Diagnosing Chronic Obstructive Pulmonary Disease Among Afghanistan and Iraq Veterans: Veterans Affair's Concordance With Clinical Guidelines for Spirometry Administration.

BACKGROUND: Early diagnosis and treatment of chronic obstructive pulmonary disease (COPD) can slow disease progression. The Department of Veterans Affairs (VA)/Department of Defense Clinical Practice Guidelines (CPG), established to improve patient outcomes, recommend the use of spirometry in the COPD diagnostic process. The aims of this study were to assess VA health care providers' performance related to CPG-recommended spirometry administration in the evaluation of newly diagnosed COPD among veterans, determine the patient characteristics that may influence the adherence rate, and compare VA concordance rates to those of other health plans. METHODS: Administrative health care data related to Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) veterans was used to identify newly diagnosed COPD cases and the proportion of cases receiving spirometry. Cases were defined as veterans who had their first medical encounter with a coded diagnosis of COPD ≥ 6 months after their initial VA health care evaluation. The relationship between prediagnostic and comorbid conditions and the administration of CPG-concordant spirometry was examined using regression analyses. FINDINGS: Among the 923,646 OEF/OIF/OND veterans receiving VA health care between January 2002 and December 2014, 32,076 (3%) had a coded diagnosis of COPD. Among those, 22,156 (69%) were identified as newly diagnosed COPD cases; only 6,827 (31%) had CPG-concordant spirometry. Concordant spirometry was more likely to occur in veterans aged ≥40. A pre-existing tobacco use disorder marginally changed the concordance rate. DISCUSSION: VA provider adherence to CPG-concordant spirometry would decrease the prevalence of false-positive COPD cases and lead to more targeted disease treatment. Future research should focus on such cases by assessing the association between COPD diagnosis and bronchodilator responsiveness.

Health care utilization behavior of veterans who deployed to Afghanistan and Iraq.

BACKGROUND: Previous assessments of Afghanistan/Iraq Veterans have lacked a systematic overview of all injury and illness experiences captured by the Veterans Health Administration (VHA) health care services. In this initial study, we quantify the health care utilization behavior of eligible Veterans and describe the level and type of usage among them. METHODS: A roster of service members who have served in Afghanistan/Iraq and became eligible for VHA care between 2002 and 2010 and their corresponding administrative VA medical encounter data were abstracted from the VHA Office of Public Health Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Health Surveillance System. RESULTS: Between 2002 and 2010, approximately 55% of eligible Veterans accessed VHA health care. Higher utilization was observed among Veterans 50 years of age and older compared to younger Veterans. Higher utilization was also observed among Veterans with increasing cumulative deployment time. Mental disorder diagnostic codes accounted for the greatest number of visits per Veteran. CONCLUSIONS: Veterans with mental health diagnoses may need a different level of care than other VHA users. Other service factors associated with utilization require further research to better understand the underlying relationship. Current observed results may be reflective of future expected utilization patterns and may assist in resource planning and research.

Features: Health Care Use Among Iraq and Afghanistan Veterans With Infectious Diseases.

Qualified veterans were no more likely to take advantage of health care services after the VA presumptive infectious disease determination streamlined the qualification process.

Urban-rural differences in attitudes and practices toward long-acting reversible contraceptives among family planning providers in Texas.

BACKGROUND: Despite the elevated rates of teen and unplanned pregnancies across the United States, long-acting reversible contraceptives (LARCs) remain a less utilized birth control method. The present study investigated family planning providers' attitudes and considerations when recommending family planning methods and LARCs to clients. Additionally, this study explored whether urban-rural differences exist in providers' attitudes toward LARCs and in clients' use of LARCs. METHODS: Data were collected using an online survey of family planning providers at Title X clinics in Texas. Survey data was linked to family planning client data from the Family Planning Annual Report (2008). RESULTS: Findings indicated that, although providers were aware of the advantages of LARCs, clients' LARC use remains infrequent. Providers reported that the benefits of hormone implants include their effectiveness for 3 years and that they are an option for women who cannot take estrogen-based birth control. Providers acknowledged the benefits of several types of LARCs; however, urban providers were more likely to acknowledge the benefits of hormone implants compared with their rural counterparts. Results also indicated barriers to recommending LARCs, such as providers' misinformation about LARCs and their caution in recommending LARCs to adolescents. However, findings also indicated providers lack training in LARC insertion, specifically among those practicing in rural areas. CONCLUSIONS: In light of the effectiveness and longevity of LARCs, teenagers and clients living in rural areas are ideal LARC candidates. Increased training among family planning providers, especially for those practicing in rural areas, may increase their recommendations of LARCs to clients.

Virus detection and duration of illness among patients with 2009 pandemic influenza A (H1N1) virus infection in Texas.

Knowledge from early outbreaks is limited regarding the virus detection and illness duration of the 2009 pandemic influenza A (H1N1) infections. During the period from April to May 2009 in Texas, we collected serial nasopharyngeal (NP) and stool specimens from 35 participants, testing by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) and culture. The participants were aged 2 months to 71 years; 25 (71%) were under 18. The median duration of measured fever was 3.0 days and of virus detection in NP specimens was 4.2 days; however, few specimens were collected between days 5-9. The duration of virus detection (4.2 days) was similar to the duration of fever (3.5 days) (RR, 1.14; 95% CI, .66-1.95; P = .8), but was shorter than the duration of cough (11.0 days) (RR, .41; 95% CI, .24-.68; P < .001). We detected viral RNA in two participants' stools. All cultures were negative. This investigation suggests that the duration of virus detection was likely similar to the seasonal influenza virus.

Diagnosis of 2009 pandemic influenza A (pH1N1) and seasonal influenza using rapid influenza antigen tests, San Antonio, Texas, April-June 2009.

Clinicians frequently use influenza rapid antigen tests for diagnostic testing. We tested nasal wash samples from 1 April to 7 June 2009 from 1538 patients using the QuickVue Influenza A+B (Quidel) rapid influenza antigen test and compared the results with real-time reverse transcription polymerase chain reaction (rRT-PCR) assay (gold standard). The prevalence of 2009 pandemic influenza A (pH1N1) was 1.98%, seasonal influenza type A .87%, and seasonal influenza type B 2.07%. The sensitivity and specificity of the rapid test for pH1N1 was 20% (95% CI, 8-39) and 99% (95% CI, 98-99), for seasonal influenza type A 15% (95% CI, 2-45) and 99% (95% CI, 98-99), and for influenza type B was 31% (95% CI, 9-61) and 99% (95% CI, 98-99.7). Rapid influenza antigen tests were of limited use at a time when the prevalence of pH1N1 and seasonal influenza in the United States was low. Clinicians should instead rely on clinical impression and laboratory diagnosis by rRT-PCR.

Household transmission of 2009 pandemic influenza A (H1N1) and nonpharmaceutical interventions among households of high school students in San Antonio, Texas.

San Antonio, Texas, was one of the first metropolitan areas where 2009 pandemic influenza A (H1N1) virus (pH1N1) was detected. Identification of laboratory-confirmed pH1N1 in 2 students led to a preemptive 8-day closure of their high school. We assessed transmission of pH1N1 and changes in adoption of nonpharmaceutical interventions (NPIs) within households of students attending the affected school. Household secondary attack rates were 3.7% overall and 9.1% among those 0-4 years of age. Widespread adoption of NPIs was reported among household members. Respondents who viewed pH1N1 as very serious were more likely to adopt certain NPIs than were respondents who viewed pH1N1 as not very serious. NPIs may complement influenza vaccine prevention programs or be the only line of defense when pandemic vaccine is unavailable. The 2009 pandemic provided a unique opportunity to study NPIs, and these real-world experiences provide much-needed data to inform pandemic response policy.

Reductions in cigarette smoking and acute myocardial infarction mortality in Jefferson County, Texas.

After litigation against the tobacco industry ended in a settlement, the Texas legislature funded pilot projects to reduce tobacco use in selected areas of the state. Subsequent telephone surveys showed that well-funded activities were successful in reducing population rates of self-reported cigarette smoking. We present evidence that the reduction in smoking promptly led to lower rates of death from acute myocardial infarctions.

Household transmission of pandemic (H1N1) 2009, San Antonio, Texas, USA, April-May 2009.

To assess household transmission of pandemic (H1N1) 2009 in San Antonio, Texas, USA, during April 15-May 8, 2009, we investigated 77 households. The index case-patient was defined as the household member with the earliest onset date of symptoms of acute respiratory infection (ARI), influenza-like illness (ILI), or laboratory-confirmed pandemic (H1N1) 2009. Median interval between illness onset in index and secondary case-patients was 4 days (range 1-9 days); the index case-patient was likely to be < or =18 years of age (p = 0.034). The secondary attack rate was 4% for pandemic (H1N1) 2009, 9% for ILI, and 13% for ARI. The secondary attack rate was highest for children <5 years of age (8%-19%) and lowest for adults > or =50 years of age (4%-12%). Early in the outbreak, household transmission primarily occurred from children to other household members and was lower than the transmission rate for seasonal influenza.

H1N1 2009 influenza virus infection during pregnancy in the USA.

BACKGROUND: Pandemic H1N1 2009 influenza virus has been identified as the cause of a widespread outbreak of febrile respiratory infection in the USA and worldwide. We summarised cases of infection with pandemic H1N1 virus in pregnant women identified in the USA during the first month of the present outbreak, and deaths associated with this virus during the first 2 months of the outbreak. METHODS: After initial reports of infection in pregnant women, the US Centers for Disease Control and Prevention (CDC) began systematically collecting additional information about cases and deaths in pregnant women in the USA with pandemic H1N1 virus infection as part of enhanced surveillance. A confirmed case was defined as an acute respiratory illness with laboratory-confirmed pandemic H1N1 virus infection by real-time reverse-transcriptase PCR or viral culture; a probable case was defined as a person with an acute febrile respiratory illness who was positive for influenza A, but negative for H1 and H3. We used population estimates derived from the 2007 census data to calculate rates of admission to hospital and illness. FINDINGS: From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) women were admitted to hospital. The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population (0.32 per 100 000 pregnant women, 95% CI 0.13-0.52 vs 0.076 per 100 000 population at risk, 95% CI 0.07-0.09). Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC; all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation. INTERPRETATION: Pregnant women might be at increased risk for complications from pandemic H1N1 virus infection. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs. FUNDING: US CDC.

Training mental health professionals to assess and manage suicidal behavior: can provider confidence and practice behaviors be altered?

Remarkably little systematic research has studied the effects of clinical suicidology training on changing practitioner attitudes and behaviors. In the current study we investigated whether training in an empirically-based assessment and treatment approach to suicidal patients administered through a continuing education workshop could meaningfully impact professional practices, clinic policy, clinician confidence, and beliefs posttraining and 6 months later. At the 6 month follow-up we found that 44% of practitioners reported increased confidence in assessing suicide risk, 54% reported increased confidence in managing suicidal patients, 83% reported changing suicide care practices, and 66% reported changing clinic policy. These results suggest that a brief and carefully developed workshop training experience can potentially change provider perceptions and behaviors with a possible impact on clinical care therein.

Binge drinking among U.S. active-duty military personnel.

BACKGROUND: Binge drinking (drinking on a single occasion >or=5 drinks for men or >or=4 drinks for women) is a common risk behavior among U.S. adults that is associated with many adverse health and social consequences. However, little is known about binge drinking among active-duty military personnel (ADMP). The objectives of this study were to quantify episodes of binge drinking, to characterize ADMP who binge-drink, and to examine the relationship between binge drinking and related harms. METHODS: The prevalence of binge drinking and related harms was assessed from responses to the 2005 Department of Defense Survey of Health Related Behaviors Among Military Personnel (n=16,037), an anonymous, self-administered survey. The data were analyzed in 2007 after the release of the public-use data. RESULTS: In 2005, a total of 43.2% of ADMP reported past-month binge drinking, resulting in 29.7 episodes per person per year. In all, 67.1% of binge episodes were reported by personnel aged 17-25 years (46.7% of ADMP), and 25.1% of these episodes were reported by underage youth (aged 17-20 years). Heavy drinkers (19.8% of ADMP) were responsible for 71.5% of the binge-drinking episodes and had the highest number of annual per-capita episodes of binge drinking (112.6 episodes). Compared to nonbinge drinkers, binge drinkers were more likely to report alcohol-related harms, including job performance problems (AOR=6.5; 95% CI=4.65, 9.15); alcohol-impaired driving (AOR=4.9; 95% CI=3.68, 6.49); and criminal justice problems (AOR=6.2; 95% CI=4.00, 9.72). CONCLUSIONS: Binge drinking is common among ADMP and is strongly associated with adverse health and social consequences. Effective interventions (e.g., the enforcement and retainment of the minimum legal drinking age) to prevent binge drinking should be implemented across the military and in conjunction with military communities to discourage binge drinking.

A low-intensity intervention to prevent annual weight gain in active duty Air Force members.

Elevated body weight among active duty Air Force (ADAF) members is a substantial and growing problem, and typically results from gaining small amounts of weight each year over many years. We designed a strategy to prevent annual weight gain in ADAF members using self-directed behavior change booklets followed by weekly e-mails about diet and physical activity for a year. The intervention was universally offered to ADAF members meeting selection criteria at five U.S. Air Force bases (n = 3,502); members at 60 other U.S. Air Force bases served as controls (n = 65,089). The intervention was completely effective at preventing weight gain in a subgroup of men (those above the lowest three ranks, with baseline weight above maximum allowable) and in women, while controls continued to gain weight. Since the intervention did not require personalized contact, this approach has promise for large-scale population-based efforts aimed at preventing weight gain in working adults.

Unplanned pregnancy among active duty servicewomen, U.S. Air Force, 2001.

Unplanned pregnancy is a major public health problem in the United States. Although the U.S. Air Force has the highest proportion of active duty women of any of the U.S. military services, there are no published data on the occurrence of unplanned pregnancy among active duty Air Force (ADAF) women. Civilian female interviewers conducted telephone interviews with a random sample of 2,348 ADAF women during early 2002, using questions that were closely based on the 1995 National Survey of Family Growth. During 2001, approximately 12% of ADAF women had one or more pregnancies. By National Survey of Family Growth criteria, approximately 54% of these pregnancies were unplanned. Thus, approximately 7% of ADAF women had one or more unplanned pregnancies during 2001. Roughly one-half of unplanned pregnancies represented contraceptive nonuse and the other half represented contraceptive failure or misuse. Unplanned pregnancy is a serious and frequently occurring problem among ADAF women, with many opportunities for prevention.

One-year costs of increased screening and treatment for breast cancer in the Air Force Medical Service.

The Air Force Medical Service is attempting to increase the screening mammography rate among women enrolled to U.S. Air Force military treatment facilities from 72% to 86% (a 20% relative increase). A study was performed to estimate the costs (from testing and first-year treatment) of this targeted increase. We estimated additional 1-year costs using two approaches referred to as the Primary Care Optimization (PCO) approach and the TRICARE Prime benefit (TPB) approach. Under the PCO approach, women ages > or = 50 years are screened every 2 years, whereas under the TPB approach, women are screened every 2 years from ages 40 to 49 years and annually beginning at age 50 years. As of December 31, 2000, 68,360 women ages 40 to 49 years and 70,563 women ages 50 to 69 years were enrolled to U.S. Air Force military treatment facilities. Additional 1-year costs (and additional cases detected by screening) were estimated at dollars 447,096 for the PCO approach (58 additional cases) and dollars 1,340,140 for the TPB approach (72 additional cases). Compared with the PCO approach, under the TPB approach, the 1-year costs of increased screening and treatment for breast cancer at U.S. Air Force military treatment facilities would be three times higher, but the number of additional cases detected by screening would be only 24% higher.

A novel approach for mental health disease management: the Air Force Medical Service's interdisciplinary model.

Mental health disorders are one of the most substantial public health problems affecting society today, accounting for roughly 15% of the overall burden of disease from all causes in the United States. Although primary care (PC) has the potential to be the frontline for recognition and management of behavioral health conditions, this has been a challenge historically. In order to more effectively address the broad scope of behavioral health needs, the Air Force Medical Service (AFMS) established a new model of behavioral health care. Through a series of coordinated steps, the AFMS ultimately placed trained behavioral health providers into PC clinics to serve as consultants to PC providers (PCPs). Behavioral Health Consultants (BHCs) provide focused assessments, present healthcare options to patients, and deliver brief collaborative interventions in the PC setting. BHCs see patients at the request of the PCP, in 15-30-min appointments. In the pilot study, patients averaged 1.6 visits to the BHC. Over 70% of patients fell into six categories of presenting problems: situational reactions, depressive disorders, adjustment disorders, anxiety disorders, health promotion, and obesity. Patient data (n = 76) suggest 97% of patients seen were either "satisfied" or "very satisfied" with BHC services, and 100% of the PCPs (n = 23, 68% response rate) were highly satisfied and indicated they would "definitely recommend" others use BHC services for their patients. Both the implications and the limitations of this pilot study are discussed.

What's the relative risk? A method to directly estimate risk ratios in cohort studies of common outcomes.

PURPOSE: In cohort studies of common outcomes, odds ratios (ORs) may seriously overestimate the true effect of an exposure on the outcome of interest (as measured by the risk ratio [RR]). Since few study designs require ORs (most frequently, case-control studies), their popularity is due to the widespread use of logistic regression. Because ORs are used to approximate RRs so frequently, methods have been published in the general medical literature describing how to convert ORs to RRs; however, these methods may produce inaccurate confidence intervals (CIs). The authors explore the use of binomial regression as an alternative technique to directly estimate RRs and associated CIs in cohort studies of common outcomes. METHODS: Using actual study data, the authors describe how to perform binomial regression using the SAS System for Windows, a statistical analysis program widely used by US health researchers. RESULTS: In a sample data set, the OR for the exposure of interest overestimated the RR more than twofold. The 95% CIs for the OR and converted RR were wider than for the directly estimated RR. CONCLUSIONS: The authors argue that for cohort studies, the use of logistic regression should be sharply curtailed, and that instead, binomial regression be used to directly estimate RRs and associated CIs.

Costs of excess body weight among active duty personnel, U.S. Air Force, 1997.

Although the increasing public health impact of excess body weight in the U.S. general population has received national attention, the impact of excess body weight among active duty military personnel is unknown. A study was conducted to determine the direct (increased medical care) and indirect (lost workdays) costs of excess body weight among active duty Air Force (ADAF) personnel in 1997. Based on measured height and weight values, in 1997, 20.4% of ADAF men and 20.5% of ADAF women had body weights that exceeded their official maximum allowable weight for height. Total excess body weight-attributable costs were estimated at $22.8 million per year, with annual direct and indirect costs estimated at $19.3 million (approximately 6% of total annual expenditures for ADAF medical care) and $3.5 million, respectively. Attributable lost workdays were estimated at 28,351 per year. Annual excess body weight-attributable costs among ADAF personnel are high, both in dollars and lost duty days.

Recent trends in workload, input costs, and expenditures in the Air Force Medical Service Direct Care System.

A study was conducted to examine the relationship between two types of trends in the Air Force Medical Service Direct Care System (AFMS/DCS): trends in expenditures, total and by categories; and trends in medical workload, defined as the sum of inpatient admissions and outpatient clinic visits. Expenditure and medical workload data were extracted from the Medical Expense and Performance Reporting System Executive Query System. Medical inflation data were obtained from the Bureau of Labor Statistics Producer Price Index series. Between fiscal years 1995 and 1999, the AFMS/DCS experienced a 21.2% decrease in medical workload, but total (nominal) expenditures declined only 3.6%. Of all expenditure categories, only inpatient medical care, outpatient medical care, and military-funded private sector care for active duty personnel (supplemental care) have any direct relationship with AFMS/DCS medical workload. Real expenditures for the three categories above decreased by 20.3% during the 5-year period. Accounting for inflation and considering only expenditures related to medical workload, these results suggest that the AFMS/DCS is spending approximately 20% less money to do approximately 20% less work.