Opportunities to improve measurement-based care practices in mental health care systems: A case example of electronic mental health screening and measurement.

INTRODUCTION: Measurement-based care (MBC) involves the systematic collection of data to inform clinical decision-making and monitor treatment outcomes. In addition to benefitting patients and providers, data on MBC implementation can also be used to inform quality improvement efforts within existing health care systems. METHOD: The method was retrospective chart review. We collected data on electronic mental health (MH) screens and symptom measures recorded by MH providers. Patients were 28,376 veterans who received MH services in a northeastern region. RESULTS: Although rates varied by MH condition and clinic type, screening for alcohol misuse, depression, and posttraumatic stress disorder appeared to occur with regularity. MH symptom measurement was less frequent than screening but included measures of alcohol and substance use, posttraumatic stress disorder, depression, and suicidal ideation. Patient demographics (e.g., age, military service era, sex, MH diagnosis) and frequency of clinic contact emerged as significant predictors of symptom measurement. DISCUSSION: In this article, we illustrate how data on MH screening and measurement can be organized, analyzed, and interpreted to identify opportunities to enhance MBC practices in MH care. We conclude with a discussion of how large data set analyses can contribute to programmatic MBC initiatives. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Military veteran cancer survivors' preferences for a program to address lifestyle change and psychosocial wellness following treatment.

This study aimed to understand military veteran cancer survivors' preferences regarding the delivery of post-treatment wellness services. Thirty-three military veteran cancer survivors were interviewed about their perceptions of three models of health service delivery (home-, primary care-, and oncology-based services). Conventional qualitative content analysis revealed strengths and weaknesses of each service delivery model's content and structure (e.g., program location, inclusion of emotional support, access to clinical experts). All service delivery programs had strengths, with clinic-based programs offering the greatest breadth of services deemed important for wellness by cancer survivors.

Perceptions of barriers and facilitators to health behavior change among veteran cancer survivors.

OBJECTIVE: This study aimed to identify barriers and facilitators to health behavior change related to body size in a sample of veteran cancer survivors. METHODS: A qualitative study was conducted with a sample of 35 male and female cancer survivors receiving care at a Veterans Administration comprehensive cancer center. Participants completed individual interviews regarding barriers and facilitators to lifestyle change and responded to a brief questionnaire regarding current health behaviors. RESULTS: Participants reported suboptimal adherence to recommended health behavior goals and the majority were overweight or obese (80%). Qualitative analysis revealed numerous barriers and facilitators to health behavior change across six broad categories: environmental factors, health services delivery factors, health-related factors, factors related to attitudes toward change, factors related to enacting change, and motivational factors. Veteran cancer survivors were impacted by common barriers to change affecting the general population, cancer-specific factors related to personal diagnosis and treatment history, and health service delivery factors related to the Veterans Administration health care system. CONCLUSIONS: There are many barriers and facilitators that exist in diverse domains for veteran cancer survivors, each of which offers unique challenges and opportunities for improving engagement in behavior change following cancer diagnosis and treatment.

A program to improve detection of undiagnosed dementia in primary care and its association with healthcare utilization.

OBJECTIVE: Alzheimer's disease and related dementias are common and costly, with increased healthcare utilization for patients with these disorders. The current study describes a novel dementia detection program for veterans and examines whether program-eligible patients have higher healthcare utilization than age-matched comparison patients. DESIGN: Using a telephone-based case-finding approach, the detection program used risk factors available in the electronic medical record (EMR) and telephone-based brief cognitive screening. Holding illness severity constant, dementia detection and healthcare utilization were compared across age-matched groups with and without program risk factors. SETTING: Five Veterans Affairs Healthcare Network Upstate New York primary care clinics. PARTICIPANTS: Veterans aged 70 years and older. MEASUREMENTS: EMR data and the Charlson comorbidity index. RESULTS: Program-eligible patients (n = 5,333) demonstrated significantly greater levels of medical comorbidity relative to comparison patients and were on average more than twice as likely to be admitted to the hospital. They also had nearly double the number of outpatient visits to several services. Similar patterns were seen in those who screened positive on a brief cognitive measure, compared with those who screened negative. CONCLUSIONS: A novel program using EMR data to assist in the detection of newly diagnosed dementia in a clinical setting was found to be useful in identifying older veterans with multiple comorbid medical conditions and increased utilization of hospital and clinic services. Results suggest undetected cognitive impairment and dementia may significantly contribute to healthcare utilization and costs of care in older veterans.

Lasting impact: understanding the psychosocial implications of cancer among military veterans.

This qualitative study aimed to identify Veterans' perceptions of how cancer affects their life following treatment, particularly in relation to treatment side effects and identity as a cancer survivor. A diverse sample of 35 Veteran cancer survivors participated in semistructured, individual interviews. Thematic analysis revealed the enduring impact of diagnosis and chronic uncertainty regarding recurrence, psychological side effects that were periodic and typically self-managed, and physical side effects as common, but considered an acceptable trade-off for increased chances of survival. Perceptions of the term cancer survivor varied considerably among participants. Implications for survivorship wellness and care planning are discussed.

Growth curve analysis of BMI in relation to primary care utilization in prostate cancer survivors.

SUMMARY: Cancer survivors are advised to maintain a healthy BMI to optimize quality of life. In the VA healthcare system, multidisciplinary primary care clinics are responsible for screening and management of overweight or obesity, but it is unclear if cancer survivors are accessing or benefiting from these services. This study aimed to determine if primary care utilization was associated with changes in BMI of prostate cancer survivors, a group with very high rates of long-term survival. Data on demographics, comorbidities, cancer treatment, body size, and number of primary care encounters (medical, behavioral health, nutrition, and weight management program) were collected from electronic medical records and the local tumor registry for 406 early stage prostate cancer survivors who were overweight or obese at diagnosis. Growth curve modeling assessed BMI trajectories in relation to primary care utilization. Results indicated that survivors averaged 18 primary care encounters over the observation period but rarely accessed behavioral health, nutrition, or weight management program services. The average BMI trajectory was non-linear, showing an increase in BMI until 3.2 years after diagnosis followed by deceleration. Primary care utilization was inversely associated with BMI growth, (ß = -0.05, p < 0.01). This association was not impacted by demographic, cancer treatment, or comorbidities. Although primary medical care encounters were associated with modest reductions in BMI, overweight or obese prostate cancer survivors appear to be underutilizing the full range of primary care services that could address the motivational, informational, dietary, and physical activity barriers associated with weight loss.:

Longitudinal assessment of BMI in relation to ADT use among early stage prostate cancer survivors.

INTRODUCTION: The use of androgen deprivation therapy (ADT) for prostate cancer is on the rise, but its adverse side effects may include increased fat mass and decreased lean muscle mass. The net effect of ADT on BMI is unknown. METHODS: Primary, incident cases of early stage prostate cancer (n = 473) were identified from the Buffalo VA Medical Center tumor registry and matched to body size, demographic, comorbidity, and treatment exposure data from veteran medical records. Multilevel modeling was used to assess the association between ADT and changes in BMI. RESULTS: On average, survivors were overweight at diagnosis and showed small, non-significant changes in BMI over time. However, among those survivors with a history of ADT, a significant decrease of 0.05 BMI units per year was associated with each additional dose of ADT (p < 0.001). When the association between BMI rate of change and ADT was allowed to vary with respect to age, additional doses of ADT predicted stronger decreases in BMI for younger survivors as compared to older survivors (p < 0.05). Neither a history of surgery nor radiation influenced the association between ADT use and BMI. CONCLUSIONS: Declines in BMI in relation to ADT exposure may be reflective of unfavorable changes in body composition, especially decreased muscle mass, that is most pronounced in younger survivors. IMPLICATIONS FOR CANCER SURVIVORS: Survivors on ADT may benefit from close monitoring of physical functioning and referral for exercise interventions to preserve muscle mass and improve health related quality of life.

Use of common medications and breast cancer risk.

Prescription and over-the-counter medications are widely used in the United States and many western countries. More than two-thirds of women ages >45 years, who are at greatest risk for breast cancer, take prescription medication. In light of the ubiquitous nature of medication use and the fact that breast cancer remains the most common cancer in women, research on the role of medication use in breast cancer etiology is warranted. We summarize the epidemiologic evidence on the association between breast cancer risk and use of common medications, including antibiotics, antidepressants, statins, antihypertensives, and nonsteroidal anti-inflammatory drugs. Overall, there is little evidence that would implicate the use of antibiotics, antidepressants, statins, and antihypertensives in the etiology of breast cancer. Although several prospective studies and a randomized low-dose aspirin chemoprevention trial have not shown lower risk of breast cancer among aspirin users, most studies that have examined the potential chemoprotective effect of nonsteroidal anti-inflammatory drugs have shown significant risk reductions for regular and prolonged use of these drugs. The existing literature on the role of medication use in breast carcinogenesis is complicated. Interpretation of the evidence is hampered due to major methodologic differences across studies, including exposure assessment, exposure classification, and adjustment for potential confounding variables. These differences largely stem from the fact that the majority of articles on this topic represent secondary data analyses from studies with inadequate information on exposure or confounders. Thus, future epidemiologic studies specifically designed to study these ubiquitous and biologically plausible exposures are warranted.

Diet and breast cancer: a review of the prospective observational studies.

The role of diet for the risk of breast cancer is of great interest as a potentially modifiable risk factor. The evidence from prospective observational studies was reviewed and summarized on selected dietary factors, gene-diet interactions, and breast cancer incidence. Dietary factors were considered that, based on their nutritional constituents, are of particular interest in the context of breast cancer: fat intake, biomarkers of fat intake, fruit and vegetable consumption, antioxidant vitamins (vitamins A, C, E, and beta-carotene), serum antioxidants, carbohydrate intake, glycemic index and glycemic load, dairy consumption (including vitamin D), consumption of soy products and isoflavones, green tea, heterocyclic amines, and adolescent diet. The PubMed database was searched for all prospective studies that relate these dietary items to the incidence of breast cancer or consider gene-diet interactions. Among the prospective epidemiologic studies conducted on diet and breast cancer incidence and gene-diet interactions and breast cancer incidence, to date there is no association that is consistent, strong, and statistically significant, with the exception of alcohol intake, overweight, and weight gain. The apparent lack of association between diet and breast cancer may reflect a true absence of association between diet and breast cancer incidence or may be due to measurement error exceeding the variation in the diet studied, lack of sufficient follow-up, and focus on an age range of low susceptibility. The risk of breast cancer can be reduced by avoidance of weight gain in adulthood and limiting the consumption of alcohol.

Environmental pollutants and breast cancer: epidemiologic studies.

Laboratory research has shown that numerous environmental pollutants cause mammary gland tumors in animals; are hormonally active, specifically mimicking estrogen, which is a breast cancer risk factor; or affect susceptibility of the mammary gland to carcinogenesis. An assessment of epidemiologic research on these pollutants identified in toxicologic studies can guide future research and exposure reduction aimed at prevention. The PubMed database was searched for relevant literature and systematic critical reviews were entered in a database available at URL: www.silentspring.org/sciencereview and URL: www.komen.org/environment (accessed April 10, 2007). Based on a relatively small number of studies, the evidence to date generally supports an association between breast cancer and polycyclic aromatic hydrocarbons (PAHs) and polychlorinated biphenyls (PCBs) in conjunction with certain genetic polymorphisms involved in carcinogen activation and steroid hormone metabolism. Evidence regarding dioxins and organic solvents is sparse and methodologically limited but suggestive of an association. Methodologic problems include inadequate exposure assessment, a lack of access to highly exposed and unexposed populations, and a lack of preclinical markers to identify associations that may be obscured by disease latency. Among chemicals identified in toxicologic research as relevant to breast cancer, many have not been investigated in humans. The development of better exposure assessment methods is needed to fill this gap. In the interim, weaknesses in the epidemiologic literature argue for greater reliance on toxicologic studies to develop national policies to reduce chemical exposures that may be associated with breast cancer. Substantial research progress in the last 5 years suggests that the investigation of environmental pollutants will lead to strategies to reduce breast cancer risk.

Regular analgesic use and risk of multiple myeloma.

Analgesic use has been implicated in the chemoprevention of a number of solid tumors, but to date no previous research has focused on the role of analgesics in the etiology of multiple myeloma (MM). We conducted a hospital-based case-control study of 117 patients with primary, incident MM and 483 age and residence matched controls without benign or malignant neoplasms. All participants received medical services at Roswell Park Cancer Institute in Buffalo, NY, and completed a comprehensive epidemiological questionnaire. Participants who reported analgesic use at least once a week for at least 6 months were classified as regular users; individuals who did not use analgesics regularly served as the reference group throughout the analyses. We used unconditional logistic regression analyses to compute crude and adjusted odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Compared to non-users, regular aspirin users were not at reduced risk of MM (adjusted OR=0.99; 95% CI 0.65-1.49), nor were participants with the highest frequency or duration of aspirin use. A significant risk elevation was found for participants who were regular acetaminophen users (adjusted OR=2.95; 95% CI 1.72-5.08). Further, marked increases in risk of MM were noted with both greater frequency (>7 tablets weekly; adjusted OR=4.36; 95% CI 1.70-11.2) and greater duration (>10 years; adjusted OR=3.26; 95% CI 1.52-7.02) of acetaminophen use. We observed no evidence of a chemoprotective effect of aspirin on MM risk, but observed significant risk elevations with various measures of acetaminophen use. Our results warrant further investigation in population-based case-control and cohort studies and should be interpreted with caution in light of the limited sample size and biases inherent in hospital-based studies.

Risk of ovarian cancer associated with BMI varies by menopausal status.

Obesity has been linked to increased risk of several malignancies, but the role of obesity in the etiology of ovarian cancer remains unclear. Therefore, a hospital-based case-control study was conducted to investigate the association between body size and risk of ovarian cancer. Participants included 427 women with primary, incident ovarian cancer and 854 cancer-free controls. All participants received medical services at Roswell Park Cancer Institute in Buffalo, NY between 1982 and 1998 and completed a comprehensive epidemiological questionnaire. The instrument included questions regarding height and usual wt prior to survey. Participants were classified as underweight/normal (BMI < or = 24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), or obese (BMI > or = 30.0 kg/m2). Compared with underweight/normal participants, being overweight (adjusted odds ratio [OR] = 1.02; 95% CI 0.77-1.36) or obese (adjusted OR = 1.17; 95% CI 0.84-1.65) was not significantly associated with an elevated risk of ovarian cancer. After stratification by menopausal status, BMI showed no significant association to ovarian cancer risk among postmenopausal women (> or = 50 y old). However, among premenopausal women (<50 y old), those classified as obese had a significantly increased risk (adjusted OR = 2.19; 95% CI 1.19-4.04) compared with women classified as normal/underweight. These findings suggest a potential influence of menopausal status on the total endogenous hormonal environment, including estrogens, androgens, and insulin-like growth factors, when considering the association between body size and ovarian cancer risk. In light of the fact that obesity is a modifiable risk factor, further investigation on this topic is warranted.

Consumption of coffee, but not black tea, is associated with decreased risk of premenopausal breast cancer.

Caffeine has been suggested as a possible risk factor for breast cancer, potentially through its effect of facilitating the development of benign breast disease. However, coffee and tea also contain polyphenols, which exhibit anticarcinogenic properties. A hospital-based, case-control study was conducted to evaluate the role of coffee, decaffeinated coffee, and black tea in breast cancer etiology. Study participants included 1932 cases with primary, incident breast cancer and 1895 hospital controls with nonneoplastic conditions. All participants completed a comprehensive epidemiological questionnaire. Among premenopausal women, consumption of regular coffee was associated with linear declines in breast cancer risk (P for trend = 0.03); consumers of >or=4 cups/d experienced a 40% risk reduction (odds ratio = 0.62, 95% CI 0.39-0.98). No clear associations between intake of black tea or decaffeinated coffee and breast cancer risk were noted among premenopausal women, although black tea was associated with a protective effect unique to a subsample of cases with lobular histology. Among postmenopausal women, breast cancer risk was not associated with consumption of coffee, tea, or decaffeinated coffee. Results among postmenopausal women did not differ by histologic subtype. Our findings support a protective effect of coffee intake on premenopausal, but not postmenopausal breast cancer risk. Further studies are warranted to confirm these findings.

Associations between black tea and coffee consumption and risk of lung cancer among current and former smokers.

Although cigarette smoking is a clear risk factor for lung cancer, the other determinants of lung cancer risk among smokers are less clear. Tea and coffee contain catechins and flavonoids, which have been shown to exhibit anticarcinogenic properties. Conversely, caffeine may elevate cancer risk through a variety of mechanisms. The current study investigated the effects of regular consumption of black tea and coffee on lung cancer risk among 993 current and former smokers with primary incident lung cancer and 986 age-, sex-, and smoking-matched hospital controls with non-neoplastic conditions. Results indicated that lung cancer risk was not different for those with the highest black tea consumption (>or=2 cups/day) compared with nondrinkers of tea [adjusted odds ratio (aOR)=0.90; 95% confidence interval (CI)=0.66-1.24]. However, elevated lung cancer risk was observed for participants who consumed 2-3 cups of regular coffee daily (aOR=1.34; 95% CI=0.99-1.82) or >or=4 cups of regular coffee daily (aOR=1.51, 95% CI=1.11-2.05). In contrast, decaffeinated coffee drinking was associated with decreased lung cancer risk for both participants who consumed or=2 cups/day (aOR=0.64; 95% CI=0.51-0.80). These results suggest that any chemoprotective effects of phytochemicals in coffee and tea may be overshadowed by the elevated risk associated with caffeine in these beverages.

Exploring associations between serum levels of select organochlorines and thyroxine in a sample of New York state sportsmen: the New York State Angler Cohort Study.

This preliminary study investigated associations between environmental organochlorine compounds and thyroid function in a sample of 66 sportsmen selected from among participants in the New York State Angler Cohort Study. A cross-sectional design was employed with the primary goal of the analysis being the generation of specific testable hypotheses. Blood samples were analyzed for compounds based on a priori identified literature-cited evidence of thyroid disruption. These included hexachlorobenzene and polychlorinated biphenyl congeners 19, 28, 47, 118, 153, 169, 180, 183, and 187. Time of sample collection, serum triglycerides, cholesterol, high- and low-density lipoproteins, age, body mass index, and cigarette smoking were considered for each participant. Potential associations between organochlorine compounds and serum total thyroxine, controlling for potential confounders, were examined using multivariable linear regression models. The models reported consisted of all variates being entered ("full" model, R2=0.380, P=0.136) and stepwise selection of variates ("reduced" models, alpha=0.15) using the criterion of maximum partial correlation at each step. Several procedures were considered to address contaminant data below the limit of detection in the reduced models with no change in selected predictors. Hexachlorobenzene (beta=-0.113) and age (beta=0.007) were selected as predictors of serum T4 in the reduced models (R2=0.083, P=0.065). Power analysis suggested that by doubling the sample size the existing results would be statistically significant with a type I error of 0.05 and a power of 0.80. These findings are important in the design of a new specific study of thyroid function and environmental contaminants.

Physician perceptions of primary prevention: qualitative base for the conceptual shaping of a practice intervention tool.

BACKGROUND: A practice intervention must have its basis in an understanding of the physician and practice to secure its benefit and relevancy. We used a formative process to characterize primary care physician attitudes, needs, and practice obstacles regarding primary prevention. The characterization will provide the conceptual framework for the development of a practice tool to facilitate routine delivery of primary preventive care. METHODS: A focus group of primary care physician Opinion Leaders was audio-taped, transcribed, and qualitatively analyzed to identify emergent themes that described physicians' perceptions of prevention in daily practice. RESULTS: The conceptual worth of primary prevention, including behavioral counseling, was high, but its practice was significantly countered by the predominant clinical emphasis on and rewards for secondary care. In addition, lack of health behavior training, perceived low self-efficacy, and patient resistance to change were key deterrents to primary prevention delivery. Also, the preventive focus in primary care is not on cancer, but on predominant chronic nonmalignant conditions. CONCLUSIONS: The success of the future practice tool will be largely dependent on its ability to "fit" primary prevention into the clinical culture of diagnoses and treatment sustained by physicians, patients, and payers. The tool's message output must be formatted to facilitate physician delivery of patient-tailored behavioral counseling in an accurate, confident, and efficacious manner. Also, the tool's health behavior messages should be behavior-specific, not disease-specific, to draw on shared risk behaviors of numerous diseases and increase the likelihood of perceived salience and utility of the tool in primary care.