Association of Secure Messaging with Primary Care In-Person and Telephone Visits Among Veterans: a Matched Difference-in-Difference Analysis.

BACKGROUND: Secure messaging (SM) between patients and primary care teams has expanded care access but may impact other clinical encounters. OBJECTIVE: To study associations between SM use and primary care in-person and telephone visits in the Veterans Health Administration (VHA). DESIGN: The SM feature of VHA's patient portal, MyHealtheVet, supports asynchronous communication between patients and primary care teams. To study the impact of SM on in-person and telephone visits, two analyses were performed: (1) a retrospective pre-/post-analysis comparing changes after initiating SM use and (2) a difference-in-difference comparison among SM users and non-users 1 year before and after index SM use. Matching to non-users was by primary care team, demographics, and predicted propensity of SM use by Nosos comorbidity score and drive time to clinic. PATIENTS: In 2016, 154,053 Veterans initiated SM from all primary care patients (N = 5,891,893); 25,683 were propensity-matched to controls (N = 49,266) from the same primary care team not using SM. MAIN MEASURES: Primary care provider in-person visits and telephone contacts between patients and their primary care team were assessed 1 year prior and post index SM. KEY RESULTS: Overall, primary care in-person visits decreased 13.3% (p < 0.0001); telephone visits increased 13.5% (p < 0.0001). In the matched analysis, in-person primary care visits decreased by 16.0% (p < 0.0001) by SM users and 9.9% (p < 0.0001) among controls, resulting in a across-group decrease of 6.1% in-person visits after SM initiation. Telephone visits increased by 11.0% (p < 0.0001) for SM users and 4.5% for controls (p < 0.0001) resulting in an across-group increase of 6.5% telephone visits after SM initiation. CONCLUSIONS: Use of SM was associated with decreased in-person visits and increased telephone visits. This may improve clinic appointment availability, while increasing time commitments for providers for non-traditional forms of access.

Metformin effects on biochemical recurrence and metabolic signaling in the prostate.

BACKGROUND: Metformin has received considerable attention as a potential anti-cancer agent. Animal and in-vitro prostate cancer (PCa) models have demonstrated decreased tumor growth with metformin, however the precise mechanisms are unknown. We examine the effects of metformin on PCa biochemical recurrence (BCR) in a large clinical database followed by evaluating metabolic signaling changes in a cohort of men undergoing prostate needle biopsy (PNB). METHODS: Men treated for localized PCa were identified in a comprehensive clinical database between 2001 and 2010. Cox regression was performed to determine association with BCR relative to metformin use. We next identified a separate case-control cohort of men undergoing prostate needle biopsy (PNB) stratified by metformin use. Differences in mean IHC scores were compared with linear regression for phosphorylated IR, IGF-IR, AKT, and AMPK. RESULTS: One thousand seven hundred and thirty four men were evaluated for BCR with mean follow up of 41 months (range 1-121 months). "Ever" metformin use was not associated with BCR (HR 1.12, 0.77-1.65), however men reporting both pre/post-treatment metformin use had a 45% reduction in BCR (HR = 0.55 (0.31-0.96)). For the tissue-based study, 48 metformin users and 42 controls underwent PNB. Significantly greater staining in phosphorylated nuclear (p-IR, p-AKT) and cytoplasmic (p-IR, p-IGF-1R) insulin signaling proteins were seen in patients with PCa detected compared to those with negative PNB (P-values all <0.006). When stratified by metformin use, IGF-1R remained significantly elevated (P = 0.01) in men with PCa detected whereas p-AMPK (P = 0.05) was elevated only in those without PCa. CONCLUSION: Metformin use is associated with reduced BCR after treatment of localized PCa when considering pre-diagnostic and cumulative dosing. In men with cancer detected on PNB, insulin signaling markers were significantly elevated compared to negative PNB patients. The finding of IGF-1R elevation in positive PNBs versus p-AMPK elevation in negative PNBs suggests altered metabolic pathway activation precipitated by metformin use.

A preliminary exploration of the feasibility of offering men information about potential prostate cancer treatment options before they know their biopsy results.

BACKGROUND: A small pre-test study was conducted to ascertain potential harm and anxiety associated with distributing information about possible cancer treatment options at the time of biopsy, prior to knowledge about a definitive cancer diagnosis. Priming men about the availability of multiple options before they have a confirmed diagnosis may be an opportunity to engage patients in more informed decision-making. METHODS: Men with an elevated PSA test or suspicious Digital Rectal Examination (DRE) who were referred to a urology clinic for a biopsy were randomized to receive either the clinic's usual care (UC) biopsy instruction sheet (n = 11) or a pre-biopsy educational (ED) packet containing the biopsy instruction sheet along with a booklet about the biopsy procedure and a prostate cancer treatment decision aid originally written for newly diagnosed men that described in detail possible treatment options (n = 18). RESULTS: A total of 62% of men who were approached agreed to be randomized, and 83% of the ED group confirmed they used the materials. Anxiety scores were similar for both groups while awaiting the biopsy procedure, with anxiety scores trending lower in the ED group: 41.2 on a prostate-specific anxiety instrument compared to 51.7 in the UC group (p = 0.13). ED participants reported better overall quality of life while awaiting biopsy compared to the UC group (76.4 vs. 48.5, p = 0.01). The small number of men in the ED group who went on to be diagnosed with cancer reported being better informed about the risks and side effects of each option compared to men diagnosed with cancer in the UC group (p = 0.07). In qualitative discussions, men generally reported they found the pre-biopsy materials to be helpful and indicated having information about possible treatment options reduced their anxiety. However, 2 of 18 men reported they did not want to think about treatment options until after they knew their biopsy results. CONCLUSIONS: In this small sample offering pre-biopsy education about potential treatment options was generally well received by patients, appeared to be beneficial to men who went on to be diagnosed, and did not appear to increase anxiety unnecessarily among those who had a negative biopsy.

Development of a Quality Assessment Tool for Outpatient Infusion Clinics: A Literature Review and Pilot Survey.

This study aimed to develop a quality assessment tool for outpatient infusion clinics, as a lack of literature exists on the subject. The authors conducted a literature review targeting studies since 2016 to identify variables that affect patient satisfaction in outpatient infusion clinics. Due to the limited number of relevant studies found, the authors shadowed 2 infusion clinic nurses to capture additional determinants of outpatient infusion clinic quality. A total of 72 variables relevant to an outpatient infusion quality assessment tool were listed. From this list of variables, a pilot survey was conducted at an outpatient rheumatology infusion clinic to assess patient satisfaction with 16 variables of interest. The pilot survey (N = 43) revealed that patients were relatively dissatisfied with walking to clinics, lack of access to public transit, lack of parking and/or free parking, lack of privacy, and flexible scheduling and/or cancellation policies. These findings demonstrate how the assessment tool may highlight specific areas of concern at an infusion clinic to identify targets for future quality improvement initiatives. Therefore, the tool presented has the potential to improve the quality of care provided to patients attending infusion facilities.

Cascading reproductive isolation: Plant phenology drives temporal isolation among populations of a host-specific herbivore.

All organisms exist within a complex network of interacting species, thus evolutionary change may have reciprocal effects on multiple taxa. Here, we demonstrate "cascading reproductive isolation," whereby ecological differences that reduce gene flow between populations at one trophic level affect reproductive isolation (RI) among interacting species at the next trophic level. Using a combination of field, laboratory and common-garden studies and long-term herbaria records, we estimate and evaluate the relative contribution of temporal RI to overall prezygotic RI between populations of Belonocnema treatae, a specialist gall-forming wasp adapted to sister species of live oak (Quercus virginiana and Q. geminata). We link strong temporal RI between host-associated insect populations to differences between host plant budbreak phenology. Budbreak initiates flowering and the production of new leaves, which are an ephemeral resource critical to insect reproduction. As flowering time is implicated in RI between plant species, budbreak acts as a "multitrophic multi-effect trait," whereby differences in budbreak phenology contribute to RI in plants and insects. These sister oak species share a diverse community of host-specific gall-formers and insect natural enemies similarly dependent on ephemeral plant tissues. Thus, our results set the stage for testing for parallelism in a role of plant phenology in driving temporal cascading RI across multiple species and trophic levels.

Incidence of Neutropenia in Veterans Receiving Lung Cancer Chemotherapy: A Comparison of Administrative Coding and Electronic Laboratory Data.

INTRODUCTION: The frequency of neutropenia associated with lung cancer chemotherapy outside of randomized trials is largely unknown because administrative coding underestimates its prevalence. This study compared International Classification of Diseases (ICD) diagnosis codes and electronic laboratory results, alone and in combination, for identifying neutropenia events. METHODS: Retrospective cohort study of 718 veterans receiving their first course of chemotherapy for non-small cell lung cancer. Incidence of neutropenia was assessed using electronic laboratory results and ICD-9 codes captured in the Department of Veterans Affairs (VA) electronic medical records (EMR). RESULTS: A total of 118 of 718 patients (16.4 percent) were identified with an absolute neutrophil count (ANC) less than 1,000 cells/mm3, while only 49 of 718 patients (6.8 percent) had ICD-9 codes for neutropenia. Using the combination of laboratory results and diagnosis codes, 136 of 718 patients (18.9 percent) experienced a neutropenic event. Compared to laboratory results as a gold standard, diagnosis codes were specific (not present for individuals without a laboratory-documented low ANC), but not sensitive (missing for many individuals with a low ANC documented in their laboratory test results). CONCLUSION: Relying on ICD codes to identify neutropenia in administrative data likely results in under-reporting. The emerging availability of electronic laboratory results provides an opportunity to more accurately quantify patterns of neutropenia, identify individual risk factors, and assess clinical management practices-including use of colony-stimulating factor prophylaxis-in large community cohorts.

Appropriateness of Prostate Cancer Imaging among Veterans in a Delivery System without Incentives for Overutilization.

OBJECTIVE: To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system. DATA SOURCES/STUDY SETTING: Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008). STUDY DESIGN: We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it. PRINCIPAL FINDINGS: We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging. CONCLUSIONS: Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.

Comparison of demographic characteristics, surgical resection patterns, and survival outcomes for veterans and nonveterans with non-small cell lung cancer in the Pacific Northwest.

INTRODUCTION: Lung cancer is a leading cause of death in the United States and among veterans. This study compares patterns of diagnosis, treatment, and survival for veterans diagnosed with non-small cell lung cancer (NSCLC) using a recently established cancer registry for the Veterans Affairs Pacific Northwest Network with the Puget Sound Surveillance, Epidemiology, and End Results cancer registry. METHODS: A cohort of 1715 veterans with NSCLC were diagnosed between 2000 and 2006, and 7864 men were diagnosed in Washington State during the same period. Demographics, tumor characteristics, initial surgical patterns, and survival across the two registries were evaluated. RESULTS: Veterans were more likely to be diagnosed with stage I or II disease (32.8%) compared with the surrounding community (21.5%, p = 0.001). Surgical resection rates were similar for veterans (70.2%) and nonveterans (71.2%) older than 65 years with early-stage disease (p = 0.298). However, veterans younger than 65 years with early-stage disease were less likely to undergo surgical resection (83.3% versus 91.5%, p = 0.003). Because there were fewer late-stage patients among veterans, overall survival was better, although within each stage group veterans experienced worse survival compared with community patients. The largest differences were among early-stage patients with 44.6% 5-year survival for veterans compared with 57.4% for nonveterans (p = 0.004). CONCLUSIONS: The use of surgical resection among younger veterans with NSCLC may be lower compared with the surrounding community and may be contributing to poorer survival. Cancer quality of care studies have primarily focused on patients older than 65 years using Medicare claims; however, efforts to examine care for younger patients within and outside the Department of Veterans Affairs are needed.