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1.
Sr Care Pharm ; 36(1): 63, 2021 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-33384036

RESUMO

The author discusses benefits available to US Veterans starting with the Department of Veterans Affairs and going into state funding and long-term care benefits.


Assuntos
Veteranos , Hospitais de Veteranos , Humanos , Amor , Estados Unidos , United States Department of Veterans Affairs
2.
Am J Infect Control ; 49(1): 115-119, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33157181

RESUMO

A Veterans Affairs long term care facility on Long Island New York was confronted with a COVID-19 outbreak in late March to Mid-April 2020. Faced with a dwindling supply of PPE, the Infection Control team distributed supplies saved for a possible Ebola outbreak. A COVID unit was created within the nursing home facilitating the geographic isolation of cases; universal testing of residents and employees allowed for the implementation of proper quarantine measures. It was a multidisciplinary team approach led by the Infection Control team that successfully contained this outbreak.


Assuntos
Infecções Assintomáticas/epidemiologia , Portador Sadio/epidemiologia , Controle de Infecções/organização & administração , Casas de Saúde/organização & administração , Equipamento de Proteção Individual/provisão & distribução , Idoso , Idoso de 80 Anos ou mais , /prevenção & controle , Portador Sadio/diagnóstico , Portador Sadio/transmissão , Surtos de Doenças , Feminino , Pessoal de Saúde , Humanos , Controle de Infecções/métodos , Profissionais Controladores de Infecções , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Isolamento de Pacientes , Estados Unidos/epidemiologia , United States Department of Veterans Affairs
3.
PLoS One ; 15(12): e0242007, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33370307

RESUMO

PURPOSE: Progressive Tinnitus Management (PTM) is an evidence-based interdisciplinary stepped-care approach to improving quality of life for patients with tinnitus. PTM was endorsed by Department of Veterans Affairs (VA) Audiology leadership in 2009. Factors affecting implementation of PTM are unknown. We conducted a study to: 1) estimate levels of PTM program implementation in VA Audiology and Mental Health clinics across the country; and 2) identify barriers and facilitators to PTM implementation based on the experiences of VA audiologists and mental health providers. METHOD: We conducted an anonymous, web-based survey targeting Audiology and Mental Health leaders at 144 major VA facilities. Quantitative analyses summarized respondents' facility characteristics and levels of program implementation (full PTM, partial PTM, or no PTM). Qualitative analyses identified themes in factors influencing the implementation of PTM across VA sites. RESULTS: Surveys from 87 audiologists and 66 mental health clinicians revealed that few facilities offered full PTM; the majority offered partial or no PTM. Inductive analysis of the open-ended survey responses identified seven factors influencing implementation of PTM: 1) available resources, 2) service collaboration, 3) prioritization, 4) Veterans' preferences and needs, 5) clinician training, 6) awareness of (evidence-based) options, and 7) perceptions of scope of practice. CONCLUSION: Results suggest wide variation in services provided, a need for greater engagement of mental health providers in tinnitus care, and an interest among both audiologists and mental health providers in receiving tinnitus-related training. Future research should address barriers to PTM implementation, including methods to: 1) improve understanding among mental health providers of their potential role in tinnitus management; 2) enhance coordination of tinnitus-related care between health care disciplines; and 3) collect empirical data on Veterans' need for and interest in PTM, including delivery by telehealth modalities.


Assuntos
Medicina Baseada em Evidências/organização & administração , Implementação de Plano de Saúde/organização & administração , Hospitais de Veteranos/organização & administração , Zumbido/terapia , Audiologia/organização & administração , Progressão da Doença , Medicina Baseada em Evidências/estatística & dados numéricos , Implementação de Plano de Saúde/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Humanos , Comunicação Interdisciplinar , Serviços de Saúde Mental/organização & administração , Preferência do Paciente/psicologia , Preferência do Paciente/estatística & dados numéricos , Médicos/estatística & dados numéricos , Pesquisa Qualitativa , Qualidade de Vida , Inquéritos e Questionários/estatística & dados numéricos , Telemedicina/organização & administração , Telemedicina/estatística & dados numéricos , Zumbido/psicologia , Estados Unidos , United States Department of Veterans Affairs/organização & administração , Veteranos/psicologia
6.
J Opioid Manag ; 16(5): 317-328, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33226089

RESUMO

OBJECTIVE: Insomnia commonly co-occurs with depression, chronic pain, and opioid use. Both insomnia and chronic opioid analgesic use (OAU) are independent risk factors for a new depression episode (NDE). This study determined if the association between longer OAU duration and NDE was stronger in those with versus without insomnia. DESIGN: Retrospective cohort. SETTING: Veterans Health Administration electronic medical records (2000-2012). PARTICIPANTS: New opioid users in follow-up (2002-2012), free of depression for two years prior to follow-up, and aged 18-80 (n = 70,997). METHODS: NDE was ≥ 2 ICD-9 codes in a 12-month period. Insomnia before OAU initiation was ≥1 ICD-9 code. Cox proportional hazard models stratified on insomnia assessed the relationship between initiating a 1-30, 31-90, or > 90 day period of OAU and NDE while controlling for confounders using inverse probability of treatment-weighted propensity scores (PS). RESULTS: Compared to 1-30 day OAU, 31-90 day was associated with NDE in those without (HR = 1.20; 95 percent CI: 1.12-1.28) but not with insomnia (HR = 1.06; 95 percent CI: 0.86-1.32). Results showed a stronger effect of chronic (>90) OAU in those with insomnia (HR = 1.59; 95 percent CI: 1.27-1.98) compared to those without (HR = 1.31; 95 percent CI: 1.21-1.42). However, all stratum-specific effects were not significantly different (p = 0.136). CONCLUSIONS: Although stratum-specific risks were statistically similar, there was evidence for a trend that chronic OAU is a stronger risk factor for NDE in those with versus without insomnia. Providers are encouraged to monitor sleep impairment among patients on opioid therapy, as sleep may be associated with greater risk for NDE in patients with chronic OAU.


Assuntos
Analgésicos Opioides/efeitos adversos , Depressão/induzido quimicamente , Depressão/psicologia , Medicamentos sob Prescrição/efeitos adversos , Distúrbios do Início e da Manutenção do Sono/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/uso terapêutico , Estudos de Coortes , Depressão/epidemiologia , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Veteranos/psicologia , Serviços de Saúde para Veteranos Militares , Adulto Jovem
7.
J Clin Psychiatry ; 81(6)2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33049805

RESUMO

OBJECTIVE: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have previously shown efficacy for posttraumatic stress disorder (PTSD). One prior study using US Department of Veterans Affairs (VA) medical records data to compare these agents found no differences in symptom reduction in clinical practice. The current study addresses several weaknesses in that study, including limited standardization of treatment duration, inability to account for prior treatment receipt, use of an outdated symptomatic assessment for PTSD, and lack of functional outcome. METHODS: A total of 834 VA outpatients were identified with DSM-5 clinical diagnoses of PTSD between October 2016 and March 2018 who initiated one of the medications and met prespecified criteria for treatment duration and dose, combined with baseline and endpoint DSM-5 PTSD Checklist (PCL-5) measurements. Twelve-week acute-phase changes in PCL-5 score and remission of PTSD symptoms were compared among patients receiving the different medications, as was use of acute psychiatric services in the subsequent 6-month continuation phase. RESULTS: In the acute phase, patients improved by a mean of 6.8-10.1 points on the PCL-5 and 0.0%-10.9% achieved remission of PTSD symptoms. Those taking venlafaxine were significantly more likely to achieve remission (P = .008 vs fluoxetine and P < .0001 vs paroxetine, sertraline, and topiramate). In the continuation phase, there were no differences in acute psychiatric care use between medications. Those who continued their medication were less likely to use acute psychiatric services (HR = 0.55; P = .03). CONCLUSIONS: There may be an advantage to venlafaxine over other agents in achieving acute-phase remission for DSM-5 PTSD in routine clinical practice, but this finding requires further study. Regardless of the agent chosen, medication cessation during the continuation phase is associated with a higher risk of acute psychiatric care use.


Assuntos
Inibidores da Anidrase Carbônica/farmacologia , Fluoxetina/farmacologia , Avaliação de Resultados em Cuidados de Saúde , Paroxetina/farmacologia , Inibidores de Captação de Serotonina/farmacologia , Inibidores da Recaptação de Serotonina e Norepinefrina/farmacologia , Sertralina/farmacologia , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Topiramato/farmacologia , Cloridrato de Venlafaxina/farmacologia , Doença Aguda , Adulto , Inibidores da Anidrase Carbônica/administração & dosagem , Feminino , Fluoxetina/administração & dosagem , Humanos , Masculino , Adesão à Medicação , Paroxetina/administração & dosagem , Indução de Remissão , Inibidores de Captação de Serotonina/administração & dosagem , Inibidores da Recaptação de Serotonina e Norepinefrina/administração & dosagem , Sertralina/administração & dosagem , Topiramato/administração & dosagem , Estados Unidos , United States Department of Veterans Affairs , Cloridrato de Venlafaxina/administração & dosagem
9.
JAMA Netw Open ; 3(10): e2021457, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33079198

RESUMO

Importance: Despite recognition of the association between individual social and behavioral determinants of health (SDH) and patient outcomes, little is known regarding the value of SDH in explaining variation in outcomes for high-risk patients. Objective: To describe SDH factors among veterans who are at high risk for hospitalization, and to determine whether adding patient-reported SDH measures to electronic health record (EHR) measures improves estimation of 90-day and 180-day all-cause hospital admission. Design, Setting, and Participants: A survey was mailed between April 16 and June 29, 2018, to a nationally representative sample of 10 000 Veterans Affairs (VA) patients whose 1-year risk of hospitalization or death was in the 75th percentile or higher based on a VA EHR-derived risk score. The survey included multiple SDH measures, such as resilience, social support, health literacy, smoking status, transportation barriers, and recent life stressors. Main Outcomes and Measures: The EHR-based characteristics of survey respondents and nonrespondents were compared using standardized differences. Estimation of 90-day and 180-day hospital admission risk was assessed for 3 logistic regression models: (1) a base model of all prespecified EHR-based covariates, (2) a restricted model of EHR-based covariates chosen via forward selection based on minimizing Akaike information criterion (AIC), and (3) a model of EHR- and survey-based covariates chosen via forward selection based on AIC minimization. Results: In total, 4685 individuals (response rate 46.9%) responded to the survey. Respondents were comparable to nonrespondents in most characteristics, but survey respondents were older (eg, >80 years old, 881 [18.8%] vs 800 [15.1%]), comprised a higher percentage of men (4391 [93.7%] vs 4794 [90.2%]), and were composed of more White non-Hispanic individuals (3366 [71.8%] vs 3259 [61.3%]). Based on AIC, the regression model with survey-based covariates and EHR-based covariates better estimated hospital admission at 90 days (AIC, 1947.7) and 180 days (AIC, 2951.9) than restricted models with only EHR-based covariates (AIC, 1980.2 at 90 days; AIC, 2981.9 at 180 days). This result was due to inclusion of self-reported measures such as marital or partner status, health-related locus of control, resilience, smoking status, health literacy, and medication insecurity. Conclusions and Relevance: Augmenting EHR data with patient-reported social information improved estimation of 90-day and 180-day hospitalization risk, highlighting specific SDH factors that might identify individuals who are at high risk for hospitalization.


Assuntos
Autorrelato , Determinantes Sociais da Saúde/estatística & dados numéricos , Veteranos/psicologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Inquéritos e Questionários , Estados Unidos , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos/estatística & dados numéricos
10.
JAMA Netw Open ; 3(10): e2020955, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33079197

RESUMO

Importance: Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. Objective: To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. Design, Setting, and Participants: This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. Exposures: Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. Main Outcomes and Measures: Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. Results: This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: ß [SE], 2.23 [0.10]; women: ß [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). Conclusions and Relevance: While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.


Assuntos
Acesso aos Serviços de Saúde/organização & administração , Serviços de Saúde Mental/organização & administração , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Veteranos/psicologia , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Saúde Mental/estatística & dados numéricos , Pessoa de Meia-Idade , Encaminhamento e Consulta/organização & administração , Estados Unidos , United States Department of Veterans Affairs , Veteranos/estatística & dados numéricos
11.
Lancet Neurol ; 19(11): 899-907, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33098800

RESUMO

BACKGROUND: Results from the Systolic Blood Pressure Intervention Trial (SPRINT) showed that intensive control of systolic blood pressure significantly reduced the occurrence of mild cognitive impairment, but not probable dementia. We investigated the effects of intensive lowering of systolic blood pressure on specific cognitive functions in a preplanned substudy of participants from SPRINT. METHODS: SPRINT was an open-label, multicentre, randomised controlled trial undertaken at 102 sites, including academic medical centres, Veterans Affairs medical centres, hospitals, and independent clinics, in the USA and Puerto Rico. Participants were adults aged 50 years or older with systolic blood pressure higher than 130 mm Hg, but without diabetes, history of stroke, or dementia. Participants were randomly assigned (1:1) to a systolic blood pressure goal of less than 120 mm Hg (intensive treatment) versus less than 140 mm Hg (standard treatment). All major classes of antihypertensive agents were included. A subgroup of randomly assigned participants including, but not limited to, participants enrolled in an MRI substudy was then selected for a concurrent substudy of cognitive function (target 2800 participants). Each individual was assessed with a screening cognitive test battery and an extended cognitive test battery at baseline and biennially during the planned 4-year follow-up. The primary outcomes for this substudy were standardised composite scores for memory (Logical Memory I and II, Modified Rey-Osterrieth Complex Figure [immediate recall], and Hopkins Verbal Learning Test-Revised [delayed recall]) and processing speed (Trail Making Test and Digit Symbol Coding). SPRINT was registered with ClinicalTrials.gov, NCT01206062. FINDINGS: From Nov 23, 2010, to Dec 28, 2012, 2921 participants (mean age 68·4 years [SD 8·6], 1080 [37%] women) who had been randomly assigned in SPRINT were enrolled in the substudy (1448 received intensive treatment and 1473 received standard treatment). SPRINT was terminated early due to benefit observed in the primary outcome (composite of cardiovascular events). After a median follow-up of 4·1 years (IQR 3·7-5·8), there was no between-group difference in memory, with an annual decline in mean standardised domain score of -0·005 (95% CI -0·010 to 0·001) in the intensive treatment group and -0·001 (-0·006 to 0·005) in the standard treatment group (between-group difference -0·004, 95% CI -0·012 to 0·004; p=0·33). Mean standardised processing speed domain scores declined more in the intensive treatment group (between-group difference -0·010, 95% CI -0·017 to -0·002; p=0·02), with an annual decline of -0·025 (-0·030 to -0·019) for the intensive treatment group and -0·015 (-0·021 to 0·009) for the standard treatment group. INTERPRETATION: Intensive treatment to lower systolic blood pressure did not result in a clinically relevant difference compared with standard treatment in memory or processing speed in a subgroup of participants from SPRINT. The effect of blood pressure lowering might not be evident in specific domains of cognitive function, but instead distributed across multiple domains. FUNDING: National Heart, Lung, and Blood Institute, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute on Aging, National Institute of Neurological Disorders and Stroke, and the Alzheimer's Association.


Assuntos
Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Cognição/efeitos dos fármacos , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Testes de Estado Mental e Demência , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/farmacologia , Pressão Sanguínea/fisiologia , Monitorização Ambulatorial da Pressão Arterial/métodos , Monitorização Ambulatorial da Pressão Arterial/tendências , Cognição/fisiologia , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/prevenção & controle , Disfunção Cognitiva/psicologia , Feminino , Seguimentos , Humanos , Hipertensão/psicologia , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/tendências
12.
JAMA Netw Open ; 3(10): e2022531, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33084900

RESUMO

Importance: In 2018, the Veterans Health Administration (VHA) implemented the Veterans Affairs (VA) Suicide Risk Identification Strategy to improve the identification and management of suicide risk among veterans receiving VHA care. Objectives: To examine the prevalence of positive suicide screening results among veterans in ambulatory care and emergency departments (EDs) or urgent care clinics (UCCs) and to compare acuity of suicide risk among patients screened in these settings. Design, Setting, and Participants: This cross-sectional study used data from the VA's Corporate Data Warehouse (CDW) to assess veterans with at least 1 ambulatory care visit (n = 4 101 685) or ED or UCC visit (n = 1 044 056) at 140 VHA medical centers from October 1, 2018, through September 30, 2019. Exposures: Standardized suicide risk screening and evaluation tools. Main Outcomes and Measures: One-year rate of suicide risk screening and evaluation, prevalence of positive primary and secondary suicide risk screening results, and levels of acute and chronic risk based on the VHA's Comprehensive Suicide Risk Evaluation. Results: A total of 4 101 685 veterans in ambulatory care settings (mean [SD] age, 62.3 [16.4] years; 3 771 379 [91.9%] male; 2 996 974 [73.1%] White) and 1 044 056 veterans in ED or UCC settings (mean [SD] age, 59.2 [16.2] years; 932 319 [89.3%] male; 688 559 [66.0%] White) received the primary suicide screening. The prevalence of positive suicide screening results was 3.5% for primary screening and 0.4% for secondary screening in ambulatory care and 3.6% for primary screening and 2.1% in secondary screening for ED and UCC settings. Compared with veterans screened in ambulatory care, those screened in the ED or UCC were more likely to endorse suicidal ideation with intent (odds ratio [OR], 4.55; 95% CI, 4.37-4.74; P < .001), specific plan (OR, 3.16; 95% CI, 3.04-3.29; P < .001), and recent suicidal behavior (OR, 1.95; 95% CI, 1.87-2.03; P < .001) during secondary screening. Among the patients who received a Comprehensive Suicide Risk Evaluation, those in ED or UCC settings were more likely than those in ambulatory care settings to be at high acute risk (34.1% vs 8.5%; P < .001). Conclusions and Relevance: In this cross-sectional study, population-based suicide risk screening and evaluation in VHA ambulatory care and ED or UCC settings may help identify risk among patients who may not be receiving mental health treatment. Higher acuity of risk among veterans in ED or UCC settings compared with those in ambulatory care settings highlights the importance of scaling up implementation of brief evidence-based interventions in the ED or UCC to reduce suicidal behavior.


Assuntos
Programas de Rastreamento/métodos , Suicídio/psicologia , Veteranos/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-Idade , Prevalência , Suicídio/prevenção & controle , Suicídio/estatística & dados numéricos , Estados Unidos , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos/estatística & dados numéricos
13.
Drugs Aging ; 37(12): 909-916, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33026638

RESUMO

INTRODUCTION: Deprescribing, the intentional reduction of medication, is recognized as an important component of clinical care; however, standardized identification of patient attitudes and beliefs that contribute to deprescribing may be limited due to the length of current surveys. We sought to develop a short-form (≤ 15 items) of the patient perceptions of deprescribing (PPoD) questionnaire, a validated 30-item instrument that assesses dimensions relevant to deprescribing, to be used in clinical and research settings. METHODS: We conducted a secondary analysis of data from 803 US veteran respondents to the original PPoD survey, randomly divided into derivation and validation samples. In the derivation sample, we used ordinary least squares linear regression with R2 model selection to identify candidate items reflective of overall readiness for deprescribing. We then used iterative multitrait analysis, followed by confirmatory factor analysis (CFA) in the validation sample to assess the psychometric properties of the proposed short form. RESULTS: The resulting short-form PPoD consisted of 11 items representing two overarching domains reflective of overall readiness for deprescribing: 'Motivation for Deprescribing' and 'Primary Care Provider Relationship'. CFA fit statistics supported the proposed structure and the two new scales demonstrated high internal consistency reliability (Cronbach alphas: 0.82 and 0.91, respectively) and good discriminant validity (interscale correlation - 0.30). DISCUSSION: The proposed short-form PPoD captures two important sources of variance in patient readiness for deprescribing: motivation and patients' relationships with their primary care providers. This brief, 11-item survey may help foster the inclusion of patient perceptions into clinical decision making for deprescribing to yield safer, more appropriate medication use.


Assuntos
Desprescrições , Conhecimentos, Atitudes e Prática em Saúde , Participação do Paciente/psicologia , Atenção Primária à Saúde/métodos , Inquéritos e Questionários , Veteranos/psicologia , Tomada de Decisões , Análise Fatorial , Feminino , Pessoal de Saúde , Humanos , Prescrição Inadequada , Masculino , Modelos Estatísticos , Participação do Paciente/estatística & dados numéricos , Atenção Primária à Saúde/normas , Psicometria , Distribuição Aleatória , Reprodutibilidade dos Testes , Estados Unidos , United States Department of Veterans Affairs , Veteranos/estatística & dados numéricos
14.
Anesth Analg ; 131(5): e209-e212, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33094965

RESUMO

Using the 12-item World Health Organization Disability Assessment Schedule (WHODAS-12), we measured the prevalence of disability in all eligible patients during a 4-month period who were presenting for preoperative evaluation at a US Veterans Affairs hospital. Overall disability was at least moderate in more than half of these patients (total n = 472 at Durham, NC). Two of the 6 WHODAS domains, "Getting Around" and "Participation in Society," contributed most to the overall scores-25% and 20%, respectively. Further studies are needed to determine the impact of domain-specific disabilities on postoperative outcomes and to identify potential interventions to address these vulnerabilities.


Assuntos
Avaliação da Deficiência , Período Pré-Operatório , Veteranos , Adulto , Idoso , Idoso de 80 Anos ou mais , Pessoas com Deficiência , Feminino , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Limitação da Mobilidade , Prevalência , Comportamento Social , Inquéritos e Questionários , Estados Unidos , United States Department of Veterans Affairs
15.
MMWR Morb Mortal Wkly Rep ; 69(42): 1528-1534, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33090987

RESUMO

Coronavirus disease 2019 (COVID-19) is primarily a respiratory illness, although increasing evidence indicates that infection with SARS-CoV-2, the virus that causes COVID-19, can affect multiple organ systems (1). Data that examine all in-hospital complications of COVID-19 and that compare these complications with those associated with other viral respiratory pathogens, such as influenza, are lacking. To assess complications of COVID-19 and influenza, electronic health records (EHRs) from 3,948 hospitalized patients with COVID-19 (March 1-May 31, 2020) and 5,453 hospitalized patients with influenza (October 1, 2018-February 1, 2020) from the national Veterans Health Administration (VHA), the largest integrated health care system in the United States,* were analyzed. Using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, complications in patients with laboratory-confirmed COVID-19 were compared with those in patients with influenza. Risk ratios were calculated and adjusted for age, sex, race/ethnicity, and underlying medical conditions; proportions of complications were stratified among patients with COVID-19 by race/ethnicity. Patients with COVID-19 had almost 19 times the risk for acute respiratory distress syndrome (ARDS) than did patients with influenza, (adjusted risk ratio [aRR] = 18.60; 95% confidence interval [CI] = 12.40-28.00), and more than twice the risk for myocarditis (2.56; 1.17-5.59), deep vein thrombosis (2.81; 2.04-3.87), pulmonary embolism (2.10; 1.53-2.89), intracranial hemorrhage (2.85; 1.35-6.03), acute hepatitis/liver failure (3.13; 1.92-5.10), bacteremia (2.46; 1.91-3.18), and pressure ulcers (2.65; 2.14-3.27). The risks for exacerbations of asthma (0.27; 0.16-0.44) and chronic obstructive pulmonary disease (COPD) (0.37; 0.32-0.42) were lower among patients with COVID-19 than among those with influenza. The percentage of COVID-19 patients who died while hospitalized (21.0%) was more than five times that of influenza patients (3.8%), and the duration of hospitalization was almost three times longer for COVID-19 patients. Among patients with COVID-19, the risk for respiratory, neurologic, and renal complications, and sepsis was higher among non-Hispanic Black or African American (Black) patients, patients of other races, and Hispanic or Latino (Hispanic) patients compared with those in non-Hispanic White (White) patients, even after adjusting for age and underlying medical conditions. These findings highlight the higher risk for most complications associated with COVID-19 compared with influenza and might aid clinicians and researchers in recognizing, monitoring, and managing the spectrum of COVID-19 manifestations. The higher risk for certain complications among racial and ethnic minority patients provides further evidence that certain racial and ethnic minority groups are disproportionally affected by COVID-19 and that this disparity is not solely accounted for by age and underlying medical conditions.


Assuntos
Infecções por Coronavirus/complicações , Infecções por Coronavirus/terapia , Hospitalização , Influenza Humana/complicações , Influenza Humana/terapia , Pneumonia Viral/complicações , Pneumonia Viral/terapia , Idoso , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/etnologia , Feminino , Disparidades nos Níveis de Saúde , Mortalidade Hospitalar/tendências , Humanos , Influenza Humana/epidemiologia , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/etnologia , Doenças Respiratórias/epidemiologia , Doenças Respiratórias/virologia , Medição de Risco , Estados Unidos/epidemiologia , United States Department of Veterans Affairs
16.
J Clin Psychiatry ; 81(6)2020 10 20.
Artigo em Inglês | MEDLINE | ID: mdl-33084254

RESUMO

OBJECTIVE: The aim of this study was to determine the efficacy of mirtazapine, a tetracyclic antidepressant, as monotherapy for the treatment of posttraumatic stress disorder (PTSD). METHODS: This multisite, randomized, double-blind, placebo-controlled trial was conducted between April 2006 and November 2010 at the Tuscaloosa and Birmingham Veterans Affairs Medical Centers in Alabama. US military veterans who met DSM-IV criteria for PTSD were randomly assigned to placebo (n = 39) or mirtazapine (n = 39) titrated up to 45 mg/d for an 8-week double-blind period followed by an 8-week open-label phase of mirtazapine treatment. The primary outcome efficacy measure was the Structured Interview for Posttraumatic Stress Disorder (SIP). Secondary measures included other measures of PTSD, depression, and sleep. Analyses of treatment groups involved mixed-model procedures using a random intercept to test the hypotheses that mirtazapine would be more effective than placebo in reducing symptoms of PTSD and depression and improving quality of sleep. RESULTS: Seventy-eight participants were randomized with 61 completing the 8-week controlled phase and 48 completing the open-label phase. No significant differences were observed between groups on the primary outcome of SIP scores during the controlled phase (P = .418). In secondary outcomes, significant improvements per the Clinical Global Impressions-Improvement scale were found for the mirtazapine group compared to the placebo group (P = .041). The 8-week open-label phase demonstrated significant symptom improvement in SIP total score (P = .0003) and in scores on the SIP re-experiencing (P = .0007), avoidance (P = .0309), and hyperarousal (P = .0014) subscales. There were no significant differences in the occurrence of adverse events between groups. CONCLUSIONS: This study did not show efficacy of mirtazapine monotherapy in the treatment of PTSD. Identification of more effective treatments, either as monotherapy or adjunctive, for PTSD is imperative. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00302107.


Assuntos
Antidepressivos/farmacologia , Mirtazapina/farmacologia , Avaliação de Resultados em Cuidados de Saúde , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Adulto , Antidepressivos/administração & dosagem , Antidepressivos/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mirtazapina/administração & dosagem , Mirtazapina/efeitos adversos , Estados Unidos , United States Department of Veterans Affairs , Veteranos
17.
JAMA Netw Open ; 3(9): e2016445, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32960278

RESUMO

Importance: Low-value care is associated with harm among patients and with wasteful health care spending but has not been well characterized in the Veterans Health Administration. Objectives: To characterize the frequency of and variation in low-value diagnostic testing for 4 common conditions at Veterans Affairs medical centers (VAMCs) and to examine the correlation between receipt of low-value testing for each condition. Design, Setting, and Participants: This retrospective cohort study used Veterans Health Administration data from 127 VAMCs from fiscal years 2014 to 2015. Data were analyzed from April 2018 to March 2020. Exposures: Continuous enrollment in Veterans Health Administration during fiscal year 2015. Main Outcomes and Measures: Receipt of low-value testing for low back pain, headache, syncope, and sinusitis. For each condition, sensitive and specific criteria were used to evaluate the overall frequency and range of low-value testing, adjusting for sociodemographic and VAMC characteristics. VAMC-level variation was calculated using median adjusted odds ratios. The Pearson correlation coefficient was used to evaluate the degree of correlation between low-value testing for each condition at the VAMC level. Results: Among 1 022 987 veterans, the mean (SD) age was 60 (16) years, 1 008 336 (92.4%) were male, and 761 485 (69.8%) were non-Hispanic White. A total of 343 024 veterans (31.4%) were diagnosed with low back pain, 79 176 (7.3%) with headache, 23 776 (2.2%) with syncope, and 52 889 (4.8%) with sinusitis. With the sensitive criteria, overall and VAMC-level low-value testing frequency varied substantially across conditions: 4.6% (range, 2.7%-10.1%) for sinusitis, 12.8% (range, 8.6%-22.6%) for headache, 18.2% (range, 10.9%-24.6%) for low back pain, and 20.1% (range, 16.3%-27.7%) for syncope. With the specific criteria, the overall frequency of low-value testing across VAMCs was 2.4% (range, 1.3%-5.1%) for sinusitis, 8.6% (range, 6.2%-14.6%) for headache, 5.6% (range, 3.6%-7.7%) for low back pain, and 13.3% (range, 11.3%-16.8%) for syncope. The median adjusted odds ratio ranged from 1.21 for low back pain to 1.40 for sinusitis. At the VAMC level, low-value testing was most strongly correlated for syncope and headache (ρ = 0.56; P < .001) and low back pain and headache (ρ = 0.48; P < .001). Conclusions and Relevance: In this cohort study, low-value diagnostic testing was common, varied substantially across VAMCs, and was correlated between veterans' receipt of different low-value tests at the VAMC level. The findings suggest a need to address low-value diagnostic testing, even in integrated health systems, with robust utilization management practices.


Assuntos
Diagnóstico por Imagem/estatística & dados numéricos , Eletroencefalografia/estatística & dados numéricos , Cefaleia/diagnóstico , Dor Lombar/diagnóstico por imagem , Sinusite/diagnóstico por imagem , Síncope/diagnóstico por imagem , United States Department of Veterans Affairs , Procedimentos Desnecessários/estatística & dados numéricos , Doença Aguda , Adulto , Idoso , Artérias Carótidas/diagnóstico por imagem , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seios Paranasais/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Ultrassonografia/estatística & dados numéricos , Estados Unidos
18.
Medicine (Baltimore) ; 99(35): e21675, 2020 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-32871882

RESUMO

To assess the impact of allopurinol on diabetes in a retrospective cohort of Veterans' Affairs patients with gout.The New York Harbor VA computerized patient record system was searched to identify patients with an ICD-9 code for gout meeting at least 4 modified 1977 American Rheumatology Association gout diagnostic criteria. Patients were divided into subgroups based on >30 continuous days of allopurinol, versus no allopurinol. New diagnoses of diabetes, defined according to American Diabetes Association diagnostic criteria or clinical documentation explicitly stating a new diagnosis of diabetes, were identified during an observation period from January 1, 2000 through December 31, 2015.Six hundred six gout patients used allopurinol >30 continuous days, and 478 patients never used allopurinol. Over an average 7.9 ±â€Š4.8 years of follow-up, there was no significant difference in diabetes incidence between the allopurinol and non-allopurinol groups (11.7/1000 person-years vs 10.0/1000 person-years, P = .27). A lower diabetes incidence in the longest versus shortest quartiles of allopurinol use (6.3 per 1000 person-years vs 19.4 per 1000 person-years, P<.0001) was attributable to longer duration of medical follow-up.In this study, allopurinol use was not associated with decreased diabetes incidence. Prospective studies may further elucidate the relationship between hyperuricemia, gout, xanthine oxidase activity, and diabetes, and the potential impact of gout treatments on diabetes incidence.


Assuntos
Alopurinol/uso terapêutico , Diabetes Mellitus Tipo 2/epidemiologia , Supressores da Gota/uso terapêutico , Gota/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Alopurinol/administração & dosagem , Colchicina/uso terapêutico , Feminino , Seguimentos , Supressores da Gota/administração & dosagem , Humanos , Incidência , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , New York/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Ácido Úrico/sangue
20.
Subst Abus ; 41(4): 413-418, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32936695

RESUMO

The actions needed to mitigate the spread of the coronavirus 2019 (COVID-19) have forged rapid paradigm shifts across healthcare delivery. In a time of crisis, continued access to and delivery of medication for opioid use disorder (M-OUD) is essential to save lives. However, prior to COVID-19, large variability in M-OUD adoption existed across the Veteran Health Administration (VHA) and it is unknown whether the COVID-19 pandemic exacerbated this divide. For the past two years, our team worked with eight VHA facilities to enhance adoption of M-OUD through a multi-component implementation intervention. This commentary explores these providers' responses to COVID-19 and the subsequent impact on their progress toward increasing adoption of M-OUD. Briefly, the loosening of regulatory restrictions fostered accelerated adoption of M-OUD, rapid support for telehealth offered a mechanism to increase M-OUD access, and reevaluation of current practices surrounding M-OUD strengthened adoption. Overall, during the COVID-19 crisis, facilities and providers responded positively to the call for increased access to M-OUD and appropriate care of patients with OUD. The VHA providers' responses and continued progress in enhancing M-OUD amidst a crisis may, in part, be attributable to their participation in an implementation effort prior to COVID-19 that established resources, expert support, and a community of practice. We anticipate the themes presented are generalizable to other healthcare systems grappling to deliver care to patients with OUD during a crisis. We propose areas of future research and quality improvement to continue to provide access and high quality, life-saving care to patients with OUD.


Assuntos
Acesso aos Serviços de Saúde , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Desenvolvimento de Programas/métodos , Melhoria de Qualidade , United States Department of Veterans Affairs/organização & administração , Buprenorfina/uso terapêutico , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Pandemias , Estados Unidos
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