Impacts of Individual Patient Language and Neighborhood Ethnic Enclave on COVID-19 Test Positivity Among Hispanic/Latinx Patients in San Francisco.

BACKGROUND: Given the known disparities in COVID-19 within the Hispanic/Latinx community, we sought to examine the interaction between individual-level and neighborhood-level social determinants of health using linked electronic health record data. METHODS: We examined electronic health record data linked to neighborhood data among Hispanic/Latinx patients tested for COVID-19 between March 1, 2020, and February 28, 2021, from 2 large health care systems in San Francisco. Hispanic/Latinx ethnic enclave is measured using an index of census-tract level indicators of ethnicity, nativity, and language. Multilevel logistic regression models examined associations between ethnic enclave and COVID-19 positivity (COVID-19+), adjusting for patient-level sociodemographic and clinical characteristics and health system. Cross-level interactions were used to test whether associations between ethnic enclave and COVID-19+ differed by patient language preference. RESULTS: Among 26,871 patients, mean age was 37 years, 56% had Spanish-language preference, and 21% were COVID-19+. In unadjusted models, patients living in the highest versus lowest Hispanic/Latinx enclave had 3.2 higher odds of COVID-19+ (95% CI, 2.45-4.24). Adjusted, the relationship between ethnic enclave and COVID-19+ was attenuated, but not eliminated (odds ratio: 1.4; 95% CI, 1.13-1.17). Our results demonstrated a significant cross-level interaction, such that the influence of ethnic enclave was modified by patient language preference. For individuals with Spanish-language preference, risk of COVID-19+ was high regardless of neighborhood context, whereas for those with English preference, neighborhood ethnic enclave more than doubled the odds of infection. CONCLUSIONS: Findings suggest that a multilevel and intersectional approach to the study of COVID-19 inequities may illuminate dimensions of health inequity that affect marginalized communities and offer insights for targeted clinical and community-based interventions.

Associations between abrupt transition, dialysis-requiring AKI, and early mortality in ESKD among U.S. veterans.

BACKGROUND: Mortality is high within the first few months of starting chronic dialysis. Pre-ESKD trajectory of kidney function has been shown to be predictive of early death after dialysis initiation. We aim to better understand how two key aspects of pre-dialysis kidney function-an abrupt transition pattern and an episode of dialysis-requiring AKI (AKI-D) leading directly to ESKD-are associated with early mortality after dialysis initiation. METHODS: We extracted national data from U.S. Veterans Health Administration cross-linked with the United States Renal Data System (USRDS) to identify patients who initiated hemodialysis during 2009-2013. We defined abrupt transition as having a mean outpatient eGFR ≥ 30 ml/min/1.73m2 within 1 year prior to ESKD. AKI-D was identified using inpatient serum creatinine measurements (serum Cr increase by at least 50% from baseline) along with billing codes for inpatient receipt of dialysis for AKI within 30 days prior to the ESKD start date. We used multivariable proportional hazards models to examine the association between patterns of kidney function prior to ESKD and all-cause mortality within 90 days after ESKD. RESULTS: Twenty-two thousand eight hundred fifteen patients were identified in the final analytic cohort of Veterans who initiated hemodialysis and entered the USRDS. We defined five patterns of kidney function decline. Most (68%) patients (N = 15,484) did not have abrupt transition and did not suffer an episode of AKI-D prior to ESKD (reference group). The remaining groups had abrupt transition, AKI-D, or both. Patients who had an abrupt transition with (N = 503) or without (N = 3611) AKI-D had the highest risk of early mortality after ESKD onset after adjustment for demographics and comorbidities (adjusted HR 2.10, 95% CI 1.66-2.65 for abrupt transition with AKI-D; adjusted HR 2.10, 95% CI 1.90-2.33 for abrupt transition without AKI-D). In contrast, patients who experienced AKI-D without an abrupt transition pattern (N = 2141 had only a modestly higher risk of early death (adjusted HR 1.19, 95% CI 1.01-1.40). CONCLUSIONS: An abrupt decline in kidney function within 1 year prior to ESKD occurred in nearly 1 in 5 incident hemodialysis patients (18%) in this national cohort of Veterans and was strongly associated with higher early mortality after ESKD onset.

The incidence of and risk factors for hospitalized acute kidney injury among people living with HIV on antiretroviral treatment.

OBJECTIVES: The epidemiology of hospitalized acute kidney injury (AKI) among people living with HIV (PLWH) in the era of modern antiretroviral therapy (ART) for all PLWH is not well characterized. We evaluated the incidence of and risk factors for hospitalized AKI from 2005 to 2015 among PLWH on ART. METHODS: We conducted a retrospective analysis of PLWH from the Johns Hopkins HIV Clinical Cohort. We defined hospitalized AKI as a rise of ≥ 0.3 mg/dL in serum creatinine (SCr) within any 48-h period or a 50% increase in SCr from baseline and assessed associations of risk factors with incident AKI using multivariate Cox regression models. RESULTS: Most participants (75%) were black, 34% were female, and the mean age was 43 years. The incidence of AKI fluctuated annually, peaking at 40 per 1000 person-years (PY) [95% confidence interval (CI) 22-69 per 1000 PY] in 2007, and reached a nadir of 20 per 1000 PY (95% CI 11-34 per 1000 PY) in 2010. There was no significant temporal trend (-3.3% change per year; 95% CI -8.6 to 2.3%; P = 0.24). After multivariable adjustment, characteristics independently associated with AKI included black race [hazard ratio (HR) 2.44; 95% CI 1.42-4.20], hypertension (HR 1.62; 95% CI 1.09-2.38), dipstick proteinuria > 1 (HR 1.86; 95% CI 1.07-3.23), a history of AIDS (HR 1.82; 95% CI 1.29-2.56), CD4 count < 200 cells/µL (HR 1.46; 95% CI 1.02-2.07), and lower serum albumin (HR 1.73 per 1 g/dL decrease; 95% CI 1.02-2.07). CONCLUSIONS: In this contemporary cohort of PLWH, the annual incidence of first AKI fluctuated during the study period. Attention to modifiable AKI risk factors and social determinants of health may further reduce AKI incidence among PLWH.

Alcohol Use and Antiretroviral Adherence Among Patients Living with HIV: Is Change in Alcohol Use Associated with Change in Adherence?

Alcohol use increases non-adherence to antiretroviral therapy (ART) among persons living with HIV (PLWH). Dynamic longitudinal associations are understudied. Veterans Aging Cohort Study (VACS) data 2/1/2008-7/31/16 were used to fit linear regression models estimating changes in adherence (% days with ART medication fill) associated with changes in alcohol use based on annual clinically-ascertained AUDIT-C screening scores (range - 12 to + 12, 0 = no change) adjusting for demographics and initial adherence. Among 21,275 PLWH (67,330 observations), most reported no (48%) or low-level (39%) alcohol use initially, with no (55%) or small (39% ≤ 3 points) annual change. Mean initial adherence was 86% (SD 21%), mean annual change was - 3.1% (SD 21%). An inverted V-shaped association was observed: both increases and decreases in AUDIT-C were associated with greater adherence decreases relative to stable scores [p < 0.001, F (4, 21,274)]. PLWH with dynamic alcohol use (potentially indicative of alcohol use disorder) should be considered for adherence interventions.

RESUMEN: El consumo de alcohol aumenta el no-cumplimiento a la terapia antirretroviral (TARV) entre las personas que viven con VIH. No se han estudiado lo suficiente las dinámicas asociaciones longitudinales. Los datos del Estudio de la Envejecimiento de Cohorte de Veteranos (EECV) (1/2/2008­31/7/2016) fueron usados para encajar modelos de regresión lineal estimando los cambios en cumplimiento (% de días con medicaciones TARV surtidas) asociados con los cambios en el consumo de alcohol basado en los resultados anuales de las evaluaciones AUDIT-C, determinadas clínicamente, (una gama de -12 a + 12, 0 = cero cambio) adaptándose a las estadísticas demográficas y cumplimiento inicial. Entre 21,275 personas que viven con VIH (67,330 observaciones), la mayoría reportó ningún (48%) o bajos niveles del (39%) consumo de alcohol inicialmente, con ningún (55%) o muy pequeño (39% ≤ 3 puntos) cambio anual. la media inicial de cumplimiento fue 86% (DE 21%). La media de cambio anual fue -3.1% (DE 21%). Se observó una asociación de forma V invertida: tanto los aumentos como las disminuciones en AUDIT-C fueron asociados con mayor disminuciones de cumplimiento en comparación con resultados estables (p < 0.001, F (4, 21,274)). Personas que viven con VIH con el consumo dinámico de alcohol (potencialmente indicativo de un trastorno por consumo de alcohol) deben ser considerados por intervenciones de cumplimiento.

Level of Alcohol Use Associated with HIV Care Continuum Targets in a National U.S. Sample of Persons Living with HIV Receiving Healthcare.

We evaluated associations between levels of alcohol use and HIV care continuum components using national Veterans Aging Cohort Study data for all patients with HIV and AUDIT-C screening (2/1/2008-9/30/2014). Poisson regression models evaluated associations between alcohol use levels (non-drinking, low-, medium-, high-, and very high-level drinking) and: (1) engagement with care (documented CD4 cells/µl or viral load copies/ml labs), (2) ART treatment (≥ 1 prescription), and (3) viral suppression (HIV RNA < 500 copies/ml) within one year. Among 33,224 patients, alcohol use level was inversely associated with all care continuum outcomes (all p < 0.001). Adjusted prevalence of care engagement ranged from 77.8% (95% CI 77.1-78.4%) for non-drinking to 69.1% (66.6-71.6%) for high-level drinking. The corresponding range for ART treatment was 74.0% (73.3-74.7%) to 60.1% (57.3-62.9%) and for viral suppression was 57.3% (56.5-58.1%) to 38.3% (35.6-41.1%). Greater alcohol use is associated with suboptimal HIV treatment across the HIV care continuum.

Creatinine Versus Cystatin C: Differing Estimates of Renal Function in Hospitalized Veterans Receiving Anticoagulants.

BACKGROUND: Current practice in anticoagulation dosing relies on kidney function estimated by serum creatinine using the Cockcroft-Gault equation. However, creatinine can be unreliable in patients with low or high muscle mass. Cystatin C provides an alternative estimation of glomerular filtration rate (eGFR) that is independent of muscle. OBJECTIVE: We compared cystatin C-based eGFR (eGFRcys) with multiple creatinine-based estimates of kidney function in hospitalized patients receiving anticoagulants, to assess for discordant results that could impact medication dosing. DESIGN: Retrospective chart review of hospitalized patients over 1 year who received non-vitamin K antagonist anticoagulation, and who had same-day measurements of cystatin C and creatinine. PARTICIPANTS: Seventy-five inpatient veterans (median age 68) at the San Francisco VA Medical Center (SFVAMC). MAIN MEASURES: We compared the median difference between eGFR by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) study equation using cystatin C (eGFRcys) and eGFRs using three creatinine-based equations: CKD-EPI (eGFREPI), Modified Diet in Renal Disease (eGFRMDRD), and Cockcroft-Gault (eGFRCG). We categorized patients into standard KDIGO kidney stages and into drug-dosing categories based on each creatinine equation and calculated proportions of patients reclassified across these categories based on cystatin C. KEY RESULTS: Cystatin C predicted overall lower eGFR compared to creatinine-based equations, with a median difference of - 7.1 (IQR - 17.2, 2.6) mL/min/1.73 m2 versus eGFREPI, - 21.2 (IQR - 43.7, - 8.1) mL/min/1.73 m2 versus eGFRMDRD, and - 25.9 (IQR - 46.8, - 8.7) mL/min/1.73 m2 versus eGFRCG. Thirty-one to 52% of patients were reclassified into lower drug-dosing categories using cystatin C compared to creatinine-based estimates. CONCLUSIONS: We found substantial discordance in eGFR comparing cystatin C with creatinine in this group of anticoagulated inpatients. Our sample size was limited and included few women. Further investigation is needed to confirm these findings and evaluate implications for bleeding and other clinical outcomes. NIH TRIAL REGISTRY NUMBER: Not applicable.

Increased Rates of Documented Alcohol Counseling in Primary Care: More Counseling or Just More Documentation?

BACKGROUND: Clinical performance measures often require documentation of patient counseling by healthcare providers. Little is known about whether such measures encourage delivery of counseling or merely its documentation. OBJECTIVE: To assess changes in provider documentation of alcohol counseling and patient report of receiving alcohol counseling in the Veterans Administration (VA) from 2009 to 2012. DESIGN: Retrospective time-series analysis. PARTICIPANTS: A total of 5413 men who screened positive for unhealthy alcohol use at an outpatient visit and responded to a confidential mailed survey regarding alcohol counseling from a VA provider in the prior year. MAIN MEASURES: Rates of provider documentation of alcohol counseling in the electronic health record and patient report of such counseling on the survey were assessed over 4 fiscal years. Annual rates were calculated overall and with patients categorized into four mutually exclusive groups based on their own reports of alcohol counseling (yes/no) and whether alcohol counseling was documented by a provider (yes/no). KEY RESULTS: Provider documentation of alcohol counseling increased 23.6% (95% CI: 17.0, 30.2), from 59.4% to 83.0%, while patient report of alcohol counseling showed no significant change (4.0%, 95% CI: -2.3, 10.3), increasing from 66.1% to 70.1%. An 18.7% (95% CI: 11.7, 25.7) increase in the proportion of patients who reported counseling that was documented by a provider largely reflected a 14.7% decline (95% CI: 8.5, 20.8) in the proportion of patients who reported alcohol counseling that was not documented by a provider. The proportion of patients who did not report counseling but whose providers documented it did not show a significant change (4.9%, 95%CI: 0.0, 9.9). CONCLUSIONS: If patient report is accurate, increased rates of documented alcohol counseling in the VA from 2009 to 2012 predominantly reflected improved documentation of previously undocumented counseling rather than delivery of additional counseling or increased documentation of counseling that did not meaningfully occur.

High inpatient utilization among Veterans Health Administration patients with substance-use disorders and co-occurring mental health conditions.

BACKGROUND: Substance-use disorders (SUDs) are common and costly conditions. Understanding high inpatient utilization (HIU) among patients with SUD can inform the development of treatment approaches designed to reduce healthcare expenditures and improve service quality. OBJECTIVES: To examine the prevalence, type, and predictors of HIU among patients with SUD and co-occurring mental health conditions. METHODS: Service utilization and demographic and clinical variables were extracted from a national sample of Veterans Health Administration (VA) patients with SUD-only [n = 148,960 (98.3% male)], SUD plus serious mental illness ([i.e. schizophrenia- and/or bipolar-spectrum disorders; SUD/SMI; n = 75,913 (91.6% male)], and SUD plus other mental illness [SUD/MI; n = 245,675 (94.6% male)]. Regression models were used to examine HIU during a follow-up year. RESULTS: Prevalence of HIU among the SUD-only group was 6.2% (95% confidence interval (CI): 6.1%-6.3%) compared with 22.7% (95% CI: 22.4%-23.0%) and 9.7% (95% CI: 9.6%-9.8%) among the SUD/SMI and SUD/MI groups, respectively. Patients with SUD/MI represented nearly half of the HIU sample. Primary type of inpatient service use varied by comorbidity: SUD-only = medicine; SUD/SMI = psychiatric; SUD/MI similar use of psychiatric, SUD-related, and medicine. Predictors of HIU were generally similar across groups: older age, unmarried, homelessness, suicide risk, pain diagnosis, alcohol/opioid/sedative-use disorders, and prior-year emergency department/inpatient utilization. CONCLUSIONS: Substantial reductions in HIU among an SUD population will likely require treatment approaches that target patients with less-severe mental health conditions in addition to SMI. Cross-service collaborations (e.g., integration of medical providers in SUD care) and interventions designed to target issues and/or conditions that lead to HIU (e.g., homeless care services) may be critical to reducing HIU in this population.

Outpatient continuing care after residential substance use disorder treatment in the US Veterans Health Administration: Facilitators and challenges.

BACKGROUND: In the U.S. Veterans Health Administration (VHA), residential treatment programs are an important part of the continuum of care for patients with substance use disorders (SUDs). Outpatient continuing care after residential treatment helps maintain early recovery and treatment gains. Knowing more about the drivers of variation in continuing care practices and performance across residential programs might inform quality improvement efforts. METHODS: Metrics of continuing care were operationalized and calculated for each of VHA's 63 SUD Residential Rehabilitation Treatment Programs (SUD RRTPs) and 34 Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) with a SUD track in fiscal year 2012. Management and frontline staff of these programs were then interviewed to learn what factors might contribute to high or low program performance on the metrics compared with national averages. RESULTS: Among SUD RRTPs, the mean rate of outpatient SUD/MH continuing care was 59% within 7 days and 80% within 30 days, and the mean rate of SUD continuing care was 63% within 30 days. Among MH RRTPs with a SUD track, these rates were 56%, 75%, and 36%, respectively. There was substantial variability in continuing care rates across the 97 programs: 21%-93% for SUD/MH care within 7 days, 36%-100% for SUD/MH care within 30 days, and 4%-91% for SUD care within 30 days. Interviews with representatives of 44 programs revealed key facilitators of continuing care: accountability of program staff, predischarge scheduling, predischarge introductions to continuing care providers, strong patient relationships, accessibility, and persistent emphasis. Key challenges included inadequate program staffing, lack of program staff accountability, and poor accessibility. CONCLUSIONS: Wide variation in continuing care rates across programs and identification of common facilitators at high-performing programs suggest substantial opportunity for improvement for programs with lower performance.

Implementation of a pragmatic randomized trial of screening for chronic kidney disease to improve care among non-diabetic hypertensive veterans.

BACKGROUND: Whether screening for chronic kidney disease (CKD) can improve the care of persons at high risk for complications remains uncertain. We describe the design and early implementation experience of a pilot, cluster-randomized pragmatic trial to evaluate the feasibility, implementation, and effectiveness of a "triple marker" CKD screening program (creatinine, cystatin C and albumin to creatinine ratio) for improving care among hypertensive veterans seen in primary care at one Veterans Administration Hospital. METHODS/DESIGN: Non-diabetic hypertensive veterans age 18-80 without known CKD were randomized in clusters determined by primary care provider (unit of randomization) into three arms. Usual care will be compared with two incrementally intensified treatment strategies: (1) screen for CKD followed by patient and provider education or (2) screen-educate plus a clinical pharmacist-led CKD and BP management program. The primary clinical outcome is systolic blood pressure (BP) change from baseline. Secondary clinical outcome is BP control. The primary process outcomes is triple marker screening (across three arms), and secondary process outcomes include use of inhibitors of the renin-angiotensin system (ACE/ARB) overall and in persons with albuminuria, CKD recognition by PCP, use of non-steroidal anti-inflammatory drugs (NSAIDs) and NSAID education by PCP. The design uses the Veterans Health Administration electronic health record (EHR) to identify participants, deliver the interventions and ascertain study outcomes. Assessment of the program implementation will use the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Study duration is 12 months. RESULTS: A total of 1,819 patients have been randomized within 41 provider clusters. The median age (interquartile range) is 68 years (61-72), and 99% of participants are male. Approximately 16% are Black, and 5% Hispanic. In the first 6 months of the trial, 434 triple marker screening tests have been ordered, and 217(50%) have been tested. A total of 48 new CKD cases have been identified among those tested, for a preliminary yield of 22%. CONCLUSION: We have successfully implemented a pragmatic protocol that uses the EHR to identify and characterize eligible participants, deliver the intervention, and ascertain study outcomes with high rates of participation by providers and patients. Results from this study can guide design of pragmatic trials in the field of CKD. TRIAL REGISTRATION: NCT01978951 ; Date or Registration: 1/17/2014.

Are Improvements in Measured Performance Driven by Better Treatment or "Denominator Management"?

BACKGROUND: Process measures of healthcare quality are usually formulated as the number of patients who receive evidence-based treatment (numerator) divided by the number of patients in the target population (denominator). When the systems being evaluated can influence which patients are included in the denominator, it is reasonable to wonder if improvements in measured quality are driven by expanding numerators or contracting denominators. OBJECTIVE: In 2003, the US Department of Veteran Affairs (VA) based executive compensation in part on performance on a substance use disorder (SUD) continuity-of-care quality measure. The first goal of this study was to evaluate if implementing the measure in this way resulted in expected improvements in measured performance. The second goal was to examine if the proportion of patients with SUD who qualified for the denominator contracted after the quality measure was implemented, and to describe the facility-level variation in and correlates of denominator contraction or expansion. DESIGN: Using 40 quarters of data straddling the implementation of the performance measure, an interrupted time series design was used to evaluate changes in two outcomes. PARTICIPANTS: All veterans with an SUD diagnosis in all VA facilities from fiscal year 2000 to 2009. MAIN MEASURES: The two outcomes were 1) measured performance-patients retained/patients qualified and 2) denominator prevalence-patients qualified/patients with SUD program contact. KEY RESULTS: Measured performance improved over time (P < 0.001). Notably, the proportion of patients with SUD program contact who qualified for the denominator decreased more rapidly after the measure was implemented (p = 0.02). Facilities with higher pre-implementation denominator prevalence had steeper declines in denominator prevalence after implementation (p < 0.001). CONCLUSIONS: These results should motivate the development of measures that are less vulnerable to denominator management, and also the exploration of "shadow measures" to monitor and reduce undesirable denominator management.

Racial/Ethnic Differences in the Prevalence of Clinically Recognized Alcohol Use Disorders Among Patients from the U.S. Veterans Health Administration.

BACKGROUND: Alcohol use disorders (AUDs) are common and have worse consequences for racial/ethnic minority groups than whites. AUDs are often underrecognized in clinical settings, but it is unknown whether the prevalence of clinically recognized AUD varies across racial/ethnic groups. We describe the overall and age- and gender-stratified prevalence of clinically documented AUD across 3 racial/ethnic groups in a national sample of Veterans Health Administration (VA) patients. METHODS: Data from VA's National Patient Care Database identified all patients who used VA care in Fiscal Year 2012 and were documented as black, Hispanic, or white race/ethnicity. The prevalence of clinically recognized AUD based on ICD-9 diagnoses was compared across racial/ethnic groups overall and within gender and age groups using chi-square tests of independence. RESULTS: Among 4,666,403 eligible patients, 810,902 (17.4%) were black, 302,331 (6.5%) were Hispanic, and 3,553,170 (76.1%) were white. The prevalence of clinically recognized AUD was 6.5% overall, and 9.8% (95% CI 9.8 to 9.9) among black, 7.1% (95% CI 7.0 to 7.2) among Hispanic, and 5.7% (95% CI 5.6 to 5.7) among white patients (p < 0.001). This pattern generally held for men, regardless of age group, with the exception of those 18 to 29 years old, for whom no difference was observed across race/ethnicity. Among women, the prevalence of AUD was generally lowest among Hispanic and highest among black patients, with the exception of those 30 to 44 years old, for whom the highest prevalence was among whites. CONCLUSIONS: In contrast to findings from the general population, the prevalence of clinically recognized AUD among VA patients is generally highest among black men and women and lowest among white men and Hispanic women. This is the first study to describe the prevalence of clinically recognized AUD across racial/ethnic groups in a large healthcare system. Future research comparing estimates to diagnoses based on structured gold-standard assessments is needed to understand whether AUDs are under- or overidentified.

Alcohol screening scores and the risk of intensive care unit admission and hospital readmission.

BACKGROUND: The association between alcohol misuse and the need for intensive care unit admission as well as hospital readmission among those discharged from the hospital following a critical illness is unclear. This study sought to determine whether alcohol misuse was associated with (1) admission to an intensive care unit (ICU) among a cohort of patients receiving outpatient care and (2) hospital readmission among those discharged from the hospital following critical illness. METHODS: This was a retrospective cohort study conducted with data from 24 Veterans Affairs (VA) health care facilities between 2004 and 2007. Scores on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire were used to identify patients with past-year abstinence, lower-risk alcohol use, moderate alcohol misuse, or severe alcohol misuse. The primary outcome was admission to a VA intensive care unit within the year following administration of the AUDIT-C. In an analysis focused on patients discharged from the ICU, the 2 main outcomes were hospital readmission within 1 year and within 30 days. RESULTS: Among 486,115 veterans receiving outpatient care, the adjusted probability of ICU admission within 1 year was 2.0% (95% confidence interval [CI]: 1.7%-2.3%) for abstinent patients, 1.6% (95% CI: 1.3%-1.8%) for patients with lower-risk alcohol use, 1.8% (1.4%-2.3%) for patients with moderate alcohol misuse, and 2.5% (2.0%-2.9%) for patients with severe alcohol misuse. Among the 9,030 patients discharged from an ICU, the adjusted probability of hospital readmission within 1 year was 48% (46%-49%) in abstinent patients, 44% (42%-45%) in patients with lower-risk alcohol use, 42% (39%-45%) in patients with moderate alcohol misuse, and 55% (49%-60%) in patients with severe alcohol misuse. CONCLUSIONS: Alcohol misuse may represent a modifiable risk factor for a cycle of ICU admission and subsequent hospital readmission.

Extended release naltrexone for alcohol use disorders: quasi-experimental effects on mortality and subsequent detoxification episodes.

BACKGROUND: Utilization of extended release naltrexone (XRN) for alcohol use disorders (AUDs) in the U.S. Veterans Health Administration (VHA) has been limited, perhaps due to high cost, lack of established superiority over less expensive alternatives including oral naltrexone, and related formulary restrictions. Despite these barriers, pockets of higher utilization exist in VHA, allowing for the quasi-experimental examination of the effects of XRN on 1-year mortality and number of subsequent detoxification episodes among patients with high rates of psychiatric comorbidities and previous psychosocial and pharmacological addiction treatment. METHODS: Using propensity score-weighted mixed-effects logistic regression, 1-year mortality was compared between patients with AUDs who received XRN in fiscal year 2010 (n = 387) and a random sample of patients with AUDs who did not receive XRN (n = 3,759). Among the subgroup of patients who had at least 1 detoxification episode in the previous year, 1-year mortality and number of subsequent detoxification episodes were compared between those who did and did not receive XRN. RESULTS: Overall, 1-year mortality for the patients receiving XRN was significantly lower than for the comparison group who did not receive XRN (odds ratio [OR] = 0.30; p < 0.001). Among patients with a detoxification episode in the previous year, those receiving XRN had, on average, 0.80 fewer subsequent detoxification episodes (p < 0.001) and significantly lower mortality (OR = 0.78, p < 0.001) in the postindex year. CONCLUSIONS: Among patients with AUDs, those receiving XRN had lower 1-year mortality and fewer detoxifications compared to similar patients not receiving XRN. These results, although observational, support the use of XRN, especially among patients with high rates of psychiatric comorbidities and previous addiction treatment who are still struggling with AUDs and/or facing a period of vulnerability to relapse.

Probability and predictors of patients converting from negative to positive screens for alcohol misuse.

BACKGROUND: Medicare reimburses providers for annual alcohol screening. However, the benefit of rescreening patients a year after a negative screen for alcohol misuse is unknown. We hypothesized that some subgroups of patients who screen negative would have a very low probability of converting to a positive subsequent screen (e.g., <0.1%), calling into question the value of annual alcohol screening for some patient subgroups. METHODS: This retrospective cohort study estimated the probability of converting to a positive screen for alcohol misuse a year after a negative screen among outpatients from 30 Veterans Health Administration (VA) medical centers. Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) alcohol screening scores (range 0 to 12 points) from 2004 to 2008 were obtained from electronic health record data. Eligible patients screened negative on their initial screen (AUDIT-C scores 0 to 3 for men; 0 to 2 for women). The main outcome was a positive subsequent screen (AUDIT-C scores ≥4 men; ≥3 women). RESULTS: Among 21,081 women and 323,913 men who screened negative on an initial screen, 5.4% and 6.0%, respectively, screened positive a year later. The adjusted probability of converting to a positive subsequent screen varied from 2.1 to 38.9% depending on age, gender, and initial negative screen score. Women, older patients, and those with initial AUDIT-C scores of 0 were least likely to a convert to a positive subsequent screen, while younger men with AUDIT-C scores of 3 were most likely to a convert to a positive subsequent screen. CONCLUSIONS: The probability of a positive subsequent screen varied depending on age, gender, and initial negative screen score but exceeded 2% in all patient subgroups. Annual rescreening appears reasonable for all VA patients who had a negative screen the year prior.

Lessons learned from implementing a diversity, equity, and inclusion curriculum for health research professionals at a large academic research institution.

Objective: Despite advances in incorporating diversity and structural competency into medical education curriculum, there is limited curriculum for public health research professionals. We developed and implemented a four-part diversity, equity, and inclusion (DEI) training series tailored for academic health research professionals to increase foundational knowledge of core diversity concepts and improve skills. Methods: We analyzed close- and open-ended attendee survey data to evaluate within- and between-session changes in DEI knowledge and perceived skills. Results: Over the four sessions, workshop attendance ranged from 45 to 82 attendees from our 250-person academic department and represented a mix of staff (64%), faculty (25%), and trainees (11%). Most identified as female (74%), 28% as a member of an underrepresented racial and ethnic minority (URM) group, and 17% as LGBTQI. During all four sessions, attendees increased their level of DEI knowledge, and within sessions two through four, attendees' perception of DEI skills increased. We observed increased situational DEI awareness as higher proportions of attendees noted disparities in mentoring and opportunities for advancement/promotion. An increase in a perceived lack of DEI in the workplace as a problem was observed; but only statistically significant among URM attendees. Discussion: Developing applied curricula yielded measurable improvements in knowledge and skills for a diverse health research department of faculty, staff, and students. Nesting this training within a more extensive program of departmental activities to improve climate and address systematic exclusion likely contributed to the series' success. Additional research is underway to understand the series' longer-term impact on applying skills for behavior change.

Annual rescreening for alcohol misuse: diminishing returns for some patient subgroups.

BACKGROUND: Routine alcohol screening is widely recommended, and Medicare now reimburses for annual alcohol screening. Although up to 18% of patients will screen positive for alcohol misuse, the value of annual rescreening for patients who repeatedly screen negative is unknown. OBJECTIVE: To evaluate the probability of converting to a positive alcohol screen at annual rescreening among VA outpatients who previously screened negative 2-4 times. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: A total of 179,035 VA outpatients (10,588 women) who previously screened negative on 2 and up to 4 consecutive annual alcohol screens and were rescreened the next year. MEASURES: AUDIT-C alcohol screening scores (range, 0-12) were obtained from electronic medical record data. The probability of converting to a positive screen (scores: men ≥4; women, ≥3) at rescreening after 2-4 prior negative screens was evaluated overall and across subgroups based on age, sex, and prior negative screen scores (scores: men, 0-3; women, 0-2). RESULTS: The overall probability of converting to a positive subsequent screen decreased modestly from 3.5% to 1.9% as the number of prior consecutive negative screens increased from 2 to 4, yet varied widely across subgroups based on age, sex, and prior negative screen scores (0.6%-38.7%). CONCLUSIONS: The likelihood of converting to a positive screen at annual rescreening is strongly influenced by age, sex, and scaled screening scores on prior negative alcohol screens. Algorithms for the frequency of repeat alcohol screening for patients who repeatedly screen negative should be based on these factors. These results may have implications for other routine behavioral health screenings.

The challenges of improving statistical practice in alcohol treatment research.

BACKGROUND: This commentary discusses the paper by Hallgren and Witkiewitz (2013) which evaluated 5 methods for addressing missing data in clinical trials of interventions for alcohol use disorders. The authors conclude that commonly used methods (e.g., complete case analysis, single imputation methods) can produce misleading results and that better alternatives exist (e.g., multiple imputation [MI]). The problems of using inferior approaches are well-known and well-illustrated by the analysis in this paper, which serves as an educational reminder to use more statistically justified practices. METHODS: Findings of this paper are put in context of the broader statistical literature. Strategies to promote common usage of superior missing data methods are discussed. RESULTS: Solving the poor uptake of statistically justified missing data methods will require a multilevel diagnosis of the problem and likely a multifaceted response, perhaps including the establishment, publication, and enforcement of standards by scientific funding and regulatory agencies, scientific journals, and graduate program accreditation bodies. CONCLUSIONS: Little disagreement exists regarding the importance of addressing missing data in a statistically justified manner (e.g., with MI or other maximum likelihood methods). However, as with the implementation of other evidence-based practices, knowing what should be done does not alone make it happen.

AUDIT-C scores as a scaled marker of mean daily drinking, alcohol use disorder severity, and probability of alcohol dependence in a U.S. general population sample of drinkers.

BACKGROUND: Brief alcohol screening questionnaires are increasingly used to identify alcohol misuse in routine care, but clinicians also need to assess the level of consumption and the severity of misuse so that appropriate intervention can be offered. Information provided by a patient's alcohol screening score might provide a practical tool for assessing the level of consumption and severity of misuse. METHODS: This post hoc analysis of data from the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) included 26,546 U.S. adults who reported drinking in the past year and answered additional questions about their consumption, including Alcohol Use Disorders Identification Test-Consumption questionnaire (AUDIT-C) alcohol screening. Linear or logistic regression models and postestimation methods were used to estimate mean daily drinking, the number of endorsed alcohol use disorder (AUD) criteria ("AUD severity"), and the probability of alcohol dependence associated with each individual AUDIT-C score (1 to 12), after testing for effect modification by gender and age. RESULTS: Among eligible past-year drinkers, mean daily drinking, AUD severity, and the probability of alcohol dependence increased exponentially across increasing AUDIT-C scores. Mean daily drinking ranged from < 0.1 to 18.0 drinks/d, AUD severity ranged from < 0.1 to 5.1 endorsed AUD criteria, and probability of alcohol dependence ranged from < 1 to 65% across scores 1 to 12. AUD severity increased more steeply across AUDIT-C scores among women than men. Both AUD severity and mean daily drinking increased more steeply across AUDIT-C scores among younger versus older age groups. CONCLUSIONS: Results of this study could be used to estimate patient-specific consumption and severity based on age, gender, and alcohol screening score. This information could be integrated into electronic decision support systems to help providers estimate and provide feedback about patient-specific risks and identify those patients most likely to benefit from further diagnostic assessment.

Why not add consumption measures to current definitions of substance use disorders? Commentary on Rehm et al.: 'Defining substance use disorders: do we really need more than heavy use?'.

The article by Rehm and colleagues in this issue of the Journal argues that diagnoses of substance use disorders should be based solely on measures of consumption. Although the authors provide convincing arguments for inclusion of consumption measures in the diagnostic criteria for substance use disorders, we do not agree that diagnostic criteria should be restricted to measures of consumption alone. Our clinical and research experience with alcohol use disorders suggests that use of consumption measures alone would fail to identify many patients whose alcohol or drug use is adversely impacting their health. Instead, we advocate-as others have done-that measures of consumption be added to current diagnostic criteria.