Self-efficacy, male rape myth acceptance, and devaluation of emotions in sexual trauma sequelae: Findings from a sample of male veterans.

Sexual trauma is an understudied but regrettably significant problem among male Veterans. As in women, sexual trauma often results in serious mental health consequences for men. Therefore, to guide potential future interventions in this important group, we investigated associations among self-efficacy, male rape myth acceptance, devaluation of emotions, and psychiatric symptom severity after male sexual victimization. We collected data from 1,872 Gulf War era Veterans who applied for posttraumatic stress disorder (PTSD) disability benefits using standard mailed survey methods. The survey asked about history of childhood sexual abuse, sexual assault during the time of Gulf War I, and past-year sexual assault as well as Veterans' perceived self-efficacy, male rape myth acceptance, devaluation of emotions, PTSD, and depression symptoms. Structural equation modeling revealed that self-efficacy partially mediated the association between participants' sexual trauma history and psychiatric symptoms. Greater male rape myth acceptance and greater devaluation of emotions were directly associated with lower self-efficacy, but these beliefs did not moderate associations between sexual trauma and self-efficacy. In this population, sexual trauma, male rape myth acceptance, and devaluation of emotions were associated with lowered self-efficacy, which in turn was associated with more severe psychiatric symptoms. Implications for specific, trauma-focused treatment are discussed.

Impact of different privacy conditions and incentives on survey response rate, participant representativeness, and disclosure of sensitive information: a randomized controlled trial.

BACKGROUND: Anonymous survey methods appear to promote greater disclosure of sensitive or stigmatizing information compared to non-anonymous methods. Higher disclosure rates have traditionally been interpreted as being more accurate than lower rates. We examined the impact of 3 increasingly private mailed survey conditions-ranging from potentially identifiable to completely anonymous-on survey response and on respondents' representativeness of the underlying sampling frame, completeness in answering sensitive survey items, and disclosure of sensitive information. We also examined the impact of 2 incentives ($10 versus $20) on these outcomes. METHODS: A 3X2 factorial, randomized controlled trial of 324 representatively selected, male Gulf War I era veterans who had applied for United States Department of Veterans Affairs (VA) disability benefits. Men were asked about past sexual assault experiences, childhood abuse, combat, other traumas, mental health symptoms, and sexual orientation. We used a novel technique, the pre-merged questionnaire, to link anonymous responses to administrative data. RESULTS: Response rates ranged from 56.0% to 63.3% across privacy conditions (p = 0.49) and from 52.8% to 68.1% across incentives (p = 0.007). Respondents' characteristics differed by privacy and by incentive assignments, with completely anonymous respondents and $20 respondents appearing least different from their non-respondent counterparts. Survey completeness did not differ by privacy or by incentive. No clear pattern of disclosing sensitive information by privacy condition or by incentive emerged. For example, although all respondents came from the same sampling frame, estimates of sexual abuse ranged from 13.6% to 33.3% across privacy conditions, with the highest estimate coming from the intermediate privacy condition (p = 0.007). CONCLUSION: Greater privacy and larger incentives do not necessarily result in higher disclosure rates of sensitive information than lesser privacy and lower incentives. Furthermore, disclosure of sensitive or stigmatizing information under differing privacy conditions may have less to do with promoting or impeding participants' "honesty" or "accuracy" than with selectively recruiting or attracting subpopulations that are higher or lower in such experiences. Pre-merged questionnaires bypassed many historical limitations of anonymous surveys and hold promise for exploring non-response issues in future research.

Sexual assault during the time of Gulf War I: a cross-sectional survey of U.S. service men who later applied for Department of Veterans Affairs PTSD disability benefits.

OBJECTIVES: To estimate the cumulative incidence of sexual assault during the time of Gulf War I among male Gulf War I Veterans who later applied for Department of Veterans Affairs (VA) post-traumatic stress disorder disability benefits and to identify potential risk and protective factors for sexual assault within the population. METHOD: Mailed, national, cross-sectional survey supplemented with VA administrative and clinical data. RESULTS: Of 2,415 Veterans sampled, 1,700 (70%) responded. After adjusting for nonignorable missing data, the cumulative incidence of sexual assault during Gulf War I in this population ranged from 18% [95% confidence intervals (CI): 5.0%-51.9%] to 21% (95% CI: 20.0-22.0). Deployment was not associated with sexual assault [Odds Ratio (OR), 0.96; 95% CI: 0.75-1.23], but combat exposure was (OR, 1.80; 95% CI: 1.52-2.10). Other correlates of sexual assault within the population included working in a unit with greater tolerance of sexual harassment (OR, 1.80; 95% CI: 1.52-2.10) and being exposed to more sexual identity challenges (OR, 1.76; 95% CI: 1.55-2.00). CONCLUSIONS: The 9-month cumulative incidence of sexual assault in this particular population exceeded the lifetime cumulative incidence of sexual assault in U.S. civilian women. Although Persian Gulf deployment was not associated with sexual assault in this population, combat exposure was.

A comparison of small monetary incentives to convert survey non-respondents: a randomized control trial.

BACKGROUND: Maximizing response rates is critically important in order to provide the most generalizable and unbiased research results. High response rates reduce the chance of respondents being systematically different from non-respondents, and thus, reduce the risk of results not truly reflecting the study population. Monetary incentives are often used to improve response rates, but little is known about whether larger incentives improve response rates in those who previously have been unenthusiastic about participating in research. In this study we compared the response rates and cost-effectiveness of a $5 versus $2 monetary incentive accompanying a short survey mailed to patients who did not respond or refused to participate in research study with a face-to-face survey. METHODS: 1,328 non-responders were randomly assigned to receive $5 or $2 and a short, 10-question survey by mail. Reminder postcards were sent to everyone; those not returning the survey were sent a second survey without incentive. Overall response rates, response rates by incentive condition, and odds of responding to the larger incentive were calculated. Total costs (materials, postage, and labor) and incremental cost-effectiveness ratios were also calculated and compared by incentive condition. RESULTS: After the first mailing, the response rate within the $5 group was significantly higher (57.8% vs. 47.7%, p<.001); after the second mailing, the difference narrowed by 80%, resulting in a non-significant difference in cumulative rates between the $5 and $2 groups (67.3% vs. 65.4%, respectively, p=.47). Regardless of incentive or number of contacts, respondents were significantly more likely to be male, white, married, and 50-75 years old. Total costs were higher with the larger versus smaller incentive ($13.77 versus $9.95 per completed survey). CONCLUSIONS: A $5 incentive provides a significantly higher response rate than a $2 incentive if only one survey mailing is used but not if two survey mailings are used.

Validity of PTSD diagnoses in VA administrative data: comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores.

Little research has been done on the validity of posttraumatic stress disorder (PTSD) diagnoses that are found in Department of Veterans Affairs (VA) administrative data, even though they are often used in VA research. We compared PTSD diagnoses found in VA administrative data with PTSD Checklist (PCL) scores self-reported by 4,777 newly diagnosed participants in a national postal survey study. Using PCL scores of at least 50 as the gold standard, we compared positive predictive values (PPVs) for at least one versus at least two PTSD diagnoses (found within 4 months of the first) in VA administrative data overall and by subgroups of interest: age, sex, and clinic where first diagnosed. The overall PPV was 75% for at least one PTSD diagnosis and 82% for at least two PTSD diagnoses. Similarly, the PPV significantly increased for all subgroup analyses when at least two PTSD diagnoses were used. The increase in PPV was greatest for those first diagnosed in primary care and for those older than 65. To select a sample of veterans with more definitive PTSD from administrative data, researchers should select those veterans with at least two PTSD diagnoses as opposed to at least one.

Presence and correlates of racial disparities in adherence to colorectal cancer screening guidelines.

OBJECTIVES: We examined the presence and correlates of Black/White racial disparities in adherence to guidelines for colorectal cancer screening (CRCS). METHODS: The sample included 328 Black and 1827 White patients age 50-75 from 24 VA medical facilities who responded to a mailed survey with phone follow-up (response rate: 73% for Blacks and 89% for Whites). CRCS adherence and race were obtained through surveys and supplemented with administrative data. Logistic regressions estimated the contribution of demographic, health, cognitive, and environmental factors to racial disparities in adherence to CRCS guidelines. RESULTS: In unadjusted analyses, Blacks had slightly lower rates of adherence to CRCS guidelines than Whites (72% versus 77%, p<0.05). This racial disparity in CRCS adherence was explained by race differences in demographic, health, and environmental factors but not by cognitive factors. Tests for interactions revealed that the association of race with adherence varied significantly across levels of income, education, and marital status. In particular, among those who were married with higher levels of education, CRCS adherence was significantly higher for Whites; whereas among those who were unmarried, with low levels of education, adherence was significantly higher for Blacks. CONCLUSION: We found that disparities in CRCS are greatly attenuated in the VA system and both Whites and Blacks have substantially higher rates of CRCS than the national average. These results point to the success of the VA at implementing CRCS system-wide. Our findings also suggest additional initiatives may be needed for unmarried low income white men and higher income black men.

Accuracy of external cause-of-injury coding in VA polytrauma patient discharge records.

Valid and efficient methods of identifying the etiology of treated injuries are critical for characterizing patient populations and developing prevention and rehabilitation strategies. We examined the accuracy of external cause-of-injury codes (E-codes) in Veterans Health Administration (VHA) administrative data for a population of injured patients. Chart notes and E-codes were extracted for 566 patients treated at any one of four VHA Polytrauma Rehabilitation Center sites between 2001 and 2006. Two expert coders, blinded to VHA E-codes, used chart notes to assign "gold standard" E-codes to injured patients. The accuracy of VHA E-coding was examined based on these gold standard E-codes. Only 382 of 517 (74%) injured patients were assigned E-codes in VHA records. Sensitivity of VHA E-codes varied significantly by site (range: 59%-91%, p < 0.001). Sensitivity was highest for combat-related injuries (81%) and lowest for fall-related injuries (60%). Overall specificity of E-codes was high (92%). E-coding accuracy was markedly higher when we restricted analyses to records that had been assigned VHA E-codes. E-codes may not be valid for ascertaining source-of-injury data for all injuries among VHA rehabilitation inpatients at this time. Enhanced training and policies may ensure more widespread, standardized use and accuracy of E-codes for injured veterans treated in the VHA.

Mental health, frequency of healthcare visits, and colorectal cancer screening.

BACKGROUND: Research regarding the association between mental health and colorectal cancer (CRC) screening has produced mixed results. Variations may be explained by methodology, including whether potential confounders such as frequency of healthcare visits are considered. OBJECTIVE: We examined the association between mental health and CRC screening, before and after controlling for demographics, comorbidities, and outpatient visit frequency. DESIGN: Observational study based on a retrospective cohort. SUBJECTS: A total of 855 veterans receiving care at a Veterans Affairs Medical Center. MEASURES: Medical record data were used to assess CRC screening rates and mental health status (number of diagnoses and the presence of depression, anxiety, posttraumatic stress disorder, substance, or psychotic disorders). Logistic regression was used to estimate the association between mental health diagnoses and CRC screening, before and after controlling for covariates. RESULTS: Bivariate analyses suggested that CRC screening rates were higher for patients with a history of one or more mental health diagnoses (57% vs. 47%, P < 0.01). However, adjusting for timing of mental health diagnosis and outpatient visit frequency resulted in significant negative associations between CRC screening and all measures of mental health except posttraumatic stress disorder. CONCLUSIONS: Estimates of the association between mental health and CRC screening that do not adjust for outpatient visit frequency may be misleading. Veterans with mental health diagnoses were significantly less likely to be screened for CRC than their counterparts with no mental health diagnoses and an equal number of outpatient visits.

The interrelationships between and contributions of background, cognitive, and environmental factors to colorectal cancer screening adherence.

OBJECTIVES: We examined the interrelationships between and contributions of background, cognitive, and environmental factors to colorectal cancer (CRC) screening adherence. METHODS: In this study, 2,416 average risk patients aged 50-75 from 24 Veterans Affairs medical facilities responded to a mailed survey with phone follow-up (response rate 81%). Survey data (attitudes, behaviors, demographics) were linked to facility (organizational complexity) and medical records data (diagnoses, screening history). Patients with a fecal occult blood test within 15 months, sigmoidoscopy or barium enema within 5.5 years, or colonoscopy within 11 years of the survey were considered adherent. Logistic regressions estimated the association between adherence and background, cognitive, and environmental factors. Deviance ratios examined interrelationships between factors. Population attributable risks (PAR) were used to identify intervention targets. RESULTS: The association of background factors with adherence was partially explained by cognitive and environmental factors. The association of environmental factors with adherence was partially explained by cognitive factors. Cognitive and environmental factors contributed equally to adherence. Factors with the highest PARs for non-adherence were age 50-64, less than two comorbidities, and lack of physician recommendation. CONCLUSIONS: Efforts to increase physician screening recommendations for younger, healthy patients at facilities with the lowest screening rates may improve CRC adherence in this setting.

Variation in estimates of limited health literacy by assessment instruments and non-response bias.

OBJECTIVES: This paper compares estimates of poor health literacy using two widely used assessment tools and assesses the effect of non-response on these estimates. STUDY DESIGN AND SETTING: A total of 4,868 veterans receiving care at four VA medical facilities between 2004 and 2005 were stratified by age and facility and randomly selected for recruitment. Interviewers collected demographic information and conducted assessments of health literacy (both REALM and S-TOFHLA) from 1,796 participants. Prevalence estimates for each assessment were computed. Non-respondents received a brief proxy questionnaire with demographic and self-report literacy questions to assess non-response bias. Available administrative data for non-participants were also used to assess non-response bias. RESULTS: Among the 1,796 patients assessed using the S-TOFHLA, 8% had inadequate and 7% had marginal skills. For the REALM, 4% were categorized with 6th grade skills and 17% with 7-8th grade skills. Adjusting for non-response bias increased the S-TOFHLA prevalence estimates for inadequate and marginal skills to 9.3% and 11.8%, respectively, and the REALM estimates for < or = 6th and 7-8th grade skills to 5.4% and 33.8%, respectively. CONCLUSIONS: Estimates of poor health literacy varied by the assessment used, especially after adjusting for non-response bias. Researchers and clinicians should consider the possible limitations of each assessment when considering the most suitable tool for their purposes.

Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial.

RATIONALE: The effect of disease management for chronic obstructive pulmonary disease (COPD) is not well established. OBJECTIVES: To determine whether a simplified disease management program reduces hospital admissions and emergency department (ED) visits due to COPD. METHODS: We performed a randomized, adjudicator-blinded, controlled, 1-year trial at five Veterans Affairs medical centers of 743 patients with severe COPD and one or more of the following during the previous year: hospital admission or ED visit for COPD, chronic home oxygen use, or course of systemic corticosteroids for COPD. Control group patients received usual care. Intervention group patients received a single 1- to 1.5-hour education session, an action plan for self-treatment of exacerbations, and monthly follow-up calls from a case manager. MEASUREMENTS AND MAIN RESULTS: We determined the combined number of COPD-related hospitalizations and ED visits per patient. Secondary outcomes included hospitalizations and ED visits for all causes, respiratory medication use, mortality, and change in Saint George's Respiratory Questionnaire. After 1 year, the mean cumulative frequency of COPD-related hospitalizations and ED visits was 0.82 per patient in usual care and 0.48 per patient in disease management (difference, 0.34; 95% confidence interval, 0.15-0.52; P < 0.001). Disease management reduced hospitalizations for cardiac or pulmonary conditions other than COPD by 49%, hospitalizations for all causes by 28%, and ED visits for all causes by 27% (P < 0.05 for all). CONCLUSIONS: A relatively simple disease management program reduced hospitalizations and ED visits for COPD. Clinical trial registered with www.clinicaltrials.gov (NCT00126776).

The effect of perceived racial discrimination on bodily pain among older African American men.

OBJECTIVES: We examined the extent to which experiences of racial discrimination are associated with bodily pain reported by African American men. METHODS: The study sample consisted of 393 African American male veterans who responded to a national survey of patients aged 50-75 who received care from the Veterans Health Administration (VHA). Veterans were surveyed by mail, with a telephone follow-up. The response rate for African Americans in the sample was 60.5%. Pain (assessed using the bodily pain subscale of the 36-item short-form health survey), experiences of discrimination, employment, education, and income were obtained through the survey. Age, race, and mental health comorbidities were obtained from VA administrative data. Multiple regression analysis adjusting for item non-response (via imputation) and unit non-response (via propensity scores and weighting) was used to assess the association between racial discrimination and likelihood of experiencing moderate or severe pain over the past 4 weeks. RESULTS: Experiences of racial discrimination were associated with greater bodily pain (beta = -0.25, P < 0.0001), even after controlling for socioeconomic and health-related characteristics. CONCLUSION: Perceived racial discrimination was associated with greater pain among a sample of older African American male patients in the VA. Additional research is needed to replicate this finding among other populations of African Americans.

Colorectal cancer screening mode preferences among US veterans.

OBJECTIVE: To assess colorectal cancer (CRC) screening mode preferences and correlates of these preferences among US veterans at average risk for CRC. METHOD: A cross-sectional survey of a nationally representative sample of VA patients was conducted between January 2005 and December 2006. We report preference distributions for screening modes among 2068 average-risk veterans and across patient subgroups based on personal, behavioral, and environmental factors. Independent predictors of preferences are identified through hierarchical logistic regression models. RESULTS: Colonoscopy (37%) was the most preferred mode followed by fecal occult blood test (FOBT) (29%). The strongest predictors of preferences were previous screening experience, provider recommendation, and use of non-VA healthcare services. Participants in higher socioeconomic groups were more likely to choose colonoscopy and less likely to indicate no preference. CONCLUSION: Screening programs that offer only one mode fail to accommodate the preferences of a substantial proportion of patients. Within the VA, adding screening colonoscopy to programs currently offering only FOBT is likely to increase preferences for colonoscopy, as patients incorporate provider recommendations for and personal experience with colonoscopy into their preferences. This is likely to disproportionately benefit lower socioeconomic groups who do not currently have access to non-VA colonoscopy services.

Accuracy of teledermatology for pigmented neoplasms.

BACKGROUND: Accurate diagnosis and management of pigmented lesions is critical because of the morbidity and mortality associated with melanoma. OBJECTIVE: We sought to compare accuracy of store-and-forward teledermatology for pigmented neoplasms with standard, in-person clinic dermatology. METHODS: We conducted a repeated measures equivalence trial involving veterans with pigmented skin neoplasms. Each lesion was evaluated by a clinic dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and a management plan. The primary outcome was aggregated diagnostic accuracy (match of any chosen diagnosis with histopathology). We also compared the severity of inappropriately managed lesions and, for teledermatology, evaluated the incremental change in accuracy when polarized light dermatoscopy or contact immersion dermatoscopy images were viewed. RESULTS: We enrolled 542 patients with pigmented lesions, most were male (96%) and Caucasian (97%). The aggregated diagnostic accuracy rates for teledermatology (macro images, polarized light dermatoscopy, and contact immersion dermatoscopy) were not equivalent (95% confidence interval for difference within +/-10%) and were inferior (95% confidence interval lower bound <10%) to clinic dermatology. In general, the addition of dermatoscopic images did not significantly change teledermatology diagnostic accuracy rates. In contrast to diagnostic accuracy, rates of appropriate management plans for teledermatology were superior and/or equivalent to clinic dermatology (all image types: all lesions, and benign lesions). However, for the subgroup of malignant lesions (n = 124), the rate of appropriate management was significantly worse for teledermatology than for clinic dermatology (all image types). Up to 7 of 36 index melanomas would have been mismanaged via teledermatology. LIMITATIONS: Nondiverse study population and relatively small number of melanomas were limitations. CONCLUSIONS: In general, the diagnostic accuracy of teledermatology was inferior whereas management was equivalent to clinic dermatology. However, for the important subgroup of malignant pigmented lesions, both diagnostic and management accuracy of teledermatology was generally inferior to clinic dermatology and up to 7 of 36 index melanomas would have been mismanaged via teledermatology. Teledermatology and teledermatoscopy should be used with caution for patients with suspected malignant pigmented lesions.

Accuracy of teledermatology for nonpigmented neoplasms.

BACKGROUND: Studies of teledermatology utilizing the standard reference of histopathology are lacking. OBJECTIVE: To compare accuracy of store-and-forward teledermatology for non-pigmented neoplasms with in-person dermatology. METHODS: This study was a repeated-measures equivalence trial involving veterans with non-pigmented skin neoplasms. Each lesion was evaluated by an in-person dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and management plan. The primary outcome was aggregated diagnostic accuracy (percent correct matches of any chosen diagnosis with histopathology). Secondary outcomes included management plan accuracy (percent correct matches with expert panel management plan). Additional analyses included evaluation of the incremental effect of using polarized light dermatoscopy in addition to standard macro images, and evaluating benign and malignant lesion subgroups separately. RESULTS: Most of the 728 participants were male (97.8%) and Caucasian (98.9%). The aggregated diagnostic accuracy (primary outcome) of teledermatology (macro images) was not equivalent (95% confidence interval [CI] for difference within +/-10%) and was inferior (95% CI lower bound <10%) to in-person dermatology for all lesions and the subgroups of benign and malignant lesions. However, management plan accuracy was equivalent. Teledermatology aggregated diagnostic accuracy using polarized light dermatoscopy was significantly better than for macro images alone (P = .0017). The addition of polarized light dermatoscopy showed the same pattern for malignant lesions, but not for benign lesions. Most interestingly, for malignant lesions, the addition of polarized light dermatoscopy yielded equivalent aggregated diagnostic accuracy rates. LIMITATIONS: Non-diverse study population. CONCLUSIONS: Using macro images, the diagnostic accuracy of teledermatology was inferior to in-person dermatology, but accuracy of management plans was equivalent. The addition of polarized light dermatoscopy yielded significantly better aggregated diagnostic accuracy, but management plan accuracy was not significantly improved. For the important subgroup of malignant lesions, the addition of polarized light dermatoscopy yielded equivalent diagnostic accuracy between teledermatologists and clinic dermatologists.

Randomized trial showed requesting medical records with a survey produced a more representative sample than requesting separately.

OBJECTIVES: The objective of the study was to compare the effect of two approaches to requesting medical records on survey response rates, sample representativeness, and the quality of self-reported screening. STUDY DESIGN AND SETTING: Eight hundred ninety veterans aged 50-75 years from the Minneapolis VA Medical Center were randomly assigned to (1) records request included with a colorectal cancer screening survey ("with-survey" group) or (2) request in a separate mailing following a completed survey ("after-survey" group). Analyses compared response rates, the proportion and characteristics of patients providing records, and the validity of self-reported screening, by group. RESULTS: Response rates did not vary by group (with-survey 76%; after-survey 78%, P=0.45). 54% of with-survey and 47% of after-survey participants provided complete medical records (P = 0.06). In the with-survey group, patients with complete medical records were significantly more likely to be married and to have a diagnosis of posttraumatic stress disorder; in the after-survey group, they were more likely to be aged 65-75 years, Caucasian, to have a family history of colorectal cancer, and to report being screened. Validity of self-reported screening did not vary significantly by group. CONCLUSION: The with-survey approach did not significantly reduce response rates or the quality of self-reported screening and produced a higher number and more representative sample with complete records.

Validation of self-reported colorectal cancer screening behavior from a mixed-mode survey of veterans.

OBJECTIVE: The aim of the study was to validate self-reported colorectal cancer (CRC) screening using the National Cancer Institute Colorectal Cancer Screening questionnaire. MATERIALS AND METHODS: 890 patients, ages 50 to 75 years, from the Minneapolis Veterans Affairs (VA) Medical Center were surveyed by mail. Phone administration was attempted with mail nonresponders. VA and non-VA records were combined for the reference standard. Sensitivity, specificity, concordance, and report-to-records ratio (R2R) were estimated for overall and test-specific CRC adherence among respondents providing complete medical records. Secondary analyses examined variation in estimates by patient characteristics, treatment of missing and uncertain responses, and whether a strict or liberal time interval was used for assessing concordance. RESULTS: Complete medical records were available for 345 of the 686 survey responders. For overall adherence, sensitivity was 0.98, specificity was 0.59, concordance was 0.88, and R2R was 1.14. Sensitivity was 0.82 for fecal occult blood test (FOBT), 0.75 for sigmoidoscopy, 0.97 for colonoscopy, and 0.63 for double-contrast barium enema (DCBE). Specificity was 0.89 for FOBT, 0.76 for sigmoidoscopy, 0.72 for colonoscopy, and 0.85 for DCBE. Concordance was >0.80 for all tests other than sigmoidoscopy (0.76). R2R was 1.31 for FOBT, 1.33 for sigmoidoscopy, 1.42 for colonoscopy, and 6.13 for DCBE. The R2R was lower for a combined sigmoidoscopy and colonoscopy measure. Overreporting was more pronounced for older, less-educated individuals with no family history of CRC. Sensitivity and R2R improved using a liberal interval and treating uncertain responses as nonadherent (versus missing), but differences were not statistically significant. CONCLUSIONS: Self-reported CRC screening validity is generally acceptable and robust across definitional decisions, but varies by screening test and patient characteristics.

Validation of screening questions for limited health literacy in a large VA outpatient population.

OBJECTIVES: Previous studies have shown that a single question may identify individuals with inadequate health literacy. We evaluated and compared the performance of 3 health literacy screening questions for detecting patients with inadequate or marginal health literacy in a large VA population. METHODS: We conducted in-person interviews among a random sample of patients from 4 VA medical centers that included 3 health literacy screening questions and 2 validated health literacy measures. Patients were classified as having inadequate, marginal, or adequate health literacy based on the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). We evaluated the ability of each of 3 questions to detect: 1) inadequate and the combination of "inadequate or marginal" health literacy based on the S-TOFHLA and 2) inadequate and the combination of "inadequate or marginal" health literacy based on the REALM. MEASUREMENTS AND MAIN RESULTS: Of 4,384 patients, 1,796 (41%) completed interviews. The prevalences of inadequate health literacy were 6.8% and 4.2%, based on the S-TOHFLA and REALM, respectively. Comparable prevalences for marginal health literacy were 7.4% and 17%, respectively. For detecting inadequate health literacy, "How confident are you filling out medical forms by yourself?" had the largest area under the Receiver Operating Characteristic Curve (AUROC) of 0.74 (95% CI: 0.69-0.79) and 0.84 (95% CI: 0.79-0.89) based on the S-TOFHLA and REALM, respectively. AUROCs were lower for detecting "inadequate or marginal" health literacy than for detecting inadequate health literacy for each of the 3 questions. CONCLUSION: A single question may be useful for detecting patients with inadequate health literacy in a VA population.

Validity of self-reported nail counts in patients with onychomycosis: A retrospective pilot analysis.

BACKGROUND: Onychomycosis (fungal infection of the toenails or fingernails) is common, affecting up to 8% of the general population. Telephone and mailed surveys conducted to study this disease are usually completed via patient self-report. The validity of the counts of diseased nails reported by the patients participating in these surveys has not been established. OBJECTIVE: The aim of this study was to assess the interrater agreement between patient and health care professional (HCP) counts of affected nails in patients with onychomycosis. METHODS: Patient and HCP counts of infected toenails and fingernails corresponding to a total of 567 patients originating from 3 different clinical trials were retrospectively analyzed. All these patients were initially classified as mycologically positive for toenail onychomycosis, and all 3 trials used identical self-administered questions regarding counts of infected toenails and fingernails. The level of agreement between patient versus HCP counts of infected toenails and fingernails (based on collapsed and uncollapsed counts) was measured using the quadratically weighted kappa statistic. RESULTS: Thirty-eight percent (213/554, 95% confidence interval [CI] = 35% to 43%) of the 554 patients with self-reported and HCP counts of infected toenails had exact agreement; for these 554 patients, quadratically weighted kappa = 0.47 (95% CI: 0.40 to 0.54). The highest agreement rates-79, 62, and 50%-correspond to the patients with HCP counts of affected toenails equaling 1, 2, and 10, respectively; that is, HCP counts at the extremes. The agreement rates ranged from 3% to 31% for the remaining patients with HCP counts between 3 and 9. Patients tended to undercount affected toenails, irrespective of the number of affected toenails counted by HCPs. No statistically significant association was found between agreement rates and whether or not the patients had been previously treated for toenail onychomycosis (P = .91). A marginally nonsignificant association of increasing agreement rates with increasing disease duration was observed (P = .06). Among the patients who reported one or more affected fingernails (n = 122), percent agreement was similar to that of toenails (41%, 95% CI: 33.0 to 50.0%). LIMITATIONS: This pilot study is limited by its retrospective design, its homogeneous group of patients (predominantly white, male veterans), and the fact that information on intraobserver and interobserver reliability was not obtained from all of the 3 clinical trials, the sources for this analysis. CONCLUSIONS: Patients tend to undercount affected nails as compared to HCPs. Reliance on self-reported counts in epidemiological surveys may lead to an inaccurate, underestimate of disease severity.

NailQoL: a quality-of-life instrument for onychomycosis.

BACKGROUND: The disease burden onychomycosis is not trivial. The aim is to develop a quality of life instrument to measure the onychomycosis burden. METHODS: 402 patients with mycologically-confirmed onychomycosis completed a baseline questionnaire of 39 quality of life items (modified Skindex-29 questions and 10 additional nail-specific questions). Internal consistency, reproducibility and responsiveness of the final instrument, NailQoL were measured. RESULTS: 15 items consisting of symptom (3), emotion (10), and functional (2) domains were retained in NailQoL. Symptom and emotion subscales = 0.80-0.92. Administration alpha demonstrated good internal consistency (Cronbach's of the instrument to 46 patients at one month after baseline revealed good reproducibility (ICC 0.88-0.91). Responsiveness was measured in 292 patients at 18 months; statistically significant better NailQoL scores were found in individuals with complete cure (mycological and clinical) (P < 0.01). CONCLUSION: NailQoL represents a new concise, valid, reliable, and responsive instrument for measuring burden of skin disease for patients with onychomycosis.