONCLUSIONS AOM use following MOVE! initiation was uncommon, and exposure was time-limited. AOM + MOVE! was associated with a higher probability of achieving clinically significant weight loss than MOVE! alone.
Collapse
Affiliation(s)
- Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Durham, NC, USA.
| | - Edwin S Wong
- Seattle-Denver COIN, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle, WA, USA
| | - Paul A Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Katherine Hoerster
- Seattle-Denver COIN, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle, WA, USA
| | - Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, VA Bedford Medical Center, Bedford, MA, USA
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Susan D Raffa
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| |
Collapse
|
11
|
Jutkowitz E, Shewmaker P, Ford CB, Smith VA, O'Brien E, Shepherd-Banigan M, Belanger E, Plassman BL, Burke JR, Van Houtven CH, Wetle T. Association between results of an amyloid PET scan and healthcare utilization in individuals with cognitive impairment. J Am Geriatr Soc 2024; 72:707-717. [PMID: 38069618 DOI: 10.1111/jgs.18696] [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] [Received: 06/30/2023] [Revised: 10/15/2023] [Accepted: 11/05/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND The Imaging Dementia Evidence for Amyloid Scanning (IDEAS) study reports that amyloid PET scans help providers diagnose and manage Alzheimer's disease and related dementias (ADRD). Using CARE-IDEAS, an IDEAS supplemental study, we examined the association between amyloid PET scan result (elevated or non-elevated amyloid), patient characteristics, and participant healthcare utilization. METHODS We linked respondents in CARE-IDEAS study to their Medicare fee-for-service records (n = 1333). We examined participants' cognitive impairment-related, outpatient, emergency department (ED), and inpatient encounters in the year before compared with the 2 years after the amyloid PET scan. RESULTS Individuals with a non-elevated amyloid scan had more healthcare encounters throughout the overall study period than those with an elevated amyloid scan. Regardless of the amyloid scan result, cognitive impairment-related and outpatient encounters overall decreased, but ED and inpatient encounters increased in the 2 years after the scan compared with the year prior. There was minimal evidence of differences in healthcare utilization between participants with an elevated and non-elevated amyloid scan. CONCLUSIONS There is no difference in change in healthcare utilization between people with scans showing elevated and non-elevated beta-amyloid.
Collapse
Affiliation(s)
- Eric Jutkowitz
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Evidence Synthesis Program Center Providence VA Medical Center, Providence, Rhode Island, USA
| | - Peter Shewmaker
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Valerie A Smith
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Emily O'Brien
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Megan Shepherd-Banigan
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Duke Margolis Health Policy Center, Duke University, Durham, North Carolina, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Brenda L Plassman
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - James R Burke
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Courtney H Van Houtven
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Duke Margolis Health Policy Center, Duke University, Durham, North Carolina, USA
| | - Terrie Wetle
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
12
|
Hebert PL, Kumbier KE, Smith VA, Hynes DM, Govier DJ, Wong E, Kaufman BG, Shepherd-Banigan M, Rowneki M, Bohnert ASB, Ioannou GN, Boyko EJ, Iwashyna TJ, O’Hare AM, Bowling CB, Viglianti EM, Maciejewski ML. Changes in Outpatient Health Care Use After COVID-19 Infection Among Veterans. JAMA Netw Open 2024; 7:e2355387. [PMID: 38334995 PMCID: PMC10858406 DOI: 10.1001/jamanetworkopen.2023.55387] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/18/2023] [Indexed: 02/10/2024] Open
Abstract
Importance The association of COVID-19 infection with outpatient care utilization is unclear. Many studies reported population surveillance studies rather than comparing outpatient health care use between COVID-19-infected and uninfected cohorts. Objective To compare outpatient health care use across 6 categories of care (primary care, specialty care, surgery care, mental health, emergency care, and diagnostic and/or other care) between veterans with or without COVID-19 infection. Design, Setting, and Participants In a retrospective cohort study of Veterans Affairs primary care patients, veterans with COVID-19 infection were matched to a cohort of uninfected veterans. Data were obtained from the Veterans Affairs Corporate Data Warehouse and the Centers for Medicare & Medicaid Services Fee-for-Service Carrier/Physician Supplier file from January 2019 through December 2022. Data analysis was performed from September 2022 to April 2023. Exposure COVID-19 infection. Main Outcomes and Measures The primary outcome was the count of outpatient visits after COVID-19 infection. Negative binomial regression models compared outpatient use over a 1-year preinfection period, and peri-infection (0-30 days), intermediate (31-183 days), and long-term (184-365 days) postinfection periods. Results The infected (202 803 veterans; mean [SD] age, 60.5 [16.2] years; 178 624 men [88.1%]) and uninfected (202 803 veterans; mean [SD] age, 60.4 [16.5] years; 178 624 men [88.1%]) cohorts were well matched across all covariates. Outpatient use in all categories (except surgical care) was significantly elevated during the peri-infection period for veterans with COVID-19 infection compared with the uninfected cohort, with an increase in all visits of 5.12 visits per 30 days (95% CI, 5.09-5.16 visits per 30 days), predominantly owing to primary care visits (increase of 1.86 visits per 30 days; 95% CI, 1.85-1.87 visits per 30 days). Differences in outpatient use attenuated over time but remained statistically significantly higher at 184 to 365 days after infection (increase of 0.25 visit per 30 days; 95% CI, 0.23-0.27 visit per 30 days). One-half of the increased outpatient visits were delivered via telehealth. The utilization increase was greatest for veterans aged 85 years and older (6.1 visits, 95% CI, 5.9-6.3 visits) vs those aged 20 to 44 years (4.8 visits, 95% CI, 4.7-4.8 visits) and unvaccinated veterans (4.5 visits, 95% CI, 4.3-4.6 visits) vs vaccinated veterans (3.2 visits; 95% CI, 3.4-4.8 visits). Conclusions and Relevance This study found that outpatient use increased significantly in the month after infection, then attenuated but remained greater than the uninfected cohorts' use through 12 months, which suggests that there are sustained impacts of COVID-19 infection.
Collapse
Affiliation(s)
- Paul L. Hebert
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle
| | - Kyle E. Kumbier
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- Health Management and Policy, Health Data and Informatics Program, Center for Quantitative Life Sciences, College of Health, Oregon State University, Corvallis
| | - Diana J. Govier
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- School of Nursing, Oregon Health & Science University, Portland
| | - Edwin Wong
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle
| | - Brystana G. Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Amy S. B. Bohnert
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - George N. Ioannou
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Gastroenterology, University of Washington, Seattle
| | - Edward J. Boyko
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle
| | - Theodore J. Iwashyna
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Ann M. O’Hare
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle
| | - C. Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Elizabeth M. Viglianti
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- School of Nursing, Oregon Health & Science University, Portland
| |
Collapse
|
13
|
Maciejewski ML, Greene L, Grubber JM, Blalock DV, Jacobs J, Rao M, Zulman DM, Smith VA. Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients. Health Serv Res 2024; 59:e14243. [PMID: 37767603 PMCID: PMC10771909 DOI: 10.1111/1475-6773.14243] [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: 09/29/2023] Open
Abstract
OBJECTIVE Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models. PRINCIPAL FINDINGS Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures. CONCLUSIONS In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.
Collapse
Affiliation(s)
- Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Liberty Greene
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Janet M. Grubber
- Cooperative Studies Program Coordinating CenterBoston Veterans Affairs Health Care SystemBostonMassachusettsUSA
| | - Dan V. Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Josephine Jacobs
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
| | - Mayuree Rao
- Seattle‐Denver Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Donna M. Zulman
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| |
Collapse
|
14
|
Sloan CE, Morton-Oswald S, Smith VA, Sinaiko AD, Bowling CB, An J, Maciejewski ML. Real-world use of a medication out-of-pocket cost estimator in primary care one year after Medicare regulation. J Am Geriatr Soc 2024. [PMID: 38226652 DOI: 10.1111/jgs.18774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 12/02/2023] [Accepted: 12/21/2023] [Indexed: 01/17/2024]
Affiliation(s)
- Caroline E Sloan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Sarah Morton-Oswald
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Valerie A Smith
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Anna D Sinaiko
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - C Barrett Bowling
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, North Carolina, USA
| | - Jaejin An
- Kaiser Permanente Southern California, Pasadena, California, USA
| | - Matthew L Maciejewski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| |
Collapse
|
15
|
Plassman BL, Ford CB, Smith VA, DePasquale N, Burke JR, Korthauer L, Ott BR, Belanger E, Shepherd-Banigan ME, Couch E, Jutkowitz E, O’Brien EC, Sorenson C, Wetle TT, Van Houtven CH. Elevated Amyloid-β PET Scan and Cognitive and Functional Decline in Mild Cognitive Impairment and Dementia of Uncertain Etiology. J Alzheimers Dis 2024; 97:1161-1171. [PMID: 38306055 PMCID: PMC11034799 DOI: 10.3233/jad-230950] [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: 02/03/2024]
Abstract
BACKGROUND Elevated amyloid-β (Aβ) on positron emission tomography (PET) scan is used to aid diagnosis of Alzheimer's disease (AD), but many prior studies have focused on patients with a typical AD phenotype such as amnestic mild cognitive impairment (MCI). Little is known about whether elevated Aβ on PET scan predicts rate of cognitive and functional decline among those with MCI or dementia that is clinically less typical of early AD, thus leading to etiologic uncertainty. OBJECTIVE We aimed to investigate whether elevated Aβ on PET scan predicts cognitive and functional decline over an 18-month period in those with MCI or dementia of uncertain etiology. METHODS In 1,028 individuals with MCI or dementia of uncertain etiology, we evaluated the association between elevated Aβ on PET scan and change on a telephone cognitive status measure administered to the participant and change in everyday function as reported by their care partner. RESULTS Individuals with either MCI or dementia and elevated Aβ (66.6% of the sample) showed greater cognitive decline compared to those without elevated Aβ on PET scan, whose cognition was relatively stable over 18 months. Those with either MCI or dementia and elevated Aβ were also reported to have greater functional decline compared to those without elevated Aβ, even though the latter group showed significant care partner-reported functional decline over time. CONCLUSIONS Elevated Aβ on PET scan can be helpful in predicting rates of both cognitive and functional decline, even among cognitively impaired individuals with atypical presentations of AD.
Collapse
Affiliation(s)
- Brenda L. Plassman
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC, USA
- Department of Neurology, School of Medicine, Duke University, NC, USA
| | - Cassie B. Ford
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Valerie A. Smith
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC, USA
- Durham ADAPT, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Nicole DePasquale
- Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - James R. Burke
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC, USA
- Department of Neurology, School of Medicine, Duke University, NC, USA
| | - Laura Korthauer
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Brian R. Ott
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Emmanuelle Belanger
- Department of Health Services Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Megan E. Shepherd-Banigan
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Durham ADAPT, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
| | - Elyse Couch
- Department of Health Services Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Eric Jutkowitz
- Department of Health Services Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Emily C. O’Brien
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Corinna Sorenson
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Terrie T. Wetle
- Department of Health Services Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Courtney H. Van Houtven
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Durham ADAPT, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
| |
Collapse
|
16
|
Dennis PA, Stechuchak KM, Van Houtven CH, Decosimo K, Coffman CJ, Grubber JM, Lindquist JH, Sperber NR, Hastings SN, Shepherd‐Banigan M, Kaufman BG, Smith VA. Informing a home time measure reflective of quality of life: A data driven investigation of time frames and settings of health care utilization. Health Serv Res 2023; 58:1233-1244. [PMID: 37356820 PMCID: PMC10622302 DOI: 10.1111/1475-6773.14196] [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: 06/27/2023] Open
Abstract
OBJECTIVE To evaluate short- and long-term measures of health care utilization-days in the emergency department (ED), inpatient (IP) care, and rehabilitation in a post-acute care (PAC) facility-to understand how home time (i.e., days alive and not in an acute or PAC setting) corresponds to quality of life (QoL). DATA SOURCES Survey data on community-residing veterans combined with multipayer administrative data on health care utilization. STUDY DESIGN VA or Medicare health care utilization, quantified as days of care received in the ED, IP, and PAC in the 6 and 18 months preceding survey completion, were used to predict seven QoL-related measures collected during the survey. Elastic net machine learning was used to construct models, with resulting regression coefficients used to develop a weighted utilization variable. This was then compared with an unweighted count of days with any utilization. PRINCIPAL FINDINGS In the short term (6 months), PAC utilization emerged as the most salient predictor of decreased QoL, whereas no setting predominated in the long term (18 months). Results varied by outcome and time frame, with some protective effects observed. In the 6-month time frame, each weighted day of utilization was associated with a greater likelihood of activity of daily living deficits (0.5%, 95% CI: 0.1%-0.9%), as was the case with each unweighted day of utilization (0.6%, 95% CI: 0.3%-1.0%). The same was true in the 18-month time frame (for both weighted and unweighted, 0.1%, 95% CI: 0.0%-0.3%). Days of utilization were also significantly associated with greater rates of instrumental ADL deficits and fair/poor health, albeit not consistently across all models. Neither measure outperformed the other in direct comparisons. CONCLUSIONS These results can provide guidance on how to measure home time using multipayer administrative data. While no setting predominated in the long term, all settings were significant predictors of QoL measures.
Collapse
Affiliation(s)
- Paul A. Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Karen M. Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
| | - Courtney H. Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Duke‐Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Kasey Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
| | - Cynthia J. Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Biostatistics and BioinformaticsDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Janet M. Grubber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Cooperative Studies Program Coordinating Center, Veterans Affairs Boston Healthcare SystemBostonMassachusettsUSA
| | - Jennifer H. Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
| | - Nina R. Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - S. Nicole Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Geriatrics Research, Education, and Clinical Center, Durham VA Health Care SystemDurhamNorth CarolinaUSA
- Center for the Study of Aging and Human DevelopmentDuke UniversityDurhamNorth CarolinaUSA
| | - Megan Shepherd‐Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Duke‐Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Brystana G. Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Duke‐Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| |
Collapse
|
17
|
Van Houtven CH, Miller KEM, James HJ, Blunt R, Zhang W, Mariani AC, Rose S, Alolod GP, Wilson-Genderson M, Smith VA, Thomson MD, Siminoff LA. Economic costs of family caregiving for persons with advanced stage cancer: a longitudinal cohort study. J Cancer Surviv 2023:10.1007/s11764-023-01462-6. [PMID: 37823982 DOI: 10.1007/s11764-023-01462-6] [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] [Received: 07/03/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE To form a multifaceted picture of family caregiver economic costs in advanced cancer. METHODS A multi-site cohort study collected prospective longitudinal data from caregivers of patients with advanced solid tumor cancers. Caregiver survey and out-of-pocket (OOP) receipt data were collected biweekly in-person for up to 24 weeks. Economic cost measures attributed to caregiving were as follows: amount of OOP costs, debt accrual, perceived economic situation, and working for pay. Descriptive analysis illustrates economic outcomes over time. Generalized linear mixed effects models asses the association of objective burden and economic outcomes, controlling for subjective burden and other factors. Objective burden is number of activities and instrumental activities of daily living (ADL/IADL) tasks, all caregiving tasks, and amount of time spent caregiving over 24 h. RESULTS One hundred ninety-eight caregivers, 41% identifying as Black, were followed for a mean period of 16 weeks. Median 2-week out-of-pocket costs were $111. One-third of caregivers incurred debt to care for the patient and 24% reported being in an adverse economic situation. Whereas 49.5% reported working at study visit 1, 28.6% of caregivers at the last study visit reported working. In adjusted analysis, a higher number of caregiving tasks overall and ADL/IADL tasks specifically were associated with lower out-of-pocket expenses, a lower likelihood of working, and a higher likelihood of incurring debt and reporting an adverse economic situation. CONCLUSIONS Most caregivers of cancer patients with advanced stage disease experienced direct and indirect economic costs. IMPLICATIONS FOR CANCER SURVIVORS Results support the need to find solutions to lessen economic costs for caregivers of persons with advanced cancer.
Collapse
Affiliation(s)
- Courtney Harold Van Houtven
- Department of Population Health Sciences, Duke University, 215 Morris Street, Durham, NC, 27701, USA.
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA.
- Duke-Margolis Center for Health Policy, Washington, DC, USA.
| | - Katherine E M Miller
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, USA
| | - Hailey J James
- RTI International, 3040 Cornwallis Road, Durham, NC, 27709, USA
| | - Ryan Blunt
- Department of Social and Behavioral Sciences, Temple University, 1700 N. Broad Street, Philadelphia, PA, 19121, USA
| | - Wenhan Zhang
- Department of Population Health Sciences, Duke University, 215 Morris Street, Durham, NC, 27701, USA
| | - Abigail Cadua Mariani
- Department of Health Behavior and Policy, Virginia Commonwealth University, 830 E. Main Street, Richmond, VA, 23219, USA
| | - Sydney Rose
- Department of Social and Behavioral Sciences, Temple University, 1700 N. Broad Street, Philadelphia, PA, 19121, USA
| | - Gerard P Alolod
- Department of Social and Behavioral Sciences, Temple University, 1700 N. Broad Street, Philadelphia, PA, 19121, USA
| | - Maureen Wilson-Genderson
- Department of Social and Behavioral Sciences, Temple University, 1700 N. Broad Street, Philadelphia, PA, 19121, USA
| | - Valerie A Smith
- Department of Population Health Sciences, Duke University, 215 Morris Street, Durham, NC, 27701, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, 27705, USA
| | - Maria D Thomson
- Department of Health Behavior and Policy, Virginia Commonwealth University, 830 E. Main Street, Richmond, VA, 23219, USA
| | - Laura A Siminoff
- Department of Social and Behavioral Sciences, Temple University, 1700 N. Broad Street, Philadelphia, PA, 19121, USA
| |
Collapse
|
18
|
Abstract
OBJECTIVE In a large multisite cohort of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy, we compared the 5-year suicidal ideation and attempt rates with matched nonsurgical controls. BACKGROUND Bariatric surgery has significant health benefits but has also been associated with adverse mental health outcomes. METHODS Five-year rates of suicidal ideation and suicide attempts of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy from the fiscal year 2000-2016 to matched nonsurgical controls using sequential stratification using cumulative incidence functions (ideation cohort: n=38,199; attempt cohort: n=38,661 after excluding patients with past-year outcome events). Adjusted differences in suicidal ideation and suicide attempts were estimated using a Cox regression with a robust sandwich variance estimator. RESULTS In the matched cohorts for suicidal ideation analyses, the mean age was 53.47 years and the majority were males (78.7%) and White (77.7%). Over 40% were treated for depression (41.8%), had a nonrecent depression diagnosis (40.9%), and 4.1% had past suicidal ideation or suicide attempts >1 year before index. Characteristics of the suicide attempt cohort were similar. Regression results found that risk of suicidal ideation was significantly higher for surgical patients (adjusted hazard ratio=1.21, 95% CI: 1.03-1.41), as was risk of suicide attempt (adjusted hazard ratio=1.62, 95% CI: 1.22-2.15). CONCLUSIONS Bariatric surgery appears to be associated with a greater risk of suicidal ideation and attempts than nonsurgical treatment of patients with severe obesity, suggesting that patients need careful monitoring for suicidal ideation and additional psychological support after bariatric surgery.
Collapse
Affiliation(s)
- Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Theodore S. Z. Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC
| | - David E. Arterburn
- Department of Medicine, University of Washington, Seattle, WA
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - James E. Mitchell
- University of North Dakota School of Medicine and Health Sciences, Fargo, ND Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Katharine A. Bradley
- Department of Medicine, University of Washington, Seattle, WA
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Services, University of Washington, Seattle, WA
| | - Nathan A. Kimbrel
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC
- Durham Veterans Affairs (VA) Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| |
Collapse
|
19
|
Iwashyna TJ, Seelye S, Berkowitz TS, Pura J, Bohnert ASB, Bowling CB, Boyko EJ, Hynes DM, Ioannou GN, Maciejewski ML, O’Hare AM, Viglianti EM, Womer J, Prescott HC, Smith VA. Late Mortality After COVID-19 Infection Among US Veterans vs Risk-Matched Comparators: A 2-Year Cohort Analysis. JAMA Intern Med 2023; 183:1111-1119. [PMID: 37603339 PMCID: PMC10442778 DOI: 10.1001/jamainternmed.2023.3587] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/09/2023] [Indexed: 08/22/2023]
Abstract
Importance Despite growing evidence of persistent problems after acute COVID-19, how long the excess mortality risk associated with COVID-19 persists is unknown. Objective To measure the time course of differential mortality among Veterans who had a first-documented COVID-19 infection by separately assessing acute mortality from later mortality among matched groups with infected and uninfected individuals who survived and were uncensored at the start of each period. Design, Settings, and Participants This retrospective cohort study used prospectively collected health record data from Veterans Affairs hospitals across the US on Veterans who had COVID-19 between March 2020 and April 2021. Each individual was matched with up to 5 comparators who had not been infected with COVID-19 at the time of matching. This match balanced, on a month-by-month basis, the risk of developing COVID-19 using 37 variables measured in the 24 months before the date of the infection or match. A primary analysis censored comparators when they developed COVID-19 with inverse probability of censoring weighting in Cox regression. A secondary analysis did not censor. Data analyses were performed from April 2021 through June 2023. Exposure First-documented case of COVID-19 (SARS-CoV-2) infection. Main Outcome Measures Hazard ratios for all-cause mortality at clinically meaningful intervals after infection: 0 to 90, 91 to 180, 181 to 365, and 366 to 730 days. Results The study sample comprised 208 061 Veterans with first-documented COVID-19 infection (mean [SD] age, 60.5 (16.2) years; 21 936 (10.5) women; 47 645 [22.9] Black and 139 604 [67.1] White individuals) and 1 037 423 matched uninfected comparators with similar characteristics. Veterans with COVID-19 had an unadjusted mortality rate of 8.7% during the 2-year period after the initial infection compared with 4.1% among uninfected comparators, with censoring if the comparator later developed COVID-19-an adjusted hazard ratio (aHR) of 2.01 (95% CI, 1.98-2.04). The risk of excess death varied, being highest during days 0 to 90 after infection (aHR, 6.36; 95% CI, 6.20-6.51) and still elevated during days 91 to 180 (aHR, 1.18; 95% CI, 1.12-1.23). Those who survived COVID-19 had decreased mortality on days 181 to 365 (aHR, 0.92; 95% CI, 0.89-0.95) and 366 to 730 (aHR, 0.89; 95% CI, 0.85-0.92). These patterns were consistent across sensitivity analyses. Conclusion and Relevance The findings of this retrospective cohort study indicate that although overall 2-year mortality risk was worse among those infected with COVID-19, by day 180 after infection they had no excess mortality during the next 1.5 years.
Collapse
Affiliation(s)
- Theodore J. Iwashyna
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Sarah Seelye
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
| | - Theodore S. Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - John Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - Amy S. B. Bohnert
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor
| | - C. Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Durham VA Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Edward J. Boyko
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Denise M. Hynes
- VA Center to Improve Veteran Involvement in Care, Portland, Oregon
- College of Public Health and Human Sciences and Center for Quantitative Life Sciences, Oregon State University, Corvallis
- School of Nursing, Oregon Health and Science University, Portland
| | - George N. Ioannou
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Ann M. O’Hare
- VA Puget Sound Health Care System Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation for Veteran Centered and Value Driven Care, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Elizabeth M. Viglianti
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - James Womer
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Hallie C. Prescott
- Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| |
Collapse
|
20
|
Diamantidis CJ, Zepel L, Smith VA, Brookhart MA, Burks E, Bowling CB, Maciejewski ML, Wang V. Epidemiology of Community-Acquired Acute Kidney Injury Among US Veterans. Am J Kidney Dis 2023; 82:300-310. [PMID: 36963745 PMCID: PMC10517060 DOI: 10.1053/j.ajkd.2023.01.448] [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] [Received: 06/07/2022] [Accepted: 01/15/2023] [Indexed: 03/26/2023]
Abstract
RATIONALE & OBJECTIVE Community-acquired acute kidney injury (CA-AKI) develops outside of the hospital and is the most common form of AKI globally. National estimates of CA-AKI in the United States are absent due to limited availability of laboratory data. This study leverages national data from the Veterans Health Administration (VA) to estimate incidence and risk factors of CA-AKI. STUDY DESIGN Retrospective cohort study using national VA administrative and laboratory data to assess cumulative CA-AKI incidence. SETTING & PARTICIPANTS VA primary care patients in 2013-2017 with recorded outpatient serum creatinine (Scr) and no history of chronic kidney disease≥stage 5. PREDICTOR Sociodemographics, comorbidities, medication use, and health care utilization. OUTCOME Annual incidence of CA-AKI defined as a≥1.5-fold relative increase in Scr on either a subsequent outpatient Scr or inpatient Scr obtained within ≤24 hours of admission. ANALYTICAL APPROACH We calculated the relative change in Scr within 12 months of an outpatient Scr value. A Cox model was used to estimate the association between CA-AKI and baseline characteristics, accounting for repeated measurements. RESULTS Of approximately 2.5 million eligible veterans each year, the cumulative incidence of CA-AKI was approximately 2% annually. Only 27% of CA-AKI was detected at hospital admission. In adjusted analyses, high health care utilization, chronic illness, cancer, rural location, female sex, and use of renin-angiotensin aldosterone system inhibitors or diuretics were associated with increased CA-AKI risk (all, HR>1.20). LIMITATIONS Limited generalizability of results outside a veteran population, lack of a standardized definition for CA-AKI, and possibility of surveillance bias and misclassification. CONCLUSIONS CA-AKI affects 1 of every 50 US veterans annually. With less than a third of CA-AKI observed in the inpatient hospital setting, reliance on inpatient evaluation of AKI suggests significant underrecognition and missed opportunities to prevent and manage the long-term consequences of AKI.
Collapse
Affiliation(s)
- Clarissa J Diamantidis
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina; Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina.
| | - Lindsay Zepel
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina
| | - Valerie A Smith
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina; Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - M Alan Brookhart
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - Erin Burks
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina
| | - C Barrett Bowling
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina; Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Matthew L Maciejewski
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina; Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Virginia Wang
- Department of Medicine, School of Medicine, Duke University, Durham, North Carolina; Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina; Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina
| |
Collapse
|
21
|
Perfect CR, Lindquist J, Smith VA, Stanwyck C, Seidenfeld J, Van Houtven CH, Hastings SN. Are Geriatrics-Focused Primary Care Clinics Better at Diagnosing Dementia Than Traditional Clinics? A Matched Cohort Study. J Gen Intern Med 2023; 38:2710-2717. [PMID: 36941424 PMCID: PMC10506971 DOI: 10.1007/s11606-023-08136-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/01/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Dementia and mild cognitive impairment (MCI) are prevalent but underdiagnosed. OBJECTIVE To compare new dementia/MCI diagnosis rates in geriatrics-focused primary care clinics and traditional primary care clinics. DESIGN Secondary analysis of a prospective matched cohort study that spanned 2017-2021. PARTICIPANTS Community-dwelling Veterans over 65 receiving primary care in a geriatrics-focused medical home (GeriPACT) or traditional primary care home (PACT) at one of 57 Veterans Affairs sites. We excluded individuals with a documented diagnosis of dementia or MCI in the year prior to enrollment. MAIN MEASURES Diagnoses obtained from EHR. Cognitive status was assessed using modified Telephone Interview for Cognitive Status (mTICS) tool. KEY RESULTS The 470 participants included in this analysis were predominantly white, non-Hispanic males with an average age of 80.3 years. 9.4% of participants received a diagnosis of dementia/MCI after 24 months: 11.5% in GeriPACT and 7.2% in PACT. Adjusted OR for dementia/MCI diagnosis based on GeriPACT exposure was 1.47 (95% CI 0.65-3.29). Low mTICS score (≤ 27) (OR 4.89, 95% CI 2.36-10.13) and marital status (married/partnered) (OR 1.89, CI 0.99-3.59) were independent predictors of dementia/MCI diagnosis. When stratified by cognitive status: diagnosis rates were 20.8% in GeriPACT and 16.7% in PACT among those who scored lower on the cognitive assessment (mTICS ≤ 27); 7.4% in GeriPACT and 3.6% in PACT among those who scored higher (mTICS > 27). The OR for new dementia/MCI diagnosis in GeriPACT was 1.19 (95% CI 0.49-2.91) among those with a low mTICS score and 1.85 (95% CI 0.70-4.88) among those with a higher mTICS score. CONCLUSIONS Observed rates of new dementia/MCI diagnosis were higher in GeriPACT, but with considerable uncertainty around estimates. Geriatrics-focused primary care clinics may be a promising avenue for improving the detection of dementia in older adults, but further larger studies are needed to confirm this relationship.
Collapse
Affiliation(s)
- Chelsea R Perfect
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - J Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - V A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of General Internal Medicine, Duke University, Durham, NC, USA
| | - C Stanwyck
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
| | - J Seidenfeld
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Emergency Medicine, Durham VA Health Care System, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | - C H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
| | - S N Hastings
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research Education and Clinical Center (GRECC), Durham Veterans Affairs Health Care System, Durham, NC, USA
| |
Collapse
|
22
|
Smith VA, Berkowitz TSZ, Hebert P, Wong ES, Niederhausen M, Pura JA, Berry K, Green P, Korpak A, Fox A, Baraff A, Hickok A, Shahoumian TA, Bohnert ASB, Hynes DM, Boyko EJ, Ioannou GN, Iwashyna TJ, Bowling CB, O'Hare AM, Maciejewski ML. Correction: Design and analysis of outcomes following SARS-CoV-2 infection in veterans. BMC Med Res Methodol 2023; 23:194. [PMID: 37620765 PMCID: PMC10463685 DOI: 10.1186/s12874-023-02021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
Affiliation(s)
- Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Theodore S Z Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Paul Hebert
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Edwin S Wong
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University (OHSU), Portland, OR, USA
- Portland State University School of Public Health, Portland, OR, USA
| | - John A Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Kristin Berry
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Pamela Green
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Anna Korpak
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Aaron Baraff
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Alex Hickok
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Troy A Shahoumian
- Population Health: Health Solutions, Veterans Health Administration, Washington, DC, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research, Ann Arbor, VA, MI, USA
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- College of Public Health and Human Sciences, Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - George N Ioannou
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Theodore J Iwashyna
- VA Center for Clinical Management Research, Ann Arbor, VA, MI, USA
- National Clinical Scholars Program, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
- Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Ann M O'Hare
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value- Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Nephrology, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA.
| |
Collapse
|
23
|
Everett C, Christy J, Batchelder H, Morgan PA, Docherty S, Smith VA, Anderson JB, Viera A, Jackson GL. Impact of primary care usual provider type and provider interdependence on outcomes for patients with diabetes: a cohort study. BMJ Open Qual 2023; 12:e002229. [PMID: 37311623 DOI: 10.1136/bmjoq-2022-002229] [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: 12/15/2022] [Accepted: 05/23/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Interprofessional primary care (PC) teams are key to the provision of high-quality care. PC providers often 'share' patients (eg, a patient may see multiple providers in the same clinic), resulting in between-visit interdependence between providers. However, concern remains that PC provider interdependence will reduce quality of care, causing some organisations to hesitate in creating multiple provider teams. If PC provider teams are formalised, the PC usual provider of care (UPC) type (physician, nurse practitioner (NP) or physician assistant/associate (PA)) should be determined for patients with varying levels of medical complexity. OBJECTIVE To evaluate the impact of PC provider interdependence, UPC type and patient complexity on diabetes-specific outcomes for adult patients with diabetes. DESIGN Cohort study using electronic health record data from 26 PC practices in central North Carolina, USA. PARTICIPANTS Adult patients with diabetes (N=10 498) who received PC in 2016 and 2017. OUTCOME Testing for diabetes control, testing for lipid levels, mean glycated haemoglobin (HbA1c) values and mean low-density lipoprotein (LDL) values in 2017. RESULTS Receipt of guideline recommended testing was high (72% for HbA1c and 66% for LDL testing), HbA1c values were 7.5% and LDL values were 88.5 mg/dL. When controlling for a range of patient and panel level variables, increases in PC provider interdependence were not significantly associated with diabetes-specific outcomes. Similarly, there were no significant differences in the diabetes outcomes for patients with NP/PA UPCs when compared with physicians. The number and type of a patient's chronic conditions did impact the receipt of testing, but not average values for HbA1c and LDL. CONCLUSIONS A range of UPC types on PC multiple provider teams can deliver guideline-recommended diabetes care. However, the number and type of a patient's chronic conditions alone impacted the receipt of testing, but not average values for HbA1c and LDL.
Collapse
Affiliation(s)
- Christine Everett
- Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jacob Christy
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Heather Batchelder
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Perri A Morgan
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Valerie A Smith
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - John B Anderson
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Primary Care, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anthony Viera
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - George L Jackson
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Petter O'Donnel Jr. School of Public Health, Unitersity of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
24
|
Shepherd-Banigan M, Shapiro A, Stechuchak KM, Sheahan KL, Ackland PE, Smith VA, Bokhour BG, Glynn SM, Calhoun PS, Edelman D, Weidenbacher HJ, Eldridge MR, Van Houtven CH. Exploring the importance of predisposing, enabling, and need factors for promoting Veteran engagement in mental health therapy for post-traumatic stress: a multiple methods study. BMC Psychiatry 2023; 23:372. [PMID: 37237261 DOI: 10.1186/s12888-023-04840-7] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
PURPOSE This study explored Veteran and family member perspectives on factors that drive post-traumatic stress disorder (PTSD) therapy engagement within constructs of the Andersen model of behavioral health service utilization. Despite efforts by the Department of Veterans Affairs (VA) to increase mental health care access, the proportion of Veterans with PTSD who engage in PTSD therapy remains low. Support for therapy from family members and friends could improve Veteran therapy use. METHODS We applied a multiple methods approach using data from VA administrative data and semi-structured individual interviews with Veterans and their support partners who applied to the VA Caregiver Support Program. We integrated findings from a machine learning analysis of quantitative data with findings from a qualitative analysis of the semi-structured interviews. RESULTS In quantitative models, Veteran medical need for health care use most influenced treatment initiation and retention. However, qualitative data suggested mental health symptoms combined with positive Veteran and support partner treatment attitudes motivated treatment engagement. Veterans indicated their motivation to seek treatment increased when family members perceived treatment to be of high value. Veterans who experienced poor continuity of VA care, group, and virtual treatment modalities expressed less care satisfaction. Prior marital therapy use emerged as a potentially new facilitator of PTSD treatment engagement that warrants more exploration. CONCLUSIONS Our multiple methods findings represent Veteran and support partner perspectives and show that amid Veteran and organizational barriers to care, attitudes and support of family members and friends still matter. Family-oriented services and intervention could be a gateway to increase Veteran PTSD therapy engagement.
Collapse
Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, Box 90120, 100 Fuqua Drive, Durham, NC, 27708, USA
| | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA.
| | | | - Kate L Sheahan
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Valerie A Smith
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Road (152), Bedford, MA, 01730, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, The Albert Sherman Center, Worcester, MA, 01605, USA
| | - Shirley M Glynn
- UCLA Semel Institute of Neuroscience and Human Behavior, VA Greater Los Angeles Healthcare System at West Los Angeles, B151 11301 Whiltshire Boulevard, Los Angeles, CA, 90073, USA
| | - Patrick S Calhoun
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701, USA
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | | | | | - Courtney H Van Houtven
- Durham VA Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, Box 90120, 100 Fuqua Drive, Durham, NC, 27708, USA
| |
Collapse
|
25
|
Blalock DV, Pura JA, Stechuchak KM, Dennis PA, Maciejewski ML, Smith VA, Hung A, Hoerster KD, Wong ES. BMI Trends for Veterans Up to 10 Years After VA Enrollment Following Military Discharge. J Gen Intern Med 2023; 38:1423-1430. [PMID: 36219304 PMCID: PMC9552734 DOI: 10.1007/s11606-022-07818-5] [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: 05/07/2022] [Accepted: 09/15/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Obesity (body mass index [BMI]≥30kg/m2) among US adults has tripled over the past 45 years, but it is unclear how this population-level weight change has occurred. OBJECTIVE We sought to identify distinct long-term BMI trajectories and examined associations with demographic and clinical characteristics. DESIGN The design was latent trajectory modeling over 10 years of a retrospective cohort. Subgroups were identified via latent class growth mixture models, separately by sex. Weighted multinomial logistic regressions identified factors associated with subgroup membership. PARTICIPANTS Participants were a retrospective cohort of 292,331 males and 62,898 females enrolled in VA. MAIN MEASURES The main outcome measure was 6-month average VA-measured BMI over the course of 10 years. Additional electronic health record measures on demographic, clinical, and services utilization characteristics were also used to characterize latent trajectories. KEY RESULTS Four trajectories were identified for men and for women, corresponding to standard BMI categories "normal weight" (BMI <25), "overweight" (BMI 25-29.99), and "with obesity" (BMI ≥30): "normal weight" and increasing (males: 28.4%; females: 22.8%), "overweight" and increasing (36.4%; 35.6%), "with obesity" and increasing (33.6%; 40.0%), and "with obesity" and stable (males: 1.6%) or decreasing (females: 1.6%). Race, ethnicity, comorbidities, mental health diagnoses, and mental health service utilization discriminated among classes. CONCLUSIONS BMI in the 10 years following VA enrollment increased modestly. VA should continue prioritizing weight management interventions to the large number of veterans with obesity upon VA enrollment, because the majority remain with obesity.
Collapse
Affiliation(s)
- Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - John A Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Paul A Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA.
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA.
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Katherine D Hoerster
- Seattle-Denver Center for Innovation, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Edwin S Wong
- Seattle-Denver Center for Innovation, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| |
Collapse
|
26
|
Smith VA, Berkowitz TSZ, Hebert P, Wong ES, Niederhausen M, Pura JA, Berry K, Green P, Korpak A, Fox A, Baraff A, Hickok A, Shahoumian TA, Bohnert ASB, Hynes DM, Boyko EJ, Ioannou GN, Iwashyna TJ, Bowling CB, O'Hare AM, Maciejewski ML. Design and analysis of outcomes following SARS-CoV-2 infection in veterans. BMC Med Res Methodol 2023; 23:81. [PMID: 37016340 PMCID: PMC10071454 DOI: 10.1186/s12874-023-01882-z] [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] [Received: 06/02/2022] [Accepted: 03/03/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Understanding how SARS-CoV-2 infection impacts long-term patient outcomes requires identification of comparable persons with and without infection. We report the design and implementation of a matching strategy employed by the Department of Veterans Affairs' (VA) COVID-19 Observational Research Collaboratory (CORC) to develop comparable cohorts of SARS-CoV-2 infected and uninfected persons for the purpose of inferring potential causative long-term adverse effects of SARS-CoV-2 infection in the Veteran population. METHODS In a retrospective cohort study, we identified VA health care system patients who were and were not infected with SARS-CoV-2 on a rolling monthly basis. We generated matched cohorts within each month utilizing a combination of exact and time-varying propensity score matching based on electronic health record (EHR)-derived covariates that can be confounders or risk factors across a range of outcomes. RESULTS From an initial pool of 126,689,864 person-months of observation, we generated final matched cohorts of 208,536 Veterans infected between March 2020-April 2021 and 3,014,091 uninfected Veterans. Matched cohorts were well-balanced on all 39 covariates used in matching after excluding patients for: no VA health care utilization; implausible age, weight, or height; living outside of the 50 states or Washington, D.C.; prior SARS-CoV-2 diagnosis per Medicare claims; or lack of a suitable match. Most Veterans in the matched cohort were male (88.3%), non-Hispanic (87.1%), white (67.2%), and living in urban areas (71.5%), with a mean age of 60.6, BMI of 31.3, Gagne comorbidity score of 1.4 and a mean of 2.3 CDC high-risk conditions. The most common diagnoses were hypertension (61.4%), diabetes (34.3%), major depression (32.2%), coronary heart disease (28.5%), PTSD (25.5%), anxiety (22.5%), and chronic kidney disease (22.5%). CONCLUSION This successful creation of matched SARS-CoV-2 infected and uninfected patient cohorts from the largest integrated health system in the United States will support cohort studies of outcomes derived from EHRs and sample selection for qualitative interviews and patient surveys. These studies will increase our understanding of the long-term outcomes of Veterans who were infected with SARS-CoV-2.
Collapse
Affiliation(s)
- Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Theodore S Z Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Paul Hebert
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Edwin S Wong
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Oregon Health & Science University (OHSU), Portland, OR, USA
- Portland State University School of Public Health, Portland, OR, USA
| | - John A Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Kristin Berry
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Pamela Green
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Anna Korpak
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Alexandra Fox
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Aaron Baraff
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - Alex Hickok
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Troy A Shahoumian
- Population Health: Health Solutions, Veterans Health Administration, Washington, DC, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research, Ann Arbor, VA, MI, USA
- Departments of Anesthesiology and Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denise M Hynes
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- College of Public Health and Human Sciences, Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, VA Puget Sound, Seattle, WA, USA
| | - George N Ioannou
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Theodore J Iwashyna
- VA Center for Clinical Management Research, Ann Arbor, VA, MI, USA
- National Clinical Scholars Program, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - C Barrett Bowling
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
- Geriatric Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Ann M O'Hare
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, and Gastroenterology section, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Division of Nephrology, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA.
| |
Collapse
|
27
|
Greene L, Maciejewski ML, Grubber J, Smith VA, Blalock DV, Zulman DM. Association between patient-reported social, behavioral, and health factors and emergency department visits in high-risk VA patients. Health Serv Res 2023; 58:383-391. [PMID: 36310448 PMCID: PMC10012238 DOI: 10.1111/1475-6773.14094] [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: 11/04/2022] Open
Abstract
RESEARCH OBJECTIVE To identify patient-reported social risk, behavioral, and health factors associated with emergency department (ED) utilization in high-risk Veterans Affairs (VA) patients. DATA SOURCES Patient survey, VA, Medicare data. STUDY DESIGN Prospective cohort study using multivariable logistic regression to identify patient-reported factors associated with all-cause and ambulatory care sensitive condition (ACSC)-related ED visits among VA patients at high risk for hospitalization or death. DATA EXTRACTION METHODS Patient-reported measures derived from a 2018 survey sent to 10,000 VA patients; clinical and demographic characteristics derived from VA data; ED visits derived from VA and Medicare claims. PRINCIPAL FINDINGS Among 4680 survey respondents, 52.5% and 16.3% experienced an all-cause or ACSC-related ED visit in the following year, respectively. An ED visit was more likely among individuals with functional status limitations (6.0% points (Confidence Interval [CI] 0.017-0.103)) and transportation barriers (5.2% points [CI 0.005-0.099]). An ACSC-related ED visit was more likely among individuals with functional status limitations (3.2% points [CI 0.003-0.062]) and self-rated poorer health (7.4% points (CI 0.030-0.119) poor; 6.2% points (CI 0.029-0.096) fair; 4.1% points (CI 0.009-0.073) good; compared with excellent/very good). CONCLUSIONS Patient-reported factors not present in most electronic health records were significantly associated with future ED visits in high-risk VA patients.
Collapse
Affiliation(s)
- Liberty Greene
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Matthew L. Maciejewski
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Janet Grubber
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Valerie A. Smith
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Durham VA Medical CenterDurhamNorth CarolinaUSA
| | - Dan V. Blalock
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Durham VA Medical CenterDurhamNorth CarolinaUSA
| | - Donna M. Zulman
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| |
Collapse
|
28
|
Jacobs JC, Bowling CB, Brown T, Smith VA, Decosimo K, Wilson SM, Hastings SN, Shepherd-Banigan M, Allen K, Van Houtven C. Racial inequality in functional trajectories between Black and White U.S. veterans. J Am Geriatr Soc 2023; 71:1081-1092. [PMID: 36519710 PMCID: PMC10089950 DOI: 10.1111/jgs.18169] [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] [Received: 06/16/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Racial inequality in functional trajectories has been well documented in the U.S. civilian population but has not been explored among Veterans. Our objectives were to: (1) assess how functional trajectories differed for Black and White Veterans aged ≥50 and (2) explore how socioeconomic, psychosocial, and health-related factors altered the relationship between race and function. METHODS We conducted a prospective, longitudinal analysis using the 2006-2016 Health and Retirement Study. The study cohort included 3700 Veterans who self-identified as Black or White, responded to baseline psychosocial questionnaires, and were community-dwelling on first observation. We used stepwise and stratified linear mixed effects models of biannually assessed functional limitations. The outcome measure was as a count of functional limitations. Race was measured as respondent self-identification as Black or White. Demographic measures included gender and age. Socioeconomic resources included partnership status, education, income, and wealth. Psychosocial stressors included exposure to day-to-day and major discrimination, traumatic life events, stressful life events, and financial strain. Health measures included chronic and mental health diagnoses, smoking, rurality, and use of Veterans Affairs services. RESULTS Black Veterans developed functional limitations at earlier ages and experienced faster functional decline than White Veterans between the ages of 50 and 70, with convergence occurring at age 85. Once we accounted for economic resources and psychosocial stressors in multivariable analyses, the association between race and the number of functional limitations was no longer statistically significant. Lower wealth, greater financial strain, and traumatic life events were significantly associated with functional decline. CONCLUSIONS Health systems should consider how to track Veterans' function earlier in the life course to ensure that Black Veterans are able to get timely access to services that may slow premature functional decline. Providers may benefit from training about the role of economic resources and psychosocial stressors in physical health outcomes.
Collapse
Affiliation(s)
- Josephine C Jacobs
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Health Policy, Stanford University School of Medicine, Stanford, California, USA
| | - Christopher Barrett Bowling
- Durham Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Tyson Brown
- Department of Sociology, Duke University, Durham, North Carolina, USA
| | - Valerie A Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Kasey Decosimo
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
| | - Sarah M Wilson
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Susan Nicole Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Division of Geriatrics, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Megan Shepherd-Banigan
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Kelli Allen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Division of Rheumatology, Allergy, and Immunology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Courtney Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| |
Collapse
|
29
|
Miller KEM, Van Houtven CH, Kent EE, Gilleskie D, Holmes GM, Smith VA, Stearns SC. Short-term effects of comprehensive caregiver supports on caregiver outcomes. Health Serv Res 2023; 58:140-153. [PMID: 35848763 PMCID: PMC10501334 DOI: 10.1111/1475-6773.14038] [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: 01/17/2023] Open
Abstract
OBJECTIVE To estimate the association of the Veterans Health Administration (VHA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) implemented in 2011 with caregiver health and health care use. DATA SOURCES VHA claims and electronic health records from May 2009 to May 2018. STUDY DESIGN Using a retrospective, pre-post study design with inverse probability of treatment weights to address selection into treatment, we examine the association of PCAFC on caregivers who are veterans: (1) outpatient primary, specialty, and mental health care visits; (2) probability of uncontrolled hypertension and anxiety/depression; and (3) VHA health care costs. We compare outcomes for caregivers approved for PCAFC (treatment) to caregivers denied PCAFC (comparison). DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS In the year pre-application, we observe similar probabilities of having any VHA primary care (~36%), VHA specialty care (~24%), and VHA or VHA-purchased mental health care (~22%) for treatment and comparison caregivers. In the year post-application, treated caregivers had a 5.89 percentage point larger probability of any outpatient VHA primary care (p = 0.002) and 4.34 percentage points larger probability of any outpatient mental health care use (p = 0.014). Post-application, probabilities of having uncontrolled hypertension or diagnosed anxiety/depression were higher for both treated and comparison groups. In the second year post-application, treated caregivers had a 1.88 percentage point larger probability of uncontrolled hypertension (p = 0.019) and 4.68 percentage points larger probability of diagnosed anxiety/depression (predicted probabilities: treated = 0.30; comparison = 0.25; p = 0.005). We find no evidence of differences in VHA total costs by PCAFC status. CONCLUSIONS Our findings that PCAFC enrollment is associated with increased health care diagnosis and service use may reflect improved access for previously unmet needs in the population of veteran caregivers for veterans in PCAFC. The costs and value of these increases can be weighed against other effects of the program to inform national policies supporting caregivers.
Collapse
Affiliation(s)
- Katherine E. M. Miller
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham Virginia Health Care SystemDurhamNorth CarolinaUSA
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Courtney H. Van Houtven
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham Virginia Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Duke Margolis Center for Health PolicyDuke UniversityDurhamNorth CarolinaUSA
| | - Erin E. Kent
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Lineberger Comprehensive Cancer CenterThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Donna Gilleskie
- Department of EconomicsThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - G. Mark Holmes
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Valerie A. Smith
- Durham Center of Innovation to Accelerate Discovery and Practice TransformationDurham Virginia Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Sally C. Stearns
- Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Cecil G. Sheps Center for Health Services ResearchThe University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| |
Collapse
|
30
|
Mavragani A, Okusaga OO, Reuteman-Fowler JC, Oakes MM, Brown JN, Moore S, Lewinski AA, Rodriguez C, Moncayo N, Smith VA, Malone S, List J, Cho RY, Jeffreys AS, Bosworth HB. Digital Medicine System in Veterans With Severe Mental Illness: Feasibility and Acceptability Study. JMIR Form Res 2022; 6:e34893. [PMID: 36548028 PMCID: PMC9816955 DOI: 10.2196/34893] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 08/04/2022] [Accepted: 08/24/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Suboptimal medication adherence is a significant problem for patients with serious mental illness. Measuring medication adherence through subjective and objective measures can be challenging, time-consuming, and inaccurate. OBJECTIVE The primary purpose of this feasibility and acceptability study was to evaluate the impact of a digital medicine system (DMS) among Veterans (patients) with serious mental illness as compared with treatment as usual (TAU) on medication adherence. METHODS This open-label, 2-site, provider-randomized trial assessed aripiprazole refill adherence in Veterans with schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder. We randomized 26 providers such that their patients either received TAU or DMS for a period of 90 days. Semistructured interviews with patients and providers were used to examine the feasibility and acceptability of using the DMS. RESULTS We enrolled 46 patients across 2 Veterans Health Administration sites: 21 (46%) in DMS and 25 (54%) in TAU. There was no difference in the proportion of days covered by medication refill over 3 and 6 months (0.82, SD 0.24 and 0.75, SD 0.26 in DMS vs 0.86, SD 0.19 and 0.82, SD 0.21 in TAU, respectively). The DMS arm had 0.85 (SD 0.20) proportion of days covered during the period they were engaged with the DMS (mean 144, SD 100 days). Interviews with patients (n=14) and providers (n=5) elicited themes salient to using the DMS. Patient findings described the positive impact of the DMS on medication adherence, challenges with the DMS patch connectivity and skin irritation, and challenges with the DMS app that affected overall use. Providers described an overall interest in using a DMS as an objective measure to support medication adherence in their patients. However, providers described challenges with the DMS dashboard and integrating DMS data into their workflow, which decreased the usability of the DMS for providers. CONCLUSIONS There was no observed difference in refill rates. Among those who engaged in the DMS arm, the proportion of days covered by refills were relatively high (mean 0.85, SD 0.20). The qualitative analyses highlighted areas for further refinement of the DMS. TRIAL REGISTRATION ClinicalTrials.gov NCT03881449; https://clinicaltrials.gov/ct2/show/NCT03881449.
Collapse
Affiliation(s)
| | - Olaoluwa O Okusaga
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States.,Department of Psychiatry and Behavioral Health Sciences, Baylor College of Medicine, Houston, TX, United States
| | - J Corey Reuteman-Fowler
- Global Clinical Development, Otsuka Pharmaceutical Development and Commercialization Inc., Princeton, NJ, United States
| | - Megan M Oakes
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, United States.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Jamie N Brown
- Pharmacy Service, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Scott Moore
- Durham Veterans Affairs Medical Center, Durham, NC, United States.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Allison A Lewinski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, United States.,School of Nursing, Duke University, Durham, NC, United States
| | - Cristin Rodriguez
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States.,Department of Psychiatry and Behavioral Health Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Norma Moncayo
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States.,Department of Psychiatry and Behavioral Health Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Valerie A Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, United States.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, United States
| | - Shauna Malone
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, United States.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Justine List
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States.,Department of Psychiatry and Behavioral Health Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Raymond Y Cho
- Mental Health Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States.,Department of Psychiatry and Behavioral Health Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Amy S Jeffreys
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, United States
| | - Hayden B Bosworth
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, United States.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, United States
| |
Collapse
|
31
|
Ioannou GN, Bohnert ASB, O'Hare AM, Boyko EJ, Maciejewski ML, Smith VA, Bowling CB, Viglianti E, Iwashyna TJ, Hynes DM, Berry K. Effectiveness of mRNA COVID-19 Vaccine Boosters Against Infection, Hospitalization, and Death: A Target Trial Emulation in the Omicron (B.1.1.529) Variant Era. Ann Intern Med 2022; 175:1693-1706. [PMID: 36215715 PMCID: PMC9575390 DOI: 10.7326/m22-1856] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The effectiveness of a third mRNA COVID-19 vaccine dose (booster dose) against the Omicron (B.1.1.529) variant is uncertain, especially in older, high-risk populations. OBJECTIVE To determine mRNA booster vaccine effectiveness (VE) against SARS-CoV-2 infection, hospitalization, and death in the Omicron era by booster type, primary vaccine type, time since primary vaccination, age, and comorbidity burden. DESIGN Retrospective matched cohort study designed to emulate a target trial of booster vaccination versus no booster, conducted from 1 December 2021 to 31 March 2022. SETTING U.S. Department of Veterans Affairs health care system. PARTICIPANTS Persons who had received 2 mRNA COVID-19 vaccine doses at least 5 months earlier. INTERVENTION Booster monovalent mRNA vaccination (Pfizer-BioNTech's BNT162b2 or Moderna's mRNA-1273) versus no booster. MEASUREMENTS Booster VE. RESULTS Each group included 490 838 well-matched persons, who were predominantly male (88%), had a mean age of 63.0 years (SD, 14.0), and were followed for up to 121 days (mean, 79.8 days). Booster VE more than 10 days after a booster dose was 42.3% (95% CI, 40.6% to 43.9%) against SARS-CoV-2 infection, 53.3% (CI, 48.1% to 58.0%) against SARS-CoV-2-related hospitalization, and 79.1% (CI, 71.2% to 84.9%) against SARS-CoV-2-related death. Booster VE was similar for different booster types (BNT162b2 or mRNA-1273), age groups, and primary vaccination regimens but was significantly higher with longer time since primary vaccination and higher comorbidity burden. LIMITATION Predominantly male population. CONCLUSION Booster mRNA vaccination was highly effective in preventing death and moderately effective in preventing infection and hospitalization for up to 4 months after administration in the Omicron era. Increased uptake of booster vaccination, which is currently suboptimal, should be pursued to limit the morbidity and mortality of SARS-CoV-2 infection, especially in persons with high comorbidity burden. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
Collapse
Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, University of Washington, and Research and Development and Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (G.N.I.)
| | - Amy S B Bohnert
- Department of Anesthesiology, University of Michigan Medical School, and Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan (A.S.B.B.)
| | - Ann M O'Hare
- Nephrology, Veterans Affairs Puget Sound Health Care System, and University of Washington, Seattle, Washington (A.M.O.)
| | - Edward J Boyko
- General Internal Medicine, Veterans Affairs Puget Sound Health Care System, and University of Washington, Seattle, Washington (E.J.B.)
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, and Department of Population Health Sciences, Duke-Margolis Center for Health Policy, and Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina (M.L.M.)
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, and Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina (V.A.S.)
| | - C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), and Department of Medicine, Duke University, Durham, North Carolina (C.B.B.)
| | - Elizabeth Viglianti
- Center for Clinical Management Research, VA Ann Arbor Health System, and Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (E.V., T.J.I.)
| | - Theodore J Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Health System, and Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (E.V., T.J.I.)
| | - Denise M Hynes
- Center of Innovation to Improve Veteran Involvement in Care, VA Portland Healthcare System, Portland, Oregon, and Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, and Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon (D.M.H.)
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington (K.B.)
| | | |
Collapse
|
32
|
Admon AJ, Wander PL, Iwashyna TJ, Ioannou GN, Boyko EJ, Hynes DM, Bowling CB, Bohnert AS, O’Hare AM, Smith VA, Pura J, Hebert PL, Wong ES, Niederhausen M, Maciejewski ML. Consensus elements for observational research on COVID-19-related long-term outcomes. Medicine (Baltimore) 2022; 101:e31248. [PMID: 36401423 PMCID: PMC9678399 DOI: 10.1097/md.0000000000031248] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its long-term outcomes may be jointly caused by a wide range of clinical, social, and economic characteristics. Studies aiming to identify mechanisms for SARS-CoV-2 morbidity and mortality must measure and account for these characteristics to arrive at unbiased, accurate conclusions. We sought to inform the design, measurement, and analysis of longitudinal studies of long-term outcomes among people infected with SARS-CoV-2. We fielded a survey to an interprofessional group of clinicians and scientists to identify factors associated with SARS-CoV-2 infection and subsequent outcomes. Using an iterative process, we refined the resulting list of factors into a consensus causal diagram relating infection and 12-month mortality. Finally, we operationalized concepts from the causal diagram into minimally sufficient adjustment sets using common medical record data elements. Total 31 investigators identified 49 potential risk factors for and 72 potential consequences of SARS-CoV-2 infection. Risk factors for infection with SARS-CoV-2 were grouped into five domains: demographics, physical health, mental health, personal social, and economic factors, and external social and economic factors. Consequences of coronavirus disease 2019 (COVID-19) were grouped into clinical consequences, social consequences, and economic consequences. Risk factors for SARS-CoV-2 infection were developed into a consensus directed acyclic graph for mortality that included two minimally sufficient adjustment sets. We present a collectively developed and iteratively refined list of data elements for observational research in SARS-CoV-2 infection and disease. By accounting for these elements, studies aimed at identifying causal pathways for long-term outcomes of SARS-CoV-2 infection can be made more informative.
Collapse
Affiliation(s)
- Andrew J. Admon
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Department of Internal Medicine, University of Michigan Medical School, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Pandora L. Wander
- Veterans Affairs Puget Sound Health Care System, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Theodore J. Iwashyna
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; U-M Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - George N. Ioannou
- Divisions of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle Epidemiologic Research and Information Center, Seattle, WA, USA
| | - Edward J. Boyko
- Veterans Affairs Puget Sound Health Care System Seattle Division, Seattle, Washington; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Denise M. Hynes
- Center to Improve Veteran Involvement in Care, VA Portland health care System, Portland, OR, College of Public Health and Human Sciences, and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA
| | - C. Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Department of Medicine, Duke University, Durham, NC, USA
| | - Amy S.B. Bohnert
- VA Center for Clinical Management Research, LTC Charles Kettles VA Medical Center, Department of Anesthesiology, University of Michigan Medical School, Department of Epidemiology, University of Michigan School of Public Health, U-M Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Ann M. O’Hare
- Hospital and Specialty Medicine Service and Seattle-Denver Center of Innovation, VA Puget Sound Health Care System and Department of Medicine, University of Washington, Seattle, WA, USA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Department of Population Health Sciences, Duke University Medical Center, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - John Pura
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Paul L. Hebert
- Veterans Affairs Puget Sound Health Care System, Department of Medicine, University of Washington School of Public Health, Seattle WA, USA
| | - Edwin S. Wong
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System; Department of Health Services, University of Washington, Seattle, WA, USA
| | - Meike Niederhausen
- Center to Improve Veteran Involvement in Care, VA Portland health care System, Oregon Health and Science University-Portland State University School of Public Health, Oregon Health and Science University, Portland, OR, USA
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center; Department of Population Health Sciences, Duke University, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
- * Correspondence: Matthew L. Maciejewski, Department of Population Health Sciences, Duke University Medical Center, 508 Fulton St, Ste 600, Durham NC 27705, USA (e-mail: )
| |
Collapse
|
33
|
Shepherd-Banigan ME, Ford CB, Smith VA, Belanger E, Wetle TT, Plassman BL, Burke JR, DePasquale N, O’Brien EC, Sorenson C, Van Houtven CH. Amyloid-β PET Scan Results Disclosure and Care-Partner Emotional Well-Being Over Time. J Alzheimers Dis 2022; 90:775-782. [DOI: 10.3233/jad-220611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Diagnostic tests, such as amyloid-β positron emission tomography (PET) scans, can increase appropriate therapeutic management for the underlying causes of cognitive decline. To evaluate the full utility of this diagnostic tool, information is needed on whether results from amyloid-β PET scans influence care-partner outcomes. Objective: This study examines the extent to which previous disclosure of elevated amyloid (suggestive of Alzheimer’s disease (AD) etiology) versus not-elevated amyloid (not suggestive of AD etiology) is associated with changes in care-partner wellbeing. Methods: The study used data derived from a national longitudinal survey of Medicare beneficiaries (n = 921) with mild cognitive impairment (MCI) or dementia and their care-partners. Care-partner wellbeing outcomes included depressive symptoms (PHQ-8), subjective burden (4-item Zarit burden score), and a 3-item measure of loneliness. Change was measured between 4 (Time 1) and 18 (Time 2) months after receiving the scan results. Adjusted linear regression models regressed change (Time 2-Time 1) in each outcome on scan result. Results: Care-partners were primarily white, non-Hispanic, college-educated, and married to the care recipient. Elevated amyloid was not associated with statistically significant Time 1 differences in outcomes or with statistically significant changes in depressive symptoms 0.22 (–0.18, 0.61), subjective burden 0.36 (–0.01, 0.73), or loneliness 0.15 (–0.01, 0.32) for care-partners from one time point to another. Conclusion: Given advances in AD biomarker testing, future research in more diverse samples is needed to understand the influence of scan results on care-partner wellbeing across populations.
Collapse
Affiliation(s)
- Megan E. Shepherd-Banigan
- Duke University, Department of Population Health Sciences, Durham, NC, USA
- Duke-Margolis Centerfor Health Policy, Durham, NC, USA
- Durham VA Health Care System, Durham, NC, USA
| | - Cassie B. Ford
- Duke University, Department of Population Health Sciences, Durham, NC, USA
| | - Valerie A. Smith
- Duke University, Department of Population Health Sciences, Durham, NC, USA
- Durham VA Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI, USA
| | - Terrie T. Wetle
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI, USA
| | - Brenda L. Plassman
- Department of Neurology and Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - James R. Burke
- Department of Neurology and Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Nicole DePasquale
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Emily C. O’Brien
- Duke University, Department of Population Health Sciences, Durham, NC, USA
| | - Corinna Sorenson
- Duke University, Department of Population Health Sciences, Durham, NC, USA
- Duke-Margolis Centerfor Health Policy, Durham, NC, USA
- Duke University, Sanford School of Public Policy, Durham, NC, USA
| | - Courtney H. Van Houtven
- Duke University, Department of Population Health Sciences, Durham, NC, USA
- Duke-Margolis Centerfor Health Policy, Durham, NC, USA
- Durham VA Health Care System, Durham, NC, USA
| |
Collapse
|
34
|
Kobe EA, Lewinski AA, Jeffreys AS, Smith VA, Coffman CJ, Danus SM, Sidoli E, Greck BD, Horne L, Saxon DR, Shook S, Aguirre LE, Esquibel MG, Evenson C, Elizagaray C, Nelson V, Zeek A, Weppner WG, Scodellaro S, Perdew CJ, Jackson GL, Steinhauser K, Bosworth HB, Edelman D, Crowley MJ. Implementation of an Intensive Telehealth Intervention for Rural Patients with Clinic-Refractory Diabetes. J Gen Intern Med 2022; 37:3080-3088. [PMID: 34981358 PMCID: PMC8722663 DOI: 10.1007/s11606-021-07281-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/12/2021] [Accepted: 11/10/2021] [Indexed: 10/31/2022]
Abstract
BACKGROUND Rural patients with type 2 diabetes (T2D) may experience poor glycemic control due to limited access to T2D specialty care and self-management support. Telehealth can facilitate delivery of comprehensive T2D care to rural patients, but implementation in clinical practice is challenging. OBJECTIVE To examine the implementation of Advanced Comprehensive Diabetes Care (ACDC), an evidence-based, comprehensive telehealth intervention for clinic-refractory, uncontrolled T2D. ACDC leverages existing Veterans Health Administration (VHA) Home Telehealth (HT) infrastructure, making delivery practical in rural areas. DESIGN Mixed-methods implementation study. PARTICIPANTS 230 patients with clinic-refractory, uncontrolled T2D. INTERVENTION ACDC bundles telemonitoring, self-management support, and specialist-guided medication management, and is delivered over 6 months using existing VHA HT clinical staffing/equipment. Patients may continue in a maintenance protocol after the initial 6-month intervention period. MAIN MEASURES Implementation was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The primary effectiveness outcome was hemoglobin A1c (HbA1c). KEY RESULTS From 2017 to 2020, ACDC was delivered to 230 patients across seven geographically diverse VHA sites; on average, patients were 59 years of age, 95% male, 80% white, and 14% Hispanic/Latinx. Patients completed an average of 10.1 of 12 scheduled encounters during the 6-month intervention period. Model-estimated mean baseline HbA1c was 9.56% and improved to 8.14% at 6 months (- 1.43%, 95% CI: - 1.64, - 1.21; P < .001). Benefits persisted at 12 (- 1.26%, 95% CI: - 1.48, - 1.05; P < .001) and 18 months (- 1.08%, 95% CI - 1.35, - 0.81; P < .001). Patients reported increased engagement in self-management and awareness of glycemic control, while clinicians and HT nurses reported a moderate workload increase. As of this submission, some sites have maintained delivery of ACDC for up to 4 years. CONCLUSIONS When strategically designed to leverage existing infrastructure, comprehensive telehealth interventions can be implemented successfully, even in rural areas. ACDC produced sustained improvements in glycemic control in a previously refractory population.
Collapse
Affiliation(s)
| | - Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- School of Nursing, Duke University School of Medicine, Durham, NC, USA
| | - Amy S Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Susanne M Danus
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Elisabeth Sidoli
- Western North Carolina Veteran Affairs Health Care System, Asheville, NC, USA
| | - Beth D Greck
- Western North Carolina Veteran Affairs Health Care System, Asheville, NC, USA
| | - Leanne Horne
- VISN 19 Rocky Mountain Regional, Denver, CO, USA
| | - David R Saxon
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Endocrinology, Rocky Mountain Veterans Affairs Medical Center, Aurora, CO, USA
| | - Susan Shook
- New Mexico Veteran Affairs Health Care System, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Lina E Aguirre
- New Mexico Veteran Affairs Health Care System, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Mary G Esquibel
- New Mexico Veteran Affairs Health Care System, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Clarene Evenson
- Montana Veteran Affairs Health Care System, Kalispell, MT, USA
| | | | - Vivian Nelson
- Veterans Affairs Central Ohio Healthcare System, Columbus, OH, USA
| | - Amanda Zeek
- Veterans Affairs Central Ohio Healthcare System, Columbus, OH, USA
| | - William G Weppner
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Boise Veteran Affairs Medical Center, Boise, ID, USA
| | | | | | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, USA
| | - Karen Steinhauser
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.
- Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| |
Collapse
|
35
|
Crowley MJ, Tarkington PE, Bosworth HB, Jeffreys AS, Coffman CJ, Maciejewski ML, Steinhauser K, Smith VA, Dar MS, Fredrickson SK, Mundy AC, Strawbridge EM, Marcano TJ, Overby DL, Majette Elliott NT, Danus S, Edelman D. Effect of a Comprehensive Telehealth Intervention vs Telemonitoring and Care Coordination in Patients With Persistently Poor Type 2 Diabetes Control: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:943-952. [PMID: 35877092 PMCID: PMC9315987 DOI: 10.1001/jamainternmed.2022.2947] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Persistently poorly controlled type 2 diabetes (PPDM) is common and causes poor outcomes. Comprehensive telehealth interventions could help address PPDM, but effectiveness is uncertain, and barriers impede use in clinical practice. OBJECTIVE To address evidence gaps preventing use of comprehensive telehealth for PPDM by comparing a practical, comprehensive telehealth intervention to a simpler telehealth approach. DESIGN, SETTING, AND PARTICIPANTS This active-comparator, parallel-arm, randomized clinical trial was conducted in 2 Veterans Affairs health care systems. From December 2018 to January 2020, 1128 outpatients with PPDM were assessed for eligibility and 200 were randomized; PPDM was defined as maintenance of hemoglobin A1c (HbA1c) level of 8.5% or higher for 1 year or longer despite engagement with clinic-based primary care and/or diabetes specialty care. Data analyses were preformed between March 2021 and May 2022. INTERVENTIONS Each 12-month intervention was nurse-delivered and used only clinical staffing/resources. The comprehensive telehealth group (n = 101) received telemonitoring, self-management support, diet/activity support, medication management, and depression support. Patients assigned to the simpler intervention (n = 99) received telemonitoring and care coordination. MAIN OUTCOMES AND MEASURES Primary (HbA1c) and secondary outcomes (diabetes distress, diabetes self-care, self-efficacy, body mass index, depression symptoms) were analyzed over 12 months using intent-to-treat linear mixed longitudinal models. Sensitivity analyses with multiple imputation and inclusion of clinical data examined the impact of missing HbA1c measurements. Adverse events and intervention costs were examined. RESULTS The population (n = 200) had a mean (SD) age of 57.8 (8.2) years; 45 (22.5%) were women, 144 (72.0%) were of Black race, and 11 (5.5%) were of Hispanic/Latinx ethnicity. From baseline to 12 months, HbA1c change was -1.59% (10.17% to 8.58%) in the comprehensive telehealth group and -0.98% (10.17% to 9.19%) in the telemonitoring/care coordination group, for an estimated mean difference of -0.61% (95% CI, -1.12% to -0.11%; P = .02). Sensitivity analyses showed similar results. At 12 months, patients receiving comprehensive telehealth had significantly greater improvements in diabetes distress, diabetes self-care, and self-efficacy; no differences in body mass index or depression were seen. Adverse events were similar between groups. Comprehensive telehealth cost an additional $1519 per patient per year to deliver. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that compared with telemonitoring/care coordination, comprehensive telehealth improved multiple outcomes in patients with PPDM at a reasonable additional cost. This study supports consideration of comprehensive telehealth implementation for PPDM in systems with appropriate infrastructure and may enhance the value of telehealth during the COVID-19 pandemic and beyond. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03520413.
Collapse
Affiliation(s)
- Matthew J Crowley
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Hayden B Bosworth
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Amy S Jeffreys
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina
| | - Cynthia J Coffman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Matthew L Maciejewski
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.,Duke-Margolis Center for Health Policy, Duke University School of Medicine, Durham, North Carolina
| | - Karen Steinhauser
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Valerie A Smith
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Moahad S Dar
- Greenville VA Health Care Center, Greenville, North Carolina.,Division of Endocrinology, Department of Medicine, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | | | - Amy C Mundy
- Central Virginia Veterans Affairs Health Care System, Richmond
| | - Elizabeth M Strawbridge
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina
| | | | - Donna L Overby
- Central Virginia Veterans Affairs Health Care System, Richmond
| | - Nadya T Majette Elliott
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina
| | - Susanne Danus
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina
| | - David Edelman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
36
|
Van Houtven CH, Smith VA, Berkowitz TSZ, Miller KEM, Shepherd-Banigan M, Henius J, Kabat M. Predictors of discharge from the VA Caregiver Support Program. Am J Manag Care 2022; 28:e289-e295. [PMID: 35981129 DOI: 10.37765/ajmc.2022.89202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The Department of Veterans Affairs (VA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) is a clinical program providing training, a monthly stipend, and other services to caregivers of qualifying post-9/11 veterans with service-related injuries. Veteran-caregiver discharge from the program occurs when veteran recovery is achieved, participation is no longer in the veteran's best interest, or caregiving ceases. Public scrutiny about potentially inappropriate discharges resulted in a nationwide freeze on all discharges. PCAFC expanded to pre-9/11 veterans in October 2020; thus, lessons learned can continue to inform the expanded program. We pursued 3 objectives: (1) describe the discharge rate, reasons for discharge, and veteran and caregiver characteristics by discharge status; (2) identify factors associated with discharge from PCAFC nationally; and (3) characterize network variation in discharge predictors. STUDY DESIGN Retrospective observational study using VA administrative data from fiscal year (FY) 2011 to FY 2017. METHODS Using multivariable Cox proportional hazards regression, we examined factors associated with PCAFC discharge among veterans and caregivers enrolled in PCAFC during FY 2011 to FY 2016. RESULTS A total of 40.5% of all participants were discharged. Nonspouse caregivers and those applying in later years had the highest rates of discharge; spouse caregivers and those applying in earlier years had the lowest rates of discharge. In 4 of 18 networks, caregivers of Black veterans faced higher rates of discharge compared with caregivers of White veterans, and in 1 network, they faced lower rates of discharge. Substantial variability in rates of discharge was also observed across Veterans Integrated Service Networks. CONCLUSIONS Training on clinically appropriate discharge criteria could improve practice and increase equity.
Collapse
|
37
|
Miller KEM, Van Houtven CH, Smith VA, Lindquist JH, Gray K, Richardson C, Shepherd-Banigan M. Family Caregivers of Veterans Experience Clinically Significant Levels of Distress Prepandemic and During Pandemic: Implications for Caregiver Support Services. Med Care 2022; 60:530-537. [PMID: 35471419 PMCID: PMC9187587 DOI: 10.1097/mlr.0000000000001726] [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: 11/26/2022]
Abstract
BACKGROUND Of the 26.4 million family caregivers in the United States, nearly 40% report high levels of emotional strain and subjective burden. However, for the 5 million caregivers of Veterans, little is known about the experiences of caregivers of Veterans during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE The aim was to examine pandemic-related changes of caregiver well-being outcomes. RESEARCH DESIGN, SUBJECTS, AND MEASURES Using a pre/post design and longitudinal data of individual caregivers captured pre-COVID-19 and during COVID-19, we use multilevel generalized linear mixed models to examine pandemic-related changes to caregiver well-being (n=903). The primary outcome measures include Zarit Subjective Burden, Center for Epidemiologic Studies Short Depression Scale, perceived financial strain, life chaos, and loneliness. RESULTS During the pandemic, we observe slight improvements for caregivers across well-being measures except for perceived financial strain. Before the pandemic, we observed that caregivers screened positive for clinically significant caregiver burden and probable depression. While we do not observe worsening indicators of caregiver well-being during the COVID-19 pandemic, the average predicted values of indicators of caregiver well-being remain clinically significant for caregiving subjective burden and depression. CONCLUSIONS These findings illuminate pandemic-related impacts of caregivers receiving support through the Veterans Affairs (VA) pre-COVID and during the COVID-19 pandemic while caring for a population of frail, older care-recipients with a high burden of mental illness and other chronic conditions. Considering the long-term impacts of the pandemic to increase morbidity and the expected increased demand for caregivers in an aging population, these consistently high levels of distress despite receiving support highlight the need for interventions and policy reform to systematically support caregivers more broadly.
Collapse
Affiliation(s)
- Katherine E M Miller
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Courtney H Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University Medical Center
- Duke-Margolis Center for Health Policy
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University Medical Center
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Jennifer H Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Kaileigh Gray
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | | | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University Medical Center
| |
Collapse
|
38
|
Pavon JM, Berkowitz TSZ, Smith VA, Hughes JM, Hung A, Hastings SN. Potential Targets for Deprescribing in Medically Complex Older Adults with Suspected Cognitive Impairment. Geriatrics (Basel) 2022; 7:59. [PMID: 35645282 PMCID: PMC9149971 DOI: 10.3390/geriatrics7030059] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/06/2022] [Accepted: 05/16/2022] [Indexed: 12/10/2022] Open
Abstract
Deprescribing may be particularly beneficial in patients with medical complexity and suspected cognitive impairment (CI). We describe central nervous system (CNS) medication use and side effects in this population and explore the relationship between anticholinergic burden and sleep. We conducted a cross-sectional analysis of baseline data from a pilot randomized-controlled trial in older adult veterans with medical complexity (Care Assessment Need score > 90), and suspected CI (Telephone Interview for Cognitive Status score 20−31). CNS medication classes included antipsychotics, benzodiazepines, H2-receptor antagonists, hypnotics, opioids, and skeletal muscle relaxants. We also coded anticholinergic-active medications according to their Anticholinergic Cognitive Burden (ACB) score. Other measures included self-reported medication side effects and the Pittsburgh Sleep Quality Index (PSQI). ACB association with sleep (PSQI) was examined using adjusted linear regression. In this sample (N = 40), the mean number of prescribed CNS medications was 2.2 (SD 1.5), 65% experienced ≥ 1 side effect, and 50% had an ACB score ≥ 3 (high anticholinergic exposure). The ACB score ≥ 3 compared to ACB < 3 was not significantly associated with PSQI scores (avg diff in score = −0.1, 95% CI −2.1, 1.8). Although results did not demonstrate a clear relationship with worsened sleep, significant side effects and anticholinergic burden support the deprescribing need in this population.
Collapse
Affiliation(s)
- Juliessa M. Pavon
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC 27710, USA;
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC 27705, USA
- Claude D. Pepper Center, Duke University, Durham, NC 27710, USA
| | - Theodore S. Z. Berkowitz
- Health Services Research & Development, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA; (T.S.Z.B.); (V.A.S.); (J.M.H.)
| | - Valerie A. Smith
- Health Services Research & Development, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA; (T.S.Z.B.); (V.A.S.); (J.M.H.)
- Department of Population Health Sciences, Duke University, Durham, NC 27701, USA;
- Department of Medicine/Division of General Internal Medicine, Duke University, Durham, NC 27710, USA
| | - Jaime M. Hughes
- Health Services Research & Development, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA; (T.S.Z.B.); (V.A.S.); (J.M.H.)
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
- Section on Gerontology and Geriatric Medicine, Division of Public Health Sciences, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27103, USA
| | - Anna Hung
- Department of Population Health Sciences, Duke University, Durham, NC 27701, USA;
| | - Susan N. Hastings
- Department of Medicine/Division of Geriatrics, Duke University, Durham, NC 27710, USA;
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, NC 27705, USA
- Claude D. Pepper Center, Duke University, Durham, NC 27710, USA
- Health Services Research & Development, Durham Veterans Affairs Health Care System, Durham, NC 27701, USA; (T.S.Z.B.); (V.A.S.); (J.M.H.)
| |
Collapse
|
39
|
Bélanger E, D’Silva J, Carroll MS, Van Houtven CH, Shepherd-Banigan M, Smith VA, Wetle TT. Reactions to Amyloid PET Scan Results and Levels of Anxious and Depressive Symptoms: CARE IDEAS Study. Gerontologist 2022; 63:71-81. [PMID: 35436334 PMCID: PMC9872765 DOI: 10.1093/geront/gnac051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Few studies have examined care partners' reactions to their loved ones receiving amyloid-β positron emission tomography (PET) scan results, which can be indicative of Alzheimer's disease. We explored care partners' reactions qualitatively, and checked the association of scan results and diagnostic category (dementia vs mild cognitive impairment [MCI]) with care partner anxious and depressive symptoms through quantitative analysis. RESEARCH DESIGN AND METHODS Using data from 1,761 care partners in the Caregivers' Reactions and Experience, a supplemental study of the Imaging Dementia Evidence for Amyloid Scanning study, we applied an exploratory sequential mixed-methods design and examined the reactions of 196 care partners to receiving amyloid PET scan results through open-ended interview questions. Based on the qualitative content analysis, we hypothesized there would be an association of care partners' depressive (Patient Health Questionnaire-2) and anxious (6-item State-Trait Anxiety Inventory) symptoms with scan results and diagnostic category which we then tested with logistic regression models. RESULTS Content analysis of open-ended responses suggests that when scan results follow the care partner's expectations, for example, elevated amyloid in persons with dementia, care partners report relief and gratitude for the information, rather than distress. Adjusted logistic regression models of survey responses support this finding, with significantly higher odds of anxiety, but not depressive symptoms, among care partners of persons with MCI versus dementia and elevated amyloid. DISCUSSION AND IMPLICATIONS Care partners of persons with MCI reported distress and had higher odds of anxiety after receiving elevated amyloid PET scan results than care partners of persons with dementia. This has the potential to inform clinical practice through recommendations for mental health screening and referrals.
Collapse
Affiliation(s)
- Emmanuelle Bélanger
- Address correspondence to: Emmanuelle Bélanger, PhD, Center for Gerontology and Healthcare Research, Brown University School of Public Health, 121 South Main Street, 6th Floor, Providence, RI 02903, USA. E-mail:
| | - Jessica D’Silva
- Center for Gerontology and Healthcare Research, Brown University, School of Public Health, Providence, Rhode Island, USA
| | - Michaela S Carroll
- Center for Gerontology and Healthcare Research, Brown University, School of Public Health, Providence, Rhode Island, USA
| | - Courtney H Van Houtven
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA,Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Megan Shepherd-Banigan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA,Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Valerie A Smith
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA,Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Terrie T Wetle
- Center for Gerontology and Healthcare Research, Brown University, School of Public Health, Providence, Rhode Island, USA,Department of Health Services, Policy & Practice, Brown University, School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
40
|
Lange CL, Smith VA, Kahler DM. Pittsburgh Air Pollution Changes During the COVID-19 Lockdown. Environ Adv 2022; 7:100149. [PMID: 34877562 PMCID: PMC8638247 DOI: 10.1016/j.envadv.2021.100149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 06/13/2023]
Abstract
The rapid spread of COVID-19 resulted in various public lockdowns across the globe. Previous studies showed that resultant travel restrictions improved air quality. The novel results presented here focus on source-specific changes and compare air quality for multiple years controlled for precipitation. This study sought to analyze air pollution changes in Pittsburgh, a city where an industrial past and present has led to elevated levels of particulate matter with representative diameter of ≤ 2.5μm (PM2.5). Data from the Allegheny County Health Department, from monitors located near a variety of site types, were analyzed with generalized linear models that used a gamma distribution with a log link to determine the magnitude and significance of changes in air pollution during the COVID-19 lockdown. The hypothesis was that nitrogen dioxide (NO2), which is primarily linked to vehicular traffic, would decrease significantly while potential decreases in particulate matter (PM2.5 and PM10) would be less apparent. Results of the regression models showed that NO2 was significantly reduced during lockdown at both monitoring sites and that PM10 was also significantly reduced at the majority of monitoring sites. However, decreases in PM2.5 pollution were only observed at half of the monitoring locations, and the location which observed the greatest decreases is located adjacent to an industrial source. Decreases in PM2.5 at this monitoring site were likely a result of reduced industrial processes both dependent and independent of the COVID-19 lockdown. This study suggests that industrial sources are a larger contributor of particulate matter than vehicular transportation in the city of Pittsburgh and that future air pollution reduction efforts should focus attention on emission reduction at these industrial facilities.
Collapse
Affiliation(s)
- Carissa L Lange
- Center for Environmental Research and Education, Duquesne University, 600 Forbes Ave. Pittsburgh, PA, 15282 USA
| | - Valerie A Smith
- Department of Population Health Sciences, Duke University, 215 Morris St. Durham, NC, 27708, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, 200 Morris St. Durham, NC, 27708, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VAMC 508 Fulton St. Durham, NC, 27705, USA
| | - David M Kahler
- Center for Environmental Research and Education, Duquesne University, 600 Forbes Ave. Pittsburgh, PA, 15282 USA
| |
Collapse
|
41
|
Arterburn DE, Maciejewski ML, Berkowitz TSZ, Smith VA, Mitchell JE, Liu CF, Adeyemo A, Bradley KA, Olsen MK. Does Long-Term Post-Bariatric Weight Change Differ Across Antidepressants? Ann Surg Open 2022; 3:e114. [PMID: 36935766 PMCID: PMC10013150 DOI: 10.1097/as9.0000000000000114] [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: 05/26/2021] [Accepted: 11/22/2021] [Indexed: 11/25/2022] Open
Abstract
We sought to evaluate whether weight change up to 5 years after bariatric surgery differed by antidepressant class taken before surgery. Background Bariatric surgery induces significant weight loss, but outcomes are highly variable. The specific type of antidepressant used prior to surgery may be an important factor in long-term weight loss. Methods This retrospective cohort study from 2000 to 2016 compared the 5-year weight loss of 556 Veterans who were taking antidepressant monotherapy (bupropion, selective serotonin reuptake inhibitors [SSRIs], or serotonin-norepinephrine reuptake inhibitors [SNRIs]) before bariatric surgery (229 sleeve gastrectomy and 327 Roux-en-Y gastric bypass) versus 556 matched nonsurgical controls. Results Patients taking bupropion before sleeve gastrectomy had greater differential weight loss between surgical patients and matched controls than those taking SSRIs at 1 (8.9 pounds; 95% confidence interval [CI], 1.6-16.3; P = 0.02) and 2 years (17.6 pounds; 95% CI, 5.9-29.3; P = 0.003), but there was no difference at 5 years (11.9 pounds; 95% CI, -8.9 to 32.8; P = 0.26). Findings were similar for gastric bypass patients taking bupropion compared to SSRIs at 1 (9.7 pounds; 95% CI, 2.0-17.4; P = 0.014), 2 (12.0 pounds; 95% CI, -0.5 to 24.5; P = 0.06), and 5 years (4.8 pounds; 95% CI, -16.7 to 26.3; P = 0.66). No significant differences were observed comparing patients taking SNRI versus SSRI medications. Conclusions Sleeve gastrectomy and gastric bypass patients taking bupropion had greater weight loss than those taking SSRIs, although these differences may wane over time. Bupropion may be the first-line antidepressant of choice among patients with severe obesity considering bariatric surgery.
Collapse
Affiliation(s)
- David E. Arterburn
- From the Kaiser Permanente Washington Health Research Institute, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Theodore S. Z. Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - James E. Mitchell
- University of North Dakota School of Medicine and Health Sciences, Fargo, ND
| | - Chuan-Fen Liu
- Department of Health Services, University of Washington, Seattle, WA
| | - Adenike Adeyemo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC
| | - Katharine A. Bradley
- From the Kaiser Permanente Washington Health Research Institute, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
- Department of Health Services, University of Washington, Seattle, WA
| | - Maren K. Olsen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| |
Collapse
|
42
|
Everett CM, Docherty SL, Matheson E, Morgan PA, Price A, Christy J, Michener L, Smith VA, Anderson JB, Viera A, Jackson GL. Teaming up in primary care: Membership boundaries, interdependence, and coordination. JAAPA 2022; 35:1-10. [PMID: 34985006 PMCID: PMC9869344 DOI: 10.1097/01.jaa.0000805840.00477.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/03/2023]
Abstract
OBJECTIVE Increased demand for quality primary care and value-based payment has prompted interest in implementing primary care teams. Evidence-based recommendations for implementing teams will be critical to successful PA participation. This study sought to describe how primary care providers (PCPs) define team membership boundaries and coordinate tasks. METHODS This mixed-methods study included 28 PCPs from a primary care network. We analyzed survey data using descriptive statistics and interview data using content analysis. RESULTS Ninety-six percent of PCPs reported team membership. Team models fell into one of five categories. The predominant coordination mechanism differed by whether coordination was required in a visit or between visits. CONCLUSIONS Team-based primary care is a strategy for improving access to quality primary care. Most PCPs define team membership based on within-visit task interdependencies. Our findings suggest that team-based interventions can focus on clarifying team membership, increasing interaction between clinicians, and enhancing the electronic health record to facilitate between-visit coordination.
Collapse
Affiliation(s)
- Christine M Everett
- At Duke University in Durham, N.C., Christine M. Everett is an associate professor in the Division of PA Studies in the School of Medicine's Department of Family Medicine and Community Health and the Department of Population Health Sciences, and Sharron L. Docherty is a professor in the School of Nursing. Elaine Matheson is advanced practice provider medical director at Duke Primary Care in Durham. Perri A. Morgan is a professor in the Division of PA Studies in the Department of Family Medicine and Community Health and the Department of Population Health. In the Department of Family Medicine and Community Health, Ashley Price is a research program lead, Jacob Christy is a clinical research coordinator, and Lloyd Michener is a professor emeritus. Valerie A. Smith is an associate professor in the Department of Population Health and in the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham VA Health Care System. John B. Anderson, Jr., is an associate professor in the Department of Family Medicine and Community Health and chief medical officer at Duke Primary Care. Anthony Viera is a professor and chair in the Department of Family Medicine and Community Health. George L. Jackson is a professor in the Department of Population Health, Department of Internal Medicine, Department of Family Medicine and Community Health and at ADAPT. The authors disclose that this research was supported by a grant from the National Institutes of Aging (K01AG53378). The grant funding source had no role in the design, conduct, collection, management, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript. The authors have disclosed no other potential conflicts of interest, financial or otherwise. The views expressed in this paper are those of the authors and do not reflect the position or policy of Duke University, Duke Health System, the Department of Veterans Affairs, or the US government
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Shepherd-Banigan M, Ford CB, DePasquale N, Smith VA, Belanger E, Lippmann SJ, O'Brien EC, Van Houtven CH. Making the Informal Formal: Discussing and Completing Advance Care Plans in Care Dyads with Cognitive Impairment. J Palliat Care 2021; 37:289-297. [PMID: 34898305 DOI: 10.1177/08258597211063047] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Discussing advance care planning (ACP) with care partners may be a steppingstone to the completion of advance directives (ADs) for persons with cognitive impairment (PwCIs). OBJECTIVES To examine whether PwCI-reported occurrence of and PwCI-care partner agreement about ACP discussions are associated with completion of ADs. DESIGN AND SUBJECTS We conducted a secondary, cross-sectional analysis of data from 1672 PwCI-care partner dyads in the BLINDED study. PwCIs were Medicare beneficiaries in the US, aged >65 years, and diagnosed with mild cognitive impairment or dementia. Care partners were identified by PwCIs as being most involved in their health care. MEASUREMENTS PwCIs' completion of ADs was determined by 1 or more affirmative responses to dichotomous indicators for formalizing a living will, medical directive, or durable power of attorney for health care. Discussion occurrence was based on PwCI reports and agreement between PwCI and care partner reports of prior conversations about PwCIs' ACP preferences between PwCIs and care partners. RESULTS In logistic regression models adjusted for PwCI and care partner characteristics, PwCIs who had (vs. had not) discussed ACP were 10% more likely to complete ADs. PwCIs from dyads agreeing (vs. disagreeing) a discussion occurred were 7% more likely to complete ADs. PwCIs from care dyads in agreement (vs. disagreement) about non-discussion were 11% less likely to formalize ADs. CONCLUSIONS Discussing ACP with care partners plays a direct, positive role in completing ADs among PwCIs. Health care providers who approach ACP as a dyadic, communicative decision-making process from the outset may facilitate PwCIs' uptake of ADs.
Collapse
Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Duke-Margolis Center for Health Policy, Durham, NC, USA
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Nicole DePasquale
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Valerie A Smith
- Durham VA Health Care System, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA.,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Courtney H Van Houtven
- Durham VA Health Care System, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Duke-Margolis Center for Health Policy, Durham, NC, USA
| |
Collapse
|
44
|
Diamantidis CJ, Zepel L, Wang V, Smith VA, Hudson Scholle S, Tamayo L, Maciejewski ML. Disparities in Chronic Kidney Disease Progression by Medicare Advantage Enrollees. Am J Nephrol 2021; 52:949-957. [PMID: 34875668 DOI: 10.1159/000519758] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The prevalence of chronic kidney disease (CKD) in Medicare beneficiaries has quadrupled in the past 2 decades, but little is known about risk factors affecting the progression of CKD. This study aims to understand the progression in Medicare Advantage enrollees and whether it differs by provider recognition of CKD, race and ethnicity, or geographic location. In a large cohort of Medicare Advantage (MA) enrollees, we examined whether CKD progression, up to 5 years after study entry, differed by demographic and clinical factors and identified additional risk factors of CKD progression. METHODS In a cohort of 1,002,388 MA enrollees with CKD stages 1-4 based on 2013-2018 labs, progression was estimated using a mixed-effects model that adjusted for demographics, geographic location, comorbidity, urine albumin-to-creatinine ratio, clinical recognition via diagnosed CKD, and time-fixed effects. Race and ethnicity, geographic location, and clinical recognition of CKD were interacted with time in 3 separate regression models. RESULTS Mean (median) follow-up was 3.1 (3.0) years. Black and Hispanic MA enrollees had greater kidney function at study entry than other beneficiaries, but their kidney function declined faster. MA enrollees with clinically recognized CKD had estimated glomerular filtration rate levels that were 18.6 units (95% confidence interval [CI]: 18.5-18.7) lower than levels of unrecognized patients, but kidney function declined more slowly in enrollees with clinical recognition. There were no differences in CKD progression by geography. After removal of the race coefficient from the eGFR equation in a sensitivity analysis, kidney function was much lower in all years among Black MA enrollees, but patterns of progression remained the same. DISCUSSION/CONCLUSIONS These results suggest that patients with clinically recognized CKD and racial and ethnic minorities merit closer surveillance and management to reduce their risk of faster progression.
Collapse
Affiliation(s)
- Clarissa Jonas Diamantidis
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lindsay Zepel
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- OptumLabs Visiting Fellow, Cambridge, Massachusetts, USA
| | - Virginia Wang
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Valerie A Smith
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | | | - Loida Tamayo
- Centers for Medicare & Medicaid Services, Baltimore, Maryland, USA
| | - Matthew L Maciejewski
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| |
Collapse
|
45
|
Smith VA, Van Houtven CH, Lindquist JH, Hastings SN. Evaluation of a geriatrics primary care model using prospective matching to guide enrollment. BMC Med Res Methodol 2021; 21:167. [PMID: 34399689 PMCID: PMC8366154 DOI: 10.1186/s12874-021-01360-4] [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] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 07/01/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Few definitive guidelines exist for rigorous large-scale prospective evaluation of nonrandomized programs and policies that require longitudinal primary data collection. In Veterans Affairs (VA) we identified a need to understand the impact of a geriatrics primary care model (referred to as GeriPACT); however, randomization of patients to GeriPACT vs. a traditional PACT was not feasible because GeriPACT has been rolled out nationally, and the decision to transition from PACT to GeriPACT is made jointly by a patient and provider. We describe our study design used to evaluate the comparative effectiveness of GeriPACT compared to a traditional primary care model (referred to as PACT) on patient experience and quality of care metrics. METHODS We used prospective matching to guide enrollment of GeriPACT-PACT patient dyads across 57 VA Medical Centers. First, we identified matches based an array of administratively derived characteristics using a combination of coarsened exact and distance function matching on 11 identified key variables that may function as confounders. Once a GeriPACT patient was enrolled, matched PACT patients were then contacted for recruitment using pre-assigned priority categories based on the distance function; if eligible and consented, patients were enrolled and followed with telephone surveys for 18 months. RESULTS We successfully enrolled 275 matched dyads in near real-time, with a median time of 7 days between enrolling a GeriPACT patient and a closely matched PACT patient. Standardized mean differences of < 0.2 among nearly all baseline variables indicates excellent baseline covariate balance. Exceptional balance on survey-collected baseline covariates not available at the time of matching suggests our procedure successfully controlled many known, but administratively unobserved, drivers of entrance to GeriPACT. CONCLUSIONS We present an important process to prospectively evaluate the effects of different treatments when randomization is infeasible and provide guidance to researchers who may be interested in implementing a similar approach. Rich matching variables from the pre-treatment period that reflect treatment assignment mechanisms create a high quality comparison group from which to recruit. This design harnesses the power of national administrative data coupled with collection of patient reported outcomes, enabling rigorous evaluation of non-randomized programs or policies.
Collapse
Affiliation(s)
- Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W Chapel Hill St Suite 600, NC, 27701, Durham, USA.
- Department of Population Health Sciences, Duke University School of Medicine, 411 W Chapel Hill St Suite 600, NC, Durham, USA.
- Department of General Internal Medicine, Duke University, 411 W Chapel Hill St Suite 600, NC, Durham, USA.
| | - Courtney Harold Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W Chapel Hill St Suite 600, NC, 27701, Durham, USA
- Department of Population Health Sciences, Duke University School of Medicine, 411 W Chapel Hill St Suite 600, NC, Durham, USA
- Duke-Margolis Center for Health Policy, Durham, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, NC, Durham, USA
| | - Jennifer H Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W Chapel Hill St Suite 600, NC, 27701, Durham, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W Chapel Hill St Suite 600, NC, 27701, Durham, USA
- Department of Population Health Sciences, Duke University School of Medicine, 411 W Chapel Hill St Suite 600, NC, Durham, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, NC, Durham, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, NC, Durham, USA
- Geriatrics Research Education and Clinical Center (GRECC), Durham Veterans Affairs Health Care System, NC, Durham, USA
| |
Collapse
|
46
|
Affiliation(s)
- Valerie A Smith
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| |
Collapse
|
47
|
Kaufman BG, Whitaker R, Mahendraratnam N, Hurewitz S, Yi J, Smith VA, McClellan M. State variation in effects of state social distancing policies on COVID-19 cases. BMC Public Health 2021; 21:1239. [PMID: 34182972 PMCID: PMC8237534 DOI: 10.1186/s12889-021-11236-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/08/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The novel coronavirus disease 2019 (COVID-19) sickened over 20 million residents in the United States (US) by January 2021. Our objective was to describe state variation in the effect of initial social distancing policies and non-essential business (NEB) closure on infection rates early in 2020. METHODS We used an interrupted time series study design to estimate the total effect of all state social distancing orders, including NEB closure, shelter-in-place, and stay-at-home orders, on cumulative COVID-19 cases for each state. Data included the daily number of COVID-19 cases and deaths for all 50 states and Washington, DC from the New York Times database (January 21 to May 7, 2020). We predicted cumulative daily cases and deaths using a generalized linear model with a negative binomial distribution and a log link for two models. RESULTS Social distancing was associated with a 15.4% daily reduction (Relative Risk = 0.846; Confidence Interval [CI] = 0.832, 0.859) in COVID-19 cases. After 3 weeks, social distancing prevented nearly 33 million cases nationwide, with about half (16.5 million) of those prevented cases among residents of the Mid-Atlantic census division (New York, New Jersey, Pennsylvania). Eleven states prevented more than 10,000 cases per 100,000 residents within 3 weeks. CONCLUSIONS The effect of social distancing on the infection rate of COVID-19 in the US varied substantially across states, and effects were largest in states with highest community spread.
Collapse
Affiliation(s)
- Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA.
- Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.
| | - Rebecca Whitaker
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
| | - Nirosha Mahendraratnam
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
| | - Sophie Hurewitz
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
| | - Jeremy Yi
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
| | - Valerie A Smith
- Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
- General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Mark McClellan
- Margolis Center for Health Policy, Duke University, 230 Science Drive, Durham, NC, 27705, USA
| |
Collapse
|
48
|
Abstract
OBJECTIVE To accurately model semicontinuous data from complex surveys, we extend marginalized two-part models to a design-based inferential framework and provide guidance on incorporating complex sample designs. DATA SOURCES 2014 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN We describe the use of pseudo-Maximum Likelihood Estimation and Jackknife Repeated Replication for estimating model parameters and sampling variance, respectively. We illustrate our approach using MEPS, modeling total healthcare expenditures in 2014 as a function of respondents' age and family income. We provide SAS and R code for implementing the extension, assessing model-fit indices, and evaluating the need to incorporate complex sampling features. DATA EXTRACTION METHODS Data obtained from www.meps.ahrq.gov. PRINCIPLE FINDINGS A 100 percentage-point increase in family income as a percent of the federal poverty level was associated with a 5%-6% increase in healthcare spending. People over 65 had an increase of 4-5 times compared to those younger. Accounting for complex sampling in the models led to different parameter estimates and wider confidence intervals than the unweighted models. Ignoring complex sampling could lead to inaccurate finite population inference. CONCLUSION Researchers should account for complex sampling features when analyzing semicontinuous data from surveys.
Collapse
Affiliation(s)
- Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice TransformationDurham VAMCDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal MedicineDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Brady T. West
- Survey Research CenterInstitute for Social ResearchUniversity of Michigan‐Ann ArborAnn ArborMichiganUSA
| | - Shiyu Zhang
- Survey Research CenterInstitute for Social ResearchUniversity of Michigan‐Ann ArborAnn ArborMichiganUSA
| |
Collapse
|
49
|
Shepherd-Banigan M, Smith VA, Stechuchak KM, Van Houtven CH. Informal Caregiver Support Policies Change Use of Vocational Assistance Services for Individuals With Disabilities. Med Care Res Rev 2021; 79:218-232. [PMID: 34053345 DOI: 10.1177/10775587211018548] [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: 11/15/2022]
Abstract
Support policies for caregivers improves care-recipient access to care and effects may generalize to nonhealth services. Using administrative data from the U.S. Department of Veterans Affairs (VA) for veterans <55 years, we assessed the association between enrollment in a VA caregiver support program and veteran use of vocational assistance services: the post-9/11 GI Bill, VA vocational rehabilitation and employment (VR&E), and supported employment. We applied instrumental variables to Cox proportional hazards models. Caregiver enrollment in the program increased veteran supported employment use (hazard ratio = 1.35, 95% confidence interval [1.14, 1.53]), decreased VR&E use (hazard ratio = 0.84, 95% confidence interval [0.76, 0.92]), and had no effect on the post-9/11 GI Bill. Caregiver support policies could increase access to some vocational assistance for individuals with disabilities, particularly supported employment, which is integrated into health care. Limited coordination between health and employment sectors and misaligned incentives may have inhibited effects for the post-9/11 GI Bill and VR&E.
Collapse
Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, Durham, NC, USA
- Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
| | - Valerie A Smith
- Durham VA Health Care System, Durham, NC, USA
- Duke University, Durham, NC, USA
| | | | - Courtney H Van Houtven
- Durham VA Health Care System, Durham, NC, USA
- Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
| |
Collapse
|
50
|
Wang V, Zepel L, Diamantidis CJ, Smith VA, Scholle SH, Maciejewski ML. Annual wellness visits and care management before and after dialysis initiation. BMC Nephrol 2021; 22:164. [PMID: 33947341 PMCID: PMC8097997 DOI: 10.1186/s12882-021-02368-0] [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: 11/05/2020] [Accepted: 04/20/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Demands of dialysis regimens may pose challenges for primary care provider (PCP) engagement and timely preventive care. This is especially the case for patients initiating dialysis adjusting to new logistical challenges and management of symptoms and existing comorbid conditions. Since 2011, Medicare has provided coverage for annual wellness visits (AWV), which are primarily conducted by PCPs and may be useful for older adults undergoing dialysis. Methods We used the OptumLabs® Data Warehouse to identify a cohort of 1,794 Medicare Advantage (MA) enrollees initiating dialysis in 2014–2017 and examined whether MA enrollees (1) were seen by a PCP during an outpatient visit and (2) received an AWV in the year following dialysis initiation. Results In the year after initiating dialysis, 93 % of MA enrollees had an outpatient PCP visit but only 24 % received an annual wellness visit. MA enrollees were less likely to see a PCP if they had Charlson comorbidity scores between 0 and 5 than those with scores 6–9 (odds ratio (OR) = 0.59, 95 % CI: 0.37–0.95), but more likely if seen by a nephrologist (OR = 1.60, 95 % CI: 1.01–2.52) or a PCP (OR = 15.65, 95 % CI: 9.26–26.46) prior to initiation. Following dialysis initiation, 24 % of MA enrollees had an AWV. Hispanic MA enrollees were less likely (OR = 0.57, 95 % CI: 0.39–0.84) to have an AWV than White MA enrollees, but enrollees were more likely if they initiated peritoneal dialysis (OR = 1.54, 95 % CI: 1.07–2.23) or had an AWV in the year before dialysis initiation (OR = 4.96, 95 % CI: 3.88–6.34). Conclusions AWVs are provided at low rates to MA enrollees initiating dialysis, particularly Hispanic enrollees, and represent a missed opportunity for better care management for patients with ESKD. Increasing patient awareness and provider provision of AWV use among dialysis patients may be needed, to realize better preventive care for dialysis patients.
Collapse
Affiliation(s)
- Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Lindsay Zepel
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Clarissa J Diamantidis
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA. .,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA. .,Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA. .,OptumLabs Visiting Fellow, Cambridge, MA, USA.
| |
Collapse
|