Using Video Telehealth to Facilitate Inhaler Training in Rural Patients with Obstructive Lung Disease.

BACKGROUND: Proper inhaler technique is important for effective drug delivery and symptom control in chronic obstructive pulmonary disease (COPD) and asthma, yet not all patients receive inhaler instructions. INTRODUCTION: Using a retrospective chart review of participants in a video telehealth inhaler training program, the study compared inhaler technique within and between monthly telehealth visits and reports associated with patient satisfaction. MATERIALS AND METHODS: Seventy-four (N = 74) rural patients prescribed ≥1 inhaler participated in three to four pharmacist telehealth inhaler training sessions using teach-to-goal (TTG) methodology. Within and between visit inhaler technique scores are compared, with descriptive statistics of pre- and postprogram survey results including program satisfaction and computer technical issues. Healthcare utilization is compared between pre- and post-training periods. RESULTS: Sixty-nine (93%) patients completed all three to four video telehealth inhaler training sessions. During the initial visit, patients demonstrated improvement in inhaler technique for metered dose inhalers (albuterol, budesonide/formoterol), dry powder inhalers (formoterol, mometasone, tiotropium), and soft mist inhalers (ipratropium/albuterol) (p < 0.01 for all). Improved inhaler technique was sustained at 2 months (p < 0.01). Ninety-four percent of participants were satisfied with the program. Although technical issues were common, occurring among 63% of attempted visits, most of these visits (87%) could be completed. There was no significant difference in emergency department visits and hospitalizations pre- and post-training. DISCUSSION: This study demonstrated high patient acceptance of video telehealth training and objective improvement in inhaler technique. CONCLUSIONS: Video telehealth inhaler training using the TTG methodology is a promising program that improved inhaler technique and access to inhaler teaching for rural patients with COPD or asthma.

Association Between Mental Health Staffing Level and Primary Care-Mental Health Integration Level on Provision of Depression Care in Veteran's Affairs Medical Facilities.

We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.

Deployment and Adverse Pregnancy Outcomes: Primary Findings and Methodological Considerations.

Objective To characterize the pregnancy outcomes of women Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans including prevalence of preterm delivery, low birth weight, and macrosomia, and to highlight methodological limitations that can impact findings. Methods A retrospective cohort study was conducted starting in 2014 analyzing data from the 2009 to 2011 National Health Study for a New Generation of US Veterans, which sampled Veterans deployed and not deployed to OIF/OEF. All pregnancies resulting in a live birth were included, and categorized as occurring among non-deployers, before deployment, during deployment, or after deployment. Outcomes included preterm birth, low birth weight, and macrosomia. The association of deployment with selected outcomes was estimated using separate general estimating equations to account for lack of outcome independence among women contributing multiple pregnancies. Adjustment variables included maternal age at outcome, and race/ethnicity. Results There were 2276 live births (191 preterm births, 153 low birth weight infants, and 272 macrosomic infants). Compared with pregnancies before deployment, pregnancies among non-deployers and those after deployment appeared to have greater risk of preterm birth [non-deployers: odds ratio (OR) = 2.16, 95 % confidence interval (CI) 1.25, 3.72; after deployment: OR = 1.90, 95 % CI 0.90, 4.02]. A similar pattern was observed for low birth weight. No association of deployment with macrosomia was detected. Discussion Compared with non-deployers, those who eventually deploy appear to have better pregnancy outcomes prior to deployment, but this advantage is no longer apparent after deployment. Non-deployers may not be an appropriate reference group to study the putative health impacts of deployment on pregnancy outcomes.

Medicare-VHA dual use is associated with poorer chronic wound healing.

Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non-VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare-enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow-up. We used a proportional hazards model to compare wound healing among VHA-exclusive and dual wound care users, using a time-varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow-up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use (HR = 0.63, 95%CI: 0.39-0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61-11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11-8.56, p = 0.031), were significantly higher for dual users compared to VHA-exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA-exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic wound care.

Evidence-based chronic ulcer care and lower limb outcomes among Pacific Northwest veterans.

Evidence-based ulcer care guidelines detail optimal components of care for treatment of ulcers of different etiologies. We investigated the impact of providing specific evidence-based ulcer treatment components on healing outcomes for lower limb ulcers (LLU) among veterans in the Pacific Northwest. Components of evidence-based ulcer care for venous, arterial, diabetic foot ulcers/neuropathic ulcers were abstracted from medical records. The outcome was ulcer healing. Our analysis assessed the relationship between evidence-based ulcer care by etiology, components of care provided, and healing, while accounting for veteran characteristics. A minority of veterans in all three ulcer-etiology groups received the recommended components of evidence-based care in at least 80% of visits. The likelihood of healing improved when assessment for edema and infection were performed on at least 80% of visits (hazard ratio [HR] = 3.20, p = 0.009 and HR = 3.54, p = 0.006, respectively) in patients with venous ulcers. There was no significant association between frequency of care components provided and healing among patients with arterial ulcers. Among patients with diabetic/neuropathic ulcers, the chance of healing increased 2.5-fold when debridement was performed at 80% of visits (p = 0.03), and doubled when ischemia was assessed at the first visit (p = 0.045). Veterans in the Pacific Northwest did not uniformly receive evidence-based ulcer care. Not all evidence-based ulcer care components were significantly associated with healing. At a minimum, clinicians need to address components of ulcer care associated with improved ulcer healing.

Changes in classifications of chronic lower-limb wound codes in patients with diabetes: ICD-9-CM versus ICD-10-CM.

PURPOSE: To enhance the learner's competence with knowledge of changes in classifications of chronic lower limb wound codes from ICD-9-CM to ICD-10-CM in patients with diabetes. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Identify the upcoming transition date and coding differences of ICD-9-CM and ICD-10-CM coding.2. Interpret the author's study population, methods, and design.3. Summarize the author's study findings comparing ICD-9-CM coding to ICD-10-CM coding. OBJECTIVE: To determine the sensitivity and specificity of International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) and ICD-10-CM codes for individuals with diabetes and foot ulcers. DESIGN AND METHODS: Wound care providers and researchers are concerned about the potential impacts when the United States transitions from ICD-9-CM to ICD-10-CM. To identify the impact on diabetic foot ulcers, health history and wound variables were prospectively assessed with criterion-standard data from a prospective study of 49 patients with 65 foot ulcer episodes representing 81 incident foot ulcers. The ICD-9-CM and ICD-10-CM code sets were mapped to correctly classify individuals with diabetes and foot ulcers. RESULTS: Frequencies for health history variables were similar in both systems. The ICD-9 code did not capture any data on laterality (left or right) or ulcer depth/severity. The ICD-9 captured 69 of 81 incident ulcers (85%) and 94% of heel and midfoot ulcers, whereas the ICD-10 code captured 78 of 81 incident ulcers (96%) and all incident heel or midfoot ulcers. Sensitivity and specificity for ulcer characteristics were consistently lower in ICD-9 than in ICD-10. CONCLUSIONS: The ICD-9 and ICD-10 are similar for data capture on health history variables, but wound variables are captured more accurately using ICD-10. The increased specificity of ICD-10 for ulcer location and severity improves identification and tracking ulcers during an episode of care.

Improving outcomes for diabetic patients undergoing revascularization for critical limb ischemia: does the quality of outpatient diabetic care matter?

BACKGROUND: Diabetic patients who undergo lower extremity surgical revascularization for critical limb ischemia (CLI) are at high risk for amputation or death, even when their inpatient procedures are successful. We hypothesized that postoperative outcomes might be improved in regions where diabetics with CLI receive more frequent high-quality outpatient care. METHODS: A retrospective cohort study was performed among 172,134 patients with CLI (52% male, 15% black, mean age 76 years) who underwent open and endovascular lower extremity revascularization procedures using Medicare claims (2004-2007), which included 84,653 (49%) beneficiaries who were diabetic. Regional utilization of annual serum cholesterol and hemoglobin A1c testing were used to assess the quality of outpatient diabetic care. We examined relationships between frequency of diabetic testing with amputation-free survival (AFS), major adverse limb events (MALE), and rates of readmission across all US hospital referral regions. RESULTS: There was significant regional variation in annual serum cholesterol and hemoglobin A1c testing across the United States (87% highest quartile vs. 59% lowest quartile, P < 0.01). Compared with the lowest quartile of diabetic testing, diabetic patients undergoing lower extremity revascularization in regions with the highest quartile of diabetic testing had significantly improved AFS (hazards ratio [HR]: 0.94, 95% confidence interval [CI]: 0.90-0.97; P < 0.01) and MALE (HR: 0.92, 95% CI: 0.89-0.96; P < 0.01) persisting up to 2 years after lower extremity revascularization, even after adjusting for procedure type, gender, age, race, and comorbidities. Moreover, the risk of 30-day readmission was significantly reduced in regions with the highest versus lowest quartile of diabetic testing (odds ratio: 0.91, 95% CI: 0.85-0.97; P < 0.01). Nondiabetic patients with CLI, in comparison, did not benefit to the same extent from undergoing revascularization in regions with high-quality outpatient diabetic care. CONCLUSIONS: Diabetic patients undergoing lower extremity revascularization in regions with higher utilization of diabetic care quality measures have significantly better long-term limb salvage and readmission outcomes. Our study underscores the importance of providing optimal outpatient care to diabetics following vascular surgery and outlines a potential strategy for quality improvement in these high-risk patients.

Bilateral transfemoral/transtibial amputations due to battle injuries: a comparison of Vietnam veterans with Iraq and Afghanistan servicemembers.

BACKGROUND: Multiple limb loss from combat injuries has increased as a proportion of all combat-wounded amputees. Bilateral lower-extremity limb loss is the most common, with bilateral transfemoral amputations being the most common subgroup followed by bilateral amputations consisting of a single transfemoral amputation and a single transtibial amputation (TFTT). With improvements in rehabilitation and prostheses, we believe it is important to ascertain how TFTT amputees from the present conflicts compare to those from the Vietnam War. QUESTIONS/PURPOSES: We compared self-reported (1) health status, (2) quality of life (QoL), (3) prosthetic use, and (4) function level between TFTT amputees from the Vietnam War and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). METHODS: As part of a larger survey, during 2007 to 2008, servicemembers with a diagnosis of amputation associated with battlefield injuries from the Vietnam War and OIF/OEF were identified from the Veterans Affairs and military databases. Participants were asked to respond to a questionnaire to determine their injuries, surgical history, presence of other medical problems, health status, QoL, function, and prosthetic use. We assessed QoL and health status using single-item questions and function using seven categories of physical activity. Thirteen of 298 (4.3%) participants in the Vietnam War group and 11 of 283 (3.8%) in the OIF/OEF group had sustained TFTT amputations. Mean age ± SD at followup was 61 ± 2 years and 28 ± 5 years for the Vietnam War and OIF/OEF groups, respectively. RESULTS: Excellent, very good, and good self-reported health (85% versus 82%; p = 0.85) and QoL (69% versus 72%; p = 0.85) were similar between the Vietnam War and OIF/OEF groups, respectively. Level of function was higher in the OIF/OEF group, with four of 11 reporting participation in high-impact activities compared to none in the Vietnam War group (p = 0.018). CONCLUSIONS: Participants with TFTT limb loss from both conflicts reported similar scores for QoL and health status, although those from OIF/OEF reported better function and use of prosthetic devices. It is unclear whether the improved function is from age-related changes or improvements in rehabilitation and prosthetics. Some areas of future research might include longitudinal studies of those with limb loss and assessments of physical function of older individuals with limb loss as the demographics shift to where this group of individuals becomes more prominent.

VA location and structural factors associated with on-site availability of reproductive health services.

INTRODUCTION: With the increasing number of women Veterans enrolling in the Veterans Health Administration (VA), there is growing demand for reproductive health services. Little is known regarding the on-site availability of reproductive health services at VA and how this varies by site location and type. OBJECTIVE: To describe the on-site availability of hormonal contraception, intrauterine device (IUD) placement, infertility evaluation or treatment, and prenatal care by site location and type; the characteristics of sites providing these services; and to determine whether, within this context, site location and type is associated with on-site availability of these reproductive health services. METHODS: We used data from the 2007 Veterans Health Administration Survey of Women Veterans Health Programs and Practices, a national census of VA sites serving 300 or more women Veterans assessing practice structure and provision of care for women. Hierarchical models were used to test whether site location and type (metropolitan hospital-based clinic, non-metropolitan hospital-based clinic, metropolitan community-based outpatient clinic [CBOC]) were associated with availability of IUD placement and infertility evaluation/treatment. Non-metropolitan CBOCs were excluded from this analysis (n = 2). RESULTS: Of 193 sites, 182 (94 %) offered on-site hormonal contraception, 97 (50 %) offered on-site IUD placement, 57 (30 %) offered on-site infertility evaluation/treatment, and 11 (6 %) offered on-site prenatal care. After adjustment, compared with metropolitan hospital based-clinics, metropolitan CBOCs were less likely to offer on-site IUD placement (OR 0.33; 95 % CI 0.14, 0.74). CONCLUSION: Compared with metropolitan hospital-based clinics, metropolitan CBOCs offer fewer specialized reproductive health services on-site. Additional research is needed regarding delivery of specialized reproductive health care services for women Veterans in CBOCs and clinics in non-metropolitan areas.

Weight loss after diagnosis with gestational diabetes and birth weight among overweight and obese women.

To determine if, among overweight or obese women with gestational diabetes (GDM), weight loss after GDM diagnosis is associated with lower infant birth weight within levels of overweight or obesity class. Overweight and obese women with singleton pregnancies managed for GDM at a large diabetes and pregnancy program located in Charlotte, NC between November 2000 and April 2010, were eligible for this retrospective cohort study. All were managed using a rigorous standardized clinical protocol. Clinical information including maternal pre-pregnancy body mass index, gestational weight gain, treatment, and medical and obstetric history was abstracted from medical records. The association of weight loss after GDM diagnosis and birth weight was analyzed using linear regression stratified by maternal pre-pregnancy overweight or obesity class (I, II/III). Of the 322 women in this study 19 % lost weight between diagnosis of GDM and delivery. After adjustment for maternal age, parity, race/ethnicity, gestational week at first hemoglobin A1c (A1C), A1C at diagnosis, weight gain prior to GDM, treatment with insulin or oral hypoglycemic agents, gestational age at delivery, and infant sex, weight loss was associated with 238.3 g lower mean infant birth weight among overweight women (95 % CI -393.72, -82.95 g), but was not associated with lower mean infant birth weight among obese class II/III women (95 % CI -275.61, 315.38 g). Weight loss, after diagnosis of GDM, is associated with lower infant birth weight among overweight women, but not among obese class II/III women.

Primary care provider and imaging technician satisfaction with a teledermatology project in rural Veterans Health Administration clinics.

OBJECTIVE: Assessment of a multisite rural teledermatology project between 2009 and 2012 in four Pacific Northwest states that trained primary care providers and imaging technicians in state-of-the-art techniques of telemedicine. MATERIALS AND METHODS: In 2012, we assessed provider and imaging technician acceptability and satisfaction with a 32-item survey instrument based on the Patient Satisfaction Questionnaire developed by Ware et al. (Eval Program Plann 1983;6:247-63) and modified for telemedicine by Kraai et al. (J Card Fail 2011;17:684-690). Survey questions covered eight satisfaction domains: interpersonal manner, technical quality, accessibility, finances, efficacy, continuity, physical environment, and availability. RESULTS: Overall, 71% of the primary care providers and 94% of the imaging technicians reported being satisfied or extremely satisfied with the teledermatology project. Most (95%) providers found the continuing education classes on dermatology diagnosis and treatment topics useful, and 86% reported teledermatology was a good addition to regular patient services. Most (97%) of the imaging technicians were satisfied with the ability of teledermatology to improve the description of dermatology conditions using images of the lesions or rashes, and 91% were satisfied with the convenience of teledermatology. Challenges reported by both providers and imaging technicians include an increase in workload due to more patient visits related to dermatology care and limited information technology support. CONCLUSIONS: Given the Veterans Health Administration's initiatives to promote accessible health care to underserved Veterans using telehealth, these findings can inform future program designs for teledermatology.

Does incorporation of a clinical support template in the electronic medical record improve capture of wound care data in a cohort of veterans with diabetic foot ulcers?

PURPOSE: The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention. METHODS: From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding. RESULTS: The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001). CONCLUSIONS: An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.

Antenatal haemoglobin A1c and risk of large-for-gestational-age infants in a multi-ethnic cohort of women with gestational diabetes.

Gestational diabetes mellitus (GDM) is a risk factor for delivering a large-for-gestational-age (LGA) infant. Haemoglobin A1c (A1C) is an indicator of glycaemic control. The objective of this study was to test whether higher A1C quartile at the time of diagnosis of GDM is associated with increased risk of delivering a LGA or macrosomic infant. Women with singleton pregnancies treated for GDM at a large diabetes and pregnancy programme located in Charlotte, North Carolina, were eligible for inclusion in this retrospective cohort study. Clinical information, including A1C at diagnosis, treatment, prior medical and obstetric history, and birth data were abstracted from medical records. LGA was defined as birthweight >90th percentile for gestational age and sex and macrosomia as birthweight >4000 g. Logistic regression was used to analyse the association of A1C at GDM diagnosis with risk of delivering LGA or macrosomic infants. This study included 502 women. Prevalences of LGA and macrosomia were 4% and 6% respectively. After adjustment there was no detectable trend of increased risk for LGA (P for trend = 0.12) or macrosomia (P for trend = 0.20) across increasing quartiles of A1C at GDM diagnosis. A1C at GDM diagnosis may not be linearly associated with LGA or macrosomia, possibly because of the mediating effect of strict glycaemic control in this clinical setting.

Long-term disabilities associated with combat casualties: measuring disability and reintegration in combat veterans.

Many physical and mental health problems associated with combat casualties affect the reintegration of service members into home and community life. Quantifying and measuring reintegration is important to answer questions about clinical, research, economic, and policy issues that directly affect combat veterans. Although the construct of participation presented in the International Statistical Classification of Diseases and Related Health Problems and in the International Classification of Functioning, Disability and Health provides a theoretical framework with which to understand and measure community reintegration in general, a measure was needed that specifically addressed the reintegration of combat veterans. To address this need, the Community Reintegration for Service Members global outcomes measure was developed. It consists of three scales, which measure extent of participation, perceived limitations, and satisfaction. The measure was validated in a general sample of veterans and in a sample of severely wounded service members. The computer-adapted test version shows good precision, reliability, construct validity, and predictive validity.

Teledermatology patient satisfaction in the Pacific Northwest.

BACKGROUND: The aim of this quality improvement project is to assess patient satisfaction with a store-and-forward teledermatology project and to identify factors associated with patient satisfaction and dissatisfaction. SUBJECTS AND METHODS: Veterans receiving care in rural clinics in the Pacific Northwest were surveyed using a 5-point Likert scale about satisfaction with face-to-face care for a skin complaint prior to any teledermatology exposure. One year later, veterans in the same rural clinics were surveyed about satisfaction with teledermatology care using a more comprehensive survey. Ninety-six patients completed the face-to-face satisfaction survey questions, and 501 completed the teledermatology satisfaction survey. RESULTS: Most (78%) of surveyed patients were highly satisfied or satisfied with face-to-face dermatology care. After 1 year of teledermatology, 77% of patients were highly satisfied or satisfied with teledermatology care. The mean patient satisfaction score for teledermatology was equivalent to face-to-face care (4.1±1.2 and 4.3±1.0, p=0.4). Factors associated with teledermatology patient satisfaction included short wait times for initial consultation, a perception that the initial wait time was not too long, a perception that the skin condition was properly treated, and the belief that adequate follow-up was received. Factors associated with teledermatology patient dissatisfaction included perceptions that the skin condition was not properly treated and that inadequate follow-up was received. CONCLUSIONS: Teledermatology was widely accepted by the majority of patients receiving care at rural clinics. Patient satisfaction with care received through teledermatology was equivalent to that with face-to-face dermatology.

Antepartum A1C, maternal diabetes outcomes, and selected offspring outcomes: an epidemiological review.

Between 1989 and 2004, the prevalence of gestational diabetes mellitus (GDM) in the United States increased by 122%. Glycated haemoglobin, as measured by haemoglobin A1C (A1C), can potentially identify pregnant women at high risk for adverse outcomes associated with GDM including macrosomia and post-partum glucose intolerance. Our objective was to systematically review the literature with respect to A1C levels during pregnancy and associated maternal and offspring outcomes. We used MEDLINE to identify relevant publications from 1975 to 2009. We included articles if they met the following criteria: original full text articles in English; primary exposure of antepartum A1C; women with GDM at baseline or who developed GDM during the study; primary outcome of GDM, insulin use, post-partum abnormal glucose or type 2 diabetes (T2DM), birthweight, macrosomia or large for gestational age. Case series and case reports were excluded. Twenty studies met our criteria. A1C at GDM diagnosis was positively associated with post-partum abnormal glucose. Women with post-partum T2DM or impaired glucose tolerance had mean A1C at GDM diagnosis higher than those with normal post-partum glucose (P ≤ 0.002) and a 1% increase in A1C at GDM diagnosis was associated with 2.36 times higher odds of post-partum abnormal glucose 6 weeks after delivery [95% confidence interval 1.19, 4.68]. The association of A1C and birthweight varied substantially between studies, with correlation coefficients ranging from 0.11 to 0.51. A1C, a less burdensome and costly measure than an oral glucose tolerance test, appears to be an attractive measure for identifying women at high risk of adverse outcomes associated with GDM.

Influenza vaccination rates of children in households with high-risk adults.

OBJECTIVES: Household contacts of people at high risk for influenza complications should receive yearly influenza vaccination to reduce potential viral transmission. We evaluated influenza vaccine coverage among children to determine whether or not living with a high-risk adult predicts the likelihood of being vaccinated. METHODS: Using the 2006 National Health Interview Survey, we examined influenza vaccination rates among children (aged 1-17 years) who did and did not reside in a household with an adult at high risk for influenza-related complications. RESULTS: Among 24,195 sampled families, there were 8,976 high-risk adults, 18.9% of whom reported living with a person 17 years of age of younger. Influenza vaccination rates by age group among children living with high-risk adults were 41.7% (1 year), 30.3% (2-4 years), and 20.0% (5-17 years). Unadjusted influenza vaccination rates were significantly higher for school-aged children who lived with a high-risk adult compared with those who did not (20.0% vs. 15.0%, p < 0.001). Among children younger than 5 years of age, for whom vaccination was universally recommended at the time of the survey, the rates did not differ. After adjusting for the child's age, gender, race, insurance coverage, medical visits, and chronic conditions, children who lived with a high-risk adult were not statistically more likely than those who did not live with a high-risk adult to receive influenza vaccination (odds ratio = 1.16, 95% confidence interval 0.99, 1.36). CONCLUSIONS: Children had low rates of influenza vaccination, and those who lived with high-risk adults were not significantly more likely to be vaccinated. Clinicians caring for high-risk adults should remind eligible household contacts to receive influenza vaccine.

Patient-centered care and the electronic health record: exploring functionality and gaps.

OBJECTIVE: Healthcare systems have adopted electronic health records (EHRs) to support clinical care. Providing patient-centered care (PCC) is a goal of many healthcare systems. In this study, we sought to explore how existing EHR systems support PCC; defined as understanding the patient as a whole person, building relational connections between the clinician and patient, and supporting patients in health self-management. MATERIALS AND METHODS: We assessed availability of EHR functions consistent with providing PCC including patient goals and preferences, integrated care plans, and contextual and patient-generated data. We surveyed and then interviewed technical representatives and expert clinical users of 6 leading EHR systems. Questions focused on the availability of specific data and functions related to PCC (for technical representatives) and the clinical usefulness of PCC functions (for clinicians) in their EHR. RESULTS: Technical representatives (n = 6) reported that patient communication preferences, personalized indications for medications, and end of life preferences were functions implemented across 6 systems. Clinician users (n = 10) reported moderate usefulness of PCC functions (medians of 2-4 on a 5-pointy -35t scale), suggesting the potential for improvement across systems. Interviews revealed that clinicians do not have a shared conception of PCC. In many cases, data needed to deliver PCC was available in the EHR only in unstructured form. Data systems and functionality to support PCC are under development in these EHRs. DISCUSSION AND CONCLUSION: There are current gaps in PCC functionality in EHRs and opportunities to support the practice of PCC through EHR redesign.

Development of a Tailored Behavioral Weight Loss Program for Veterans With PTSD (MOVE!+UP): A Mixed-Methods Uncontrolled Iterative Pilot Study.

PURPOSE: Veterans with post-traumatic stress disorder (PTSD) lose less weight in the Veterans Affairs (VA) weight management program (MOVE!), so we developed MOVE!+UP. DESIGN: Single-arm pre-post pilot to iteratively develop MOVE!+UP (2015-2018). SETTING: Veterans Affairs Medical Center. PARTICIPANTS: Overweight Veterans with PTSD (5 cohorts of n = 5-11 [N = 44]; n = 39 received ≥1 MOVE+UP session, with cohorts 1-4 [n = 31] = "Development" and cohort 5 [n = 8] = "Final" MOVE!+UP). INTERVENTION: MOVE!+UP weight management for Veterans with PTSD modified after each cohort. Final MOVE!+UP was coled by a licensed clinical psychologist and Veteran peer counselor in 16 two-hour in-person group sessions and 2 individual dietician visits. Sessions included general weight loss support (eg, behavioral monitoring with facilitator feedback, weekly weighing), cognitive-behavioral skills to address PTSD-specific barriers, and a 30-minute walk to a nearby park. MEASURES: To inform post-cohort modifications, we assessed weight, PTSD, and treatment targets (eg, physical activity, diet), and conducted qualitative interviews. ANALYSIS: Baseline to 16-week paired t tests and template analysis. RESULTS: Development cohorts suggested improvements (eg, additional sessions and weight loss information, professional involvement) and did not lose weight (mean [M] = 1.8 lbs (standard deviation [SD] = 8.2); P = .29. Conversely, the final cohort reported high satisfaction and showed meaningful weight (M = -14 pounds [SD = 3.7] and 71% lost ≥5% baseline weight) and PTSD (M = -17.9 [SD = 12.2]) improvements, P < .05. CONCLUSIONS: The comprehensive, 16-week, in-person, cofacilitated Final MOVE!+UP was acceptable and may improve the health of people with PTSD. Iterative development likely produced a patient-centered intervention, needing further testing.

Guideline concordant venous ulcer care predicts healing in a tertiary care Veterans Affairs Medical Center.

This study describes the impact of 80% adherence to guideline concordant care for compression therapy, moist wound-healing environment, and debridement on venous ulcer outcomes. The retrospective cohort design included patients from a tertiary care Veterans Affairs Medical Center from October 2003 to September 2007. During this 5-year interval, 155 patients with 400 venous ulcers met study inclusion. A majority of ulcers (n=362) healed, with an average time to healing of 18.1 weeks (range 2-209 weeks, median 10.4 weeks). From the multivariate Poisson regression, the likelihood of ulcer healing increased when compression therapy was provided during at least 80% of visits (relative risk [RR], 1.93; 95% confidence interval [CI], 1.27-2.92) or when a moist wound-healing environment was provided during at least 80% of visits (RR, 1.63; 95% CI, 1.09-2.42). Debridement alone was not significantly associated with ulcer healing (RR, 1.0; 95% CI, 0.61-1.64). Patients who received all three treatments during at least 80% of their visits were more likely to heal than those who received < 80% treatment (RR, 2.52; 95% CI, 1.53-4.16). Guideline concordant venous ulcer care was significantly associated with venous ulcer healing, when provided at 80% or more of patient visits.