Variables Associated With Moderate to High Loneliness Among Individuals Living With Spinal Cord Injuries and Disorders.

OBJECTIVE: To identify variables independently associated with moderate to high loneliness in individuals living with Spinal Cord Injuries or Disorders (SCI/D). DESIGN: A cross-sectional, national survey of a random sample of community-dwelling Veterans with SCI/D in the United States. Survey methodology was used to collect data on demographic and injury characteristics, general health, chronic and SCI-secondary conditions, and loneliness. SETTING: The VHA SCI/D System of Care including 25 regional SCI/D Centers (or Hubs). PARTICIPANTS: Among 2466 Veterans with SCI/D, 592 completed surveys (24%). Most participants were men (91%), white (81%), not currently married (42%), had tetraplegia (33%), and on average injured for 18 years at the time of data collection (N=562). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The dependent variable, loneliness, was collected using the UCLA-3 instrument. Loneliness was dichotomized into never/low loneliness and moderate/high loneliness (UCLA score ≥ 4). RESULTS: Bivariate analyses assessed unadjusted associations in demographics, injury characteristics, chronic disease, and SCI-secondary conditions. Multivariable logistic regression was used to identify factors independently associated with moderate/high loneliness. Participants had a mean loneliness score of 5.04, SD=1.99. The point prevalence of moderate to high loneliness was 66%. Lower duration of injury, paraplegia, being unmarried, being in fair/poor general health, having dysfunctional sleep, and having a diagnosis of bowel dysfunction were each independently associated with greater odds of moderate/high loneliness. CONCLUSIONS: Findings suggest that interventions to reduce/manage loneliness in the Veteran SCI/D population should focus on those who are more newly injured, have paraplegia, currently unmarried, have bowel problems, and experience dysfunctional sleep.

Risk Factors Associated With Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae Positive Cultures in a Cohort of US Veterans.

BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE) cause approximately 13 100 infections, with an 8% mortality rate in the United States annually. Carbapenemase-producing CRE (CP-CRE) a subset of CRE infections infections have much higher mortality rates (40%-50%). There has been little research on characteristics unique to CP-CRE. The goal of the current study was to assess differences between US veterans with non-CP-CRE and those with CP-CRE cultures. METHODS: A retrospective cohort of veterans with CRE cultures from 2013-2018 and their demographic, medical, and facility level covariates were collected. Clustered multiple logistic regression models were used to assess independent factors associated with CP-CRE. RESULTS: The study included 3096 unique patients with cultures positive for either non-CP-CRE or CP-CRE. Being African American (odds ratio, 1.44 [95% confidence interval, 1.15-1.80]), diagnosis in 2017 (3.11 [2.13-4.54]) or 2018 (3.93 [2.64-5.84]), congestive heart failure (1.35 [1.11-1.64]), and gastroesophageal reflux disease (1.39 [1.03-1.87]) were associated with CP-CRE cultures. There was no known antibiotic exposure in the previous year for 752 patients (24.3% of the included patients). Those with no known antibiotic exposure had increased frequency of prolonged proton pump inhibitor use (17.3%) compared to those with known antibiotic exposure (5.6%). DISCUSSION: Among a cohort of patients with CRE, African Americans, patients with congestive heart failure, and those with gastroesophageal reflux disease had greater odds of having a CP-CRE culture. Roughly 1 in 4 patients with CP-CRE had no known antibiotic exposure in the year before their positive culture.

Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice.

BACKGROUND: The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers. OBJECTIVES: The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider. RESEARCH DESIGN: This was a retrospective, observational over fiscal years (FY) 2015-2018. SUBJECTS: Veterans receiving primary care services paid for by the VA. MEASURES: Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year. RESULTS: There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care. CONCLUSION: As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.

Comparing VA and Community-Based Care: Trends in Sleep Studies Following the Veterans Choice Act.

BACKGROUND: To address concerns about access to care, the Veterans Access, Choice, and Accountability Act of 2014 was enacted to make care available in the community when Veterans Health Administration (VA) care was unavailable or not timely. This paper examined VA referrals for diagnostic sleep studies from federal fiscal year (FY) 2015-2018. DESIGN: Sleep studies completed between FY2015 and 2018 for Veterans tested within VA facilities (VAF) or referred to VA community care (VACC) providers were identified using VA administrative data files. Sleep studies were divided into laboratory and home studies. KEY RESULTS: The number of sleep studies conducted increased over time; the proportion of home studies increased in VAF (32 to 47%). Veterans were more likely to be referred for a sleep study to VACC if they lived in a rural or highly rural area (ORs = 1.47 and 1.55, respectively), and had public or public and private insurance (ORs = 2.01 and 1.35), and were less likely to be referred to VACC if they were age 65+ (OR = 0.72) and were in the highest utilization risk based on Nosos score (OR = 0.78). Regression analysis of sleep study type revealed that lab studies were much more likely for VACC referrals (OR = 3.16), for persons living in rural areas (OR = 1.21), with higher comorbidity scores (OR = 1.28) and for ages 44-54, 55 to 64, and 65+ (ORs = 1.12, 1.28, 1.45, respectively) compared to younger Veterans. Veterans with some or full VA copayments (ORs = 0.91 and 0.86, respectively), and overweight Veterans (OR = 0.94) were less likely to have lab studies. CONCLUSIONS: The number of sleep studies performed on Veterans increased from 2015 to 2018. Access to sleep studies improved through a combination of providing care through the Veteran Choice Program, predominantly used by rural Veterans, and increased use of home sleep studies by VA.

Association between chronic illness complexity and receipt of evidence-based depression care.

BACKGROUND: The rate of guideline concordance with antidepressant treatment for persons with depression is low. The problem may be even more pronounced for patients with depression and other multiple chronic conditions (MCC). OBJECTIVES: To study, for persons with new depressive episodes, the association between MCC and the likelihood of receiving guideline-concordant depression treatment. RESEARCH DESIGN: Retrospective cohort study using Veterans Affairs administrative data. SUBJECTS: A total of 43,189 Veterans Affairs patients who had a new depressive episode during 2007 were included. MEASURES: We assessed whether patients had an adequate supply of antidepressants during acute and continuation phases of depression treatment, which indicates guideline-concordant care. We determined the association between comorbid conditions and receipt of adequate antidepressant supplies after adjusting for potential confounders. RESULTS: Compared with patients with depression alone, those with comorbid cardiovascular/cerebrovascular disease, peptic ulcer/gastroesophageal reflux disease (GERD), or arthritis were 8%-13% more likely to receive adequate antidepressant supplies during the acute phase. Patients with depression and substance/alcohol abuse were 15% less likely to receive adequate supplies in the acute treatment phase. Those with cardiovascular/cerebrovascular disease or peptic ulcer/GERD were 9%-10% more likely to receive continuation phase guideline-concordant depression treatment. Patients with comorbid substance/alcohol abuse were 19% less likely to receive continuation phase guideline-concordant depression treatment. Relatively few of the most prevalent MCC clusters were significantly associated with receipt of guideline-concordant depression treatment. CONCLUSIONS: There was no consistent association between specific clusters of chronic conditions and adequate antidepressant supplies. There continues to be need for practice-level and system-level interventions to increase quality of depression treatment, particularly among persons with certain comorbid conditions such as cardiovascular/cerebrovascular disease, peptic ulcer/GERD, and arthritis.

Coexisting chronic conditions associated with mortality and morbidity in adult patients with asthma.

OBJECTIVE: Many asthma patients suffer from chronic conditions other than asthma. We investigated the specific contribution of common comorbidities on mortality and morbidity in adult asthma. METHODS: In an observational study of adults with incident asthma identified between 1999 and 2003 using National Veterans Affairs and Centers for Medicare and Medicaid Services encounter databases (n = 25 975, follow-up 3.0 ± 1.7 years), association between 13 most prevalent comorbidities (hypertension, ischemic heart disease (IHD), osteoarthritis, rheumatoid arthritis, diabetes, mental disorders, substance/drug abuse, enlarged prostate, depression, cancer, alcoholism, HIV and heart failure) and four conditions previously associated with asthma (sleep apnea, gastroesophageal reflux disease (GERD), rhinitis and sinusitis) and mortality, hospitalizations and asthma exacerbations were assessed using multivariate regression analyses adjusted for other clinically important covariates. RESULTS: HIV followed by alcoholism and mental disorders among 18-45-years old, and heart failure, diabetes, IHD and cancer among those ≥ 65 years old were associated with an increased risk of all-cause mortality. Many conditions were associated with increased risk for all-cause hospitalizations, but the increased risk was consistent across all ages for mental disorders. For asthma exacerbations, mental disorder followed by substance abuse and IHD were associated with increased risk among those 18-45 years old, and chronic sinusitis, mental disorder and IHD among those ≥ 65-years old. GERD was associated with decreased risk for asthma exacerbation in all ages. CONCLUSIONS: Many comorbidities are associated with poor outcome in adult asthmatics and their effect differs by age. Mental disorders are associated with increased risk of mortality and morbidity across ages.

Facilitators to alleviate loneliness and social isolation as identified by individuals with spinal cord injuries and disorders: A qualitative study.

PURPOSE/OBJECTIVE: Individuals with spinal cord injuries and disorders (SCI/D) are at increased risk for experiencing loneliness and social isolation. The aim is to describe facilitators identified by individuals living with SCI/D to alleviate loneliness and perceived social isolation. RESEARCH METHOD/DESIGN: Descriptive qualitative design using in-depth interviews with veterans with SCI/D (n = 23). Descriptive statistics was used to calculate demographic and injury characteristics. Audio-recorded and transcribed verbatim transcripts were coded and analyzed using Braun and Clarke's (2006) six thematic analysis phases. RESULTS: Participants were male (70%), white (78%), and not currently married (35%), with an average age of 66 years (42-88). Participants had paraplegia (61%), with traumatic etiology (65%) and were injured 14 years (1-45) on average. Eight themes were identified by participants living with SCI/D that described facilitators to alleviate loneliness and perceived social isolation. (a) Engage in/pursue interests; (b) Interact with/spend time with others; (c) Embrace acceptance; (d) Take part in reciprocity; (e) Find a purpose/accomplish goals; (f) Get out of residence, get outside; (g) Connect with SCI/D community/SCI/D peers; and (h) Seek help from (mental) healthcare professionals. CONCLUSIONS/IMPLICATIONS: Individuals with SCI/D identified facilitators to alleviate loneliness that encompasses changes in ways of thinking, actions to expand participation in life, and efforts focused on involving others. Findings can be used to guide healthcare delivery and develop interventions to target feelings of loneliness and social isolation in persons with SCI/D, which may be particularly impactful if they involve reciprocal interactions with peers with SCI/D. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Factors associated with perceived social isolation among veterans with spinal cord injury and disorders: Cross sectional survey.

CONTEXT/OBJECTIVE: Examine demographics, injury characteristics, objective measures of social isolation and health factors that are associated with perceived social isolation (PSI) among Veterans with spinal cord injury and disorders (SCI/D). DESIGN: Cross-sectional survey. SETTING: The Veterans Health Administrations (VHA) SCI/D system of care. PARTICIPANTS: Veterans with SCI/D who have used the VHA health care system. INTERVENTION: Not applicable. OUTCOMES MEASURES: We assessed unadjusted associations of high PSI (above population mean) vs low (normative/below population mean), and multivariable logistic regression for independent associations with PSI. RESULTS: Out of 1942 Veterans with SCI/D, 421 completed the survey (22% response rate). Over half (56%) had PSI mean scores higher than the general population. Among the objective measures, having a smaller social network size was associated with increased odds of high PSI (OR 3.59, P < .0001); additionally, for health factors, having depression (OR 3.98, P < 0.0001), anxiety (OR 2.29, P = 0.009), and post-traumatic stress (OR 2.56, P = 0.003) in the previous 6 months, and having 4 or more chronically occurring secondary conditions (OR 1.78, P = 0.045) was associated with increased odds of high PSI. The most commonly identified contributors to feelings of PSI included mobility concerns (63%), having a SCI/D (61%), and concerns about being a burden on others (57%). CONCLUSIONS: Factors such as social network size may be used to identify individuals with SCI/D at risk for PSI. Additionally, by identifying mental health problems, presence of multiple chronically occurring secondary conditions, and Veteran-identified contributors of PSI, we can target these factors in a patient-centered interventions to identify and reduce PSI.

Venous Thromboembolism Chemoprophylaxis Adherence Rates After Major Cancer Surgery.

Importance: Venous thromboembolism (VTE) represents a major source of preventable morbidity and mortality and is a leading cause of death in the US after cancer surgery. Previous research demonstrated variability in VTE chemoprophylaxis prescribing, although it is unknown how these rates compare with performance in the Veterans Health Administration (VHA). Objective: To determine VTE rates after cancer surgery, as well as rates of inpatient and outpatient (posthospital discharge) chemoprophylaxis adherence within the VHA. Design, Setting, and Participants: This retrospective cohort study within 101 hospitals of the VHA health system included patients aged 41 years or older without preexisting bleeding disorders or anticoagulation usage who underwent surgical treatment for cancer with general surgery, thoracic surgery, or urology between January 1, 2015, and December 31, 2022. The VHA Corporate Data Warehouse, Pharmacy Benefits Management database, and the Veterans Affairs Surgical Quality Improvement Program database were used to identify eligible patients. Data analysis was conducted between January 2022 and July 2023. Exposures: Inpatient surgery for cancer with general surgery, thoracic surgery, or urology. Main Outcomes and Measures: Rates of postoperative VTE events within 30 days of surgery and VTE chemoprophylaxis adherence were determined. Multivariable Poisson regression was used to determine incidence-rate ratios of inpatient and postdischarge chemoprophylaxis adherence by surgical specialty. Results: Overall, 30 039 veterans (median [IQR] age, 67 [62-71] years; 29 386 men [97.8%]; 7771 African American or Black patients [25.9%]) who underwent surgery for cancer and were at highest risk for VTE were included. The overall postoperative VTE rate was 1.3% (385 patients) with 199 patients (0.7%) receiving a diagnosis during inpatient hospitalization and 186 patients (0.6%) receiving a diagnosis postdischarge. Inpatient chemoprophylaxis was ordered for 24 139 patients (80.4%). Inpatient chemoprophylaxis ordering rates were highest for patients who underwent procedures with general surgery (10 102 of 10 301 patients [98.1%]) and lowest for patients who underwent procedures with urology (11 471 of 17 089 patients [67.1%]). Overall, 3142 patients (10.5%) received postdischarge chemoprophylaxis, with notable variation by specialty. Conclusions and Relevance: These findings indicate the overall VTE rate after cancer surgery within the VHA is low, VHA inpatient chemoprophylaxis rates are high, and postdischarge VTE chemoprophylaxis prescribing is similar to that of non-VHA health systems. Specialty and procedure variation exists for chemoprophylaxis and may be justified given the low risks of overall and postdischarge VTE.

Development and evaluation of an educational curriculum for healthcare providers on overweight/obesity management in individuals with spinal cord injury based on diverse stakeholder engagement.

BACKGROUND: Spinal cord injury (SCI) healthcare providers are aware of the harmful consequences of overweight/obesity in persons with SCI, but many are unaware of available information and lack training to guide weight management care in the SCI population. OBJECTIVE: Describe the development and content of an educational curriculum for healthcare providers to help individuals with SCI prevent or manage overweight/obesity. METHODS: The biopsychoecological framework guided curriculum planning, data collection, and product development. Thematic analysis of interviews conducted with individuals with SCI, informal caregivers, and SCI healthcare providers pinpointed central educational curriculum topics. SCI healthcare providers evaluated the curriculum. RESULTS: Seven comprehensive topics were developed: 1. Scope and consequences of overweight/obesity in SCI; 2. Classifying and measuring overweight/obesity in SCI; 3. Guidelines related to weight management in SCI; 4. Identifying challenges (and solutions) to weight management in SCI; 5. Strategies for providers to facilitate weight management; 6. Understanding goals, motivators, and desired feedback for weight management; and 7. Knowing how informal caregivers are affected by weight and weight management of care recipients with SCI. High ratings (>80% strong agreement) were achieved on content, word choice, organization, relevance, and actionability. Modification needs were identified and subsequently made to layout, visual aids, and provision of tangible resources. Providers described the curriculum as a scientifically rigorous resource that addresses a knowledge gap, provides population-specific content, and is useful across interdisciplinary teams. CONCLUSION: We developed a self-directed learning educational curriculum addressing topics most salient to stakeholders involved in overweight/obesity management of persons with SCI.

Motivators, goal setting, and helpful feedback for weight management among individuals with spinal cord injury.

Objective: To gain a fuller understanding, in the context of biopsychoecological factors, of drivers/motivators, goal setting, and feedback, individuals with spinal cord injury (SCI) find helpful to gauge their weight management progress. Research Method/Design: We conducted in-depth interviews around weight management in SCI. Participants included veterans and civilians with SCI. Thematic analysis methodology was used to categorize data into relevant recurrent and/or conceptually significant themes. Results: Twenty-five individuals identified three primary reasons they wanted to participate in weight management, including overall health and wellness, appearance, and functional mobility. Their self-identified weight management goals included reaching/maintaining a specific body weight and/or trimming a focused body part; engaging in any or more physical activity/exercise; gaining strength and endurance; participating in life and activities; and alleviating weight-related health symptoms (e.g., pain). Individuals identified progress assessments, recognition, regular check-ins, and encouragement as helpful feedback toward weight management achievement. Conclusions/Implications: Our work identified what drives weight management in individuals with SCI, what is important to them in terms of goal setting, and what feedback they would find helpful. These findings may be used in intervention planning and program development to facilitate participation and behavior modification. Weight management efforts and interventions are needed that 1) incorporate motivators for weight management that are important to individuals with SCI; 2) help them identify actionable process and performance goals to facilitate achievement of self-identified meaningful outcome goals; and 3) provide person-centered weight management progress feedback such as those identified in this study (progress assessments, recognition, regular check-ins, and encouragement). (PsycInfo Database Record (c) 2021 APA, all rights reserved).

What Are Personal Meanings of Healthy Eating and Physical Activity in Individuals Living With Spinal Cord Injury? A Qualitative Exploration.

Objectives: To explore the personal meanings of healthy eating and physical activity among individuals living with spinal cord injury (SCI) and the information and resources they find beneficial. Methods: We conducted in-depth semistructured individual interviews to understand the personal meanings of healthy eating and physical activity among individuals with SCI. We completed a thematic analysis of qualitative data. Results: Participants were 11 Veterans and 14 civilians, predominantly male, non-Hispanic White, and with paraplegia. Data were described across two categories, including the personal meaning of healthy eating and the personal meaning of physical activity/exercise. Individuals with SCI described their meaning of healthy eating around four themes: types of food, amounts/portions of food, conscious/mindful eating, and eating to enhance health. Individuals wanted information on tailored diets for individuals with paraplegia and tetraplegia and healthy foods that are easy to prepare by people with SCI. Their personal meaning of physical activity/exercise focused on four themes: types of physical activity and exercise, staying active, moving/movement, and differences from non-SCI. Desired information around physical activity included cardiovascular workouts that are effective and possible to do in a wheelchair so that people with SCI can burn enough of the calories they consume to lose or maintain weight. Conclusion: Results provide a better understanding of what healthy eating and physical activity mean to people with SCI and information they desire toward these goals, which can be used to guide patient-provider discussions, develop health promotion programs, and tailor interventions to capitalize on meaningful concepts and beliefs that facilitate healthy behaviors.

Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System.

Importance: Evidence-based care plans can fail when they do not consider relevant patient life circumstances, termed contextual factors, such as a loss of social support or financial hardship. Preventing these contextual errors can reduce obstacles to effective care. Objective: To evaluate the effectiveness of a quality improvement program in which clinicians receive ongoing feedback on their attention to patient contextual factors. Design, Setting, and Participants: In this quality improvement study, patients at 6 Department of Veterans Affairs outpatient facilities audio recorded their primary care visits from May 2017 to May 2019. Encounters were analyzed using the Content Coding for Contextualization of Care (4C) method. A feedback intervention based on the 4C coded analysis was introduced using a stepped wedge design. In the 4C coding schema, clues that patients are struggling with contextual factors are termed contextual red flags (eg, sudden loss of control of a chronic condition), and a positive outcome is prospectively defined for each encounter as a quantifiable improvement of the contextual red flag. Data analysis was performed from May to October 2019. Interventions: Clinicians received feedback at 2 intensity levels on their attention to patient contextual factors and on predefined patient outcomes at 4 to 6 months. Main Outcomes and Measures: Contextual error rates, patient outcomes, and hospitalization rates and costs were measured. Results: The patients (mean age, 62.0 years; 92% male) recorded 4496 encounters with 666 clinicians. At baseline, clinicians addressed 413 of 618 contextual factors in their care plans (67%). After either standard or enhanced feedback, they addressed 1707 of 2367 contextual factors (72%), a significant difference (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .01). In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes (adjusted odds ratio, 2.5; 95% CI, 1.5-4.1; P < .001). In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million (95% CI, $23.9-$26.6 million), at a cost of $337 242 for the intervention. Conclusions and Relevance: These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations. In addition, the intervention is associated with substantial cost savings.

Risk for death associated with medications for recently diagnosed chronic obstructive pulmonary disease.

BACKGROUND: Concerns exist regarding increased risk for mortality associated with some chronic obstructive pulmonary disease (COPD) medications. OBJECTIVE: To examine the association between various respiratory medications and risk for death in veterans with newly diagnosed COPD. DESIGN: Nested case-control study in a cohort identified between 1 October 1999 and 30 September 2003 and followed through 30 September 2004 by using National Veterans Affairs inpatient, outpatient, pharmacy, and mortality databases; Centers for Medicare & Medicaid Services databases; and National Death Index Plus data. Cause of death was ascertained for a random sample of 40% of those who died during follow-up. Case patients were categorized on the basis of all-cause, respiratory, or cardiovascular death. Mortality risk associated with medications was assessed by using conditional logistic regression adjusted for comorbid conditions, health care use, and markers of COPD severity. SETTING: U.S. Veterans Health Administration health care system. PARTICIPANTS: 32 130 case patients and 320 501 control participants in the all-cause mortality analysis. Of 11 897 patients with cause-of-death data, 2405 case patients had respiratory deaths and 3159 case patients had cardiovascular deaths. MEASUREMENTS: All-cause mortality; respiratory and cardiovascular deaths; and exposure to COPD medications, inhaled corticosteroids, ipratropium, long-acting beta-agonists, and theophylline in the 6 months preceding death. RESULTS: Adjusted odds ratios (ORs) for all-cause mortality were 0.80 (95% CI, 0.78 to 0.83) for inhaled corticosteroids, 1.11 (CI, 1.08 to 1.15) for ipratropium, 0.92 (CI, 0.88 to 0.96) for long-acting beta-agonists, and 1.05 (CI, 0.99 to 1.10) for theophylline. Ipratropium was associated with increased cardiovascular deaths (OR, 1.34 [CI, 1.22 to 1.47]), whereas inhaled corticosteroids were associated with reduced risk for cardiovascular death (OR, 0.80 [CI, 0.72 to 0.88]). Results were consistent across sensitivity analyses. LIMITATIONS: Current smoking status and lung function were not measured. Misclassification of cause-specific mortality is unknown. CONCLUSION: The possible association between ipratropium and elevated risk for all-cause and cardiovascular death needs further study.

Coded cause of death and timing of COPD diagnosis.

The aims of this study were to characterize causes of death among veterans with COPD using multiple cause of death coding, and to examine whether causes of death differed according to timing of COPD diagnosis. Veterans with COPD who died during a five-year follow-up period were identified from national VA databases linked to National Death Index files. Primary, secondary, underlying, and all-coded causes of death were compared between recent and preexistent COPD cohorts using proportional mortality ratios (PMRs), which compares proportion dying from specific causes as opposed to absolute risk of death. Of 26,357 decedents, 7,729 were categorized preexistent and 18,628 were recent COPD cases. Unspecified COPD was listed as underlying cause of death in a significantly greater proportion of preexistent COPD cases compared to recent cases, 20% vs 10%, PMR = 2.0 (95% CI: 1.9-2.1). A relatively higher proportion of recently diagnosed cases died from lung/bronchus, prostate, and site-unspecified cancers. Respiratory failure (J969) was rarely coded as an underlying or primary cause (< 1%), but was a second-code cause of death in 9% of recent and 12% of preexistent cases. Differences in coded causes of death between patients with a recent diagnosis of COPD compared to a preexistent diagnosis of COPD suggests that there is either coded cause-related bias or true differences in cause of death related to length of time with diagnosis. Thus, methods used to identify cohorts of COPD patients, i.e., incidence versus prevalence-based approaches, and coded cause of death can affect estimates of cause-specific mortality.

Development and Validation of the Real-World Progression in Diabetes (RAPIDS) Model.

INTRODUCTION: To develop and validate the first real-world data-based type 2 diabetes progression model (RAPIDS) employing econometric techniques that can study the comparative effects of complex dynamic patterns of glucose-lowering drug use. METHODS: The US Department of Veterans Affairs (VA) electronic medical record and claims databases were used to identify over 500,000 diabetes patients in 2003 with up to 9-year follow-up. The RAPIDS model contains interdependent first-order Markov processes over quarters for each of the micro- and macrovascular events, hypoglycemia, and death, as well as predictive models for 8 biomarker levels. Model parameters varied by static demographic factors and dynamic factors, such as age, duration of diabetes, 13 possible glucose-lowering treatment combinations, any blood pressure and any cholesterol-lowering medications, and cardiovascular history. To illustrate model capabilities, a simple comparative study was set up to compare observed treatment use patterns to alternate patterns if perfect adherence is assumed following initiating the use of any of these medications. RESULTS: Data were randomly split into 307,288, 105,195, and 105,081 patients to perform estimation, out-of-sample calibration, and validation, respectively. Model predictions in the validation sample closely aligned with the observed longitudinal trajectory of biomarkers and outcomes. Perfect adherence among initiators increased proportion of days covered by only 6 months. Most of this increase came from increased adherence to monotherapies and did not lead to meaningful changes in any of the outcomes over the 9-year period. CONCLUSION: Future value of increasing medication adherence among VA patients with diabetes may lie among those who never initiate treatment or are late in initiating treatment. The first-of-its-kind real-world data-based model has the potential to carry out many complex comparative-effectiveness research (CER) studies of dynamic glucose-lowering drug regimens.

Osteoarthritis: a comorbid marker for longer life?

PURPOSE: Diseases are often described and studied in isolation, yet there is increasing recognition of the complex interrelatedness of diseases and treatments in patients with multiple chronic diseases. Our objective was to describe the impact of selected diseases involving chronic inflammation (chronic obstructive pulmonary disease [COPD], osteoarthritis, and rheumatoid arthritis) on mortality. METHODS: We identified a cohort aged 55 to 64 years with one or more chronic conditions. Clusters of mutually exclusive disease combinations were created. Five-year all-cause mortality was determined and the relative risk (RR) of mortality was estimated when COPD, osteoarthritis, and rheumatoid arthritis were added to clusters. RESULTS: In 741,847 persons the 5-year mortality rates were lowest among persons with one condition and increased with more chronic conditions. The presence of osteoarthritis in a cluster was an exception where the risk was lower compared with that cluster without osteoarthritis: COPD (RR = 0.73 [95% confidence interval (CI), 0.65, 0.81]); ischemic heart disease (0.63 [0.52, 0.76]); hypertension (0.77 [0.71, 0.83]); dementia (0.63 [0.42, 0.93]); depression (0.65 [0.50, 0.84]); hypertension plus diabetes (0.85 [0.77, 0.93]); and ischemic heart disease plus hypertension (0.83 [0.73, 0.94]). CONCLUSIONS: The association between osteoarthritis and lower rates of mortality is notable and replicating these findings to explore causal relationships is important.

Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes.

AIM: Diabetic foot ulcers are associated with an increased risk of death. We evaluated whether ulcer severity at presentation predicts mortality. METHODS: Patients from a national, retrospective, cohort of veterans with type 2 diabetes who developed incident diabetic foot ulcers between January 1, 2006 and September 1, 2010, were followed until death or the end of the study period, January 1, 2012. Ulcers were characterized as early stage, osteomyelitis, or gangrene at presentation. Cox proportional hazard regression identified independent predictors of death, controlling for comorbidities, laboratory parameters, and healthcare utilization. RESULTS: 66,323 veterans were included in the cohort and followed for a mean of 27.7months: 1-, 2-, and 5-year survival rates were 80.80%, 69.01% and 28.64%, respectively. Compared to early stage ulcers, gangrene was associated with an increased risk of mortality (HR 1.70, 95% CI 1.57-1.83, p<0.001). The magnitude of this effect was greater than diagnosed vascular disease, i.e., coronary artery disease, peripheral arterial disease, or stroke. CONCLUSION: Initial diabetic foot ulcer severity is a more significant predictor of subsequent mortality than coronary artery disease, peripheral arterial disease, or stroke. Unrecognized or under-estimated vascular disease and/or sepsis secondary to gangrene should be explored as possible causal explanations.

Spirometry use in clinical practice following diagnosis of COPD.

BACKGROUND: Little is known about current use of pulmonary function testing in clinical practice. This study evaluated spirometry use in persons with COPD receiving care from the Veterans Health Administration health-care system. METHODS: Administrative data were used to identify a cohort of patients who were >/= 40 years of age with recently diagnosed COPD. Spirometry was identified using administrative data. Spirometry use was characterized over a 12-month period, and the use of spirometry around acute exacerbations and surgical procedures was examined. RESULTS: A total of 197,878 patients met the inclusion criteria in 1999. The average age was 67.5 years (SD, 10.0), and 98.2% of patients were male. A total of 66,744 patients (33.7%) underwent spirometry. The use of spirometry for newly diagnosed COPD patients decreased with age and was 3.3 times higher for those visiting pulmonologists. CONCLUSIONS: This study suggests that spirometry is inconsistently used in the diagnosis of COPD or the care of patients with COPD. This inconsistent pattern of use is seen even with the endorsement of spirometry use for patients with COPD by two national guidelines; however, the data predate the most recent version of the guidelines. It is unclear whether it is lack of physician knowledge of, attitudes about, or belief in the utility of spirometry that underlie the current patterns of physician use of this clinical tool.

Mortality risk in patients receiving drug regimens with theophylline for chronic obstructive pulmonary disease.

STUDY OBJECTIVE: To evaluate outcomes associated with six treatment regimens with theophylline versus each regimen without theophylline in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Retrospective cohort study. SETTING: Veterans Affairs health care system. PATIENTS: A total of 183,573 patients aged 45 years or older who had a diagnosis of COPD and were receiving respiratory drug therapy. MEASUREMENTS AND MAIN RESULTS: Patients' treatment regimens were identified by using data from October 1, 2002-March 31, 2003, and patients were followed for events by using data from April 1, 2003-September 30, 2005. Data from October 1, 2001-September 30, 2002, were used to define the patients' baseline characteristics. Primary outcome measures were all-cause mortality, COPD exacerbations, and COPD-related hospitalizations. Two approaches were used: first, treatment assignment was based on drug therapy at baseline, and second, exposure was measured as a time-varying covariate. Treatment groups were stratified based on propensity to receive theophylline. Mortality was compared by using Cox proportional hazards models, and other outcomes were compared with use of negative binomial models. Comparisons were conducted within individual treatment regimens that were the same with the exception of theophylline. Patients treated with ipratropium plus theophylline (largest group) compared with those treated with ipratropium alone had a 1.11-fold increase in the risk of death (95% confidence interval [CI] 1.04-1.18). For each of the other regimens, the risk of mortality associated with theophylline was greater than that in the regimens without theophylline (hazard ratios [HRs] 1.17-1.31). In the time-varying exposure analysis, theophylline (HR 1.23, 95% CI 1.09-1.39) was associated with an increased mortality risk. CONCLUSION: Patients receiving regimens that included theophylline had slightly increased risks of mortality, COPD exacerbations, and COPD hospitalizations compared with patients receiving the same regimens without theophylline. However, the benefits of theophylline on other factors, including symptoms, quality of life, and activities of daily living, were not measured. Clinicians should consider all of the potential benefits and harms associated with theophylline when making treatment recommendations.