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BACKGROUND: The Veterans Health Administration (VHA) implemented the Clinical Resource Hub (CRH) program to fill staffing gaps in primary care (PC) clinics via telemedicine and maintain veterans' healthcare access. OBJECTIVE: To evaluate PC wait times before and after CRH implementation. DESIGN: Comparative interrupted time series analysis among a retrospective observational cohort of PC clinics who did and did not use CRH during pre-implementation (October 2018-September 2019) and post-implementation (October 2019-February 2020) periods. PARTICIPANTS: Clinics completing ≥10 CRH visits per month for 2 consecutive months and propensity matched control clinics. MAIN MEASURES: Two measures of patient access (i.e., established, and new patient wait times) and one measure of clinic capacity (i.e., third next available appointment) were assessed. Clinics using CRH were 1:1 propensity score matched across clinical and demographic characteristics. Comparative interrupted time series models used linear mixed effects regression with random clinic-level intercepts and triple interaction (i.e., CRH use, pre- vs. post-implementation, and time) for trend and point estimations. KEY RESULTS: PC clinics using CRH (N = 79) were matched to clinics not using CRH (N = 79). In the 12-month pre-implementation, third next available time increased in CRH clinics (0.16 days/month; 95% CI = [0.07, 0.25]), and decreased in the 5 months post-implementation (-0.58 days/month; 95% CI = [-0.90, -0.27]). Post-implementation third next available time also decreased in control clinics (-0.48 days/month; 95% CI = [-0.81, -0.17]). Comparative differences remained non-significant. There were no statistical differences in established or new patient wait times by CRH user status, CRH implementation, or over time. CONCLUSIONS: In a national VHA telemedicine program developed to provide gap coverage for PC clinics, no wait time differences were observed between clinics using and not using CRH services. This hub-and-spoke telemedicine service is an effective model to provide gap coverage while maintaining access. Further investigation of quality and long-term access remains necessary.
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BACKGROUND: The COVID-19 pandemic encouraged telemedicine expansion. Research regarding follow-up healthcare utilization and primary care (PC) telemedicine is lacking. OBJECTIVE: To evaluate whether healthcare utilization differed across PC populations using telemedicine. DESIGN: Retrospective observational cohort study using administrative data from veterans with minimally one PC visit before the COVID-19 pandemic (March 1, 2019-February 28, 2020) and after in-person restrictions were lifted (October 1, 2020-September 30, 2021). PARTICIPANTS: All veterans receiving VHA PC services during study period. MAIN MEASURES: Veterans' exposure to telemedicine was categorized as (1) in-person only, (2) telephone telemedicine (≥ 1 telephone visit with or without in-person visits), or (3) video telemedicine (≥ 1 video visit with or without telephone and/or in-person visits). Healthcare utilization 7 days after index PC visit were compared. Generalized estimating equations estimated odds ratios for telephone or video telemedicine versus in-person only use adjusted for patient characteristics (e.g., age, gender, race, residential rurality, ethnicity), area deprivation index, comorbidity risk, and intermediate PC visits within the follow-up window. KEY RESULTS: Over the 2-year study, 3.4 million veterans had 12.9 million PC visits, where 1.7 million (50.7%), 1.0 million (30.3%), and 649,936 (19.0%) veterans were categorized as in-person only, telephone telemedicine, or video telemedicine. Compared to in-person only users, video telemedicine users experienced higher rates per 1000 patients of emergent care (15.1 vs 11.2; p < 0.001) and inpatient admissions (4.2 vs 3.3; p < 0.001). In adjusted analyses, video versus in-person only users experienced greater odds of emergent care (OR [95% CI]:1.18 [1.16, 1.19]) inpatient (OR [95% CI]: 1.29 [1.25, 1.32]), and ambulatory care sensitive condition admission (OR [95% CI]: 1.30 [1.27, 1.34]). CONCLUSIONS: Telemedicine potentially in combination with in-person care was associated with higher follow-up healthcare utilization rates compared to in-person only PC. Factors contributing to utilization differences between groups need further evaluation.
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COVID-19 , Telemedicina , Humanos , Estudos Retrospectivos , Pandemias , Saúde dos Veteranos , Pacientes Internados , Aceitação pelo Paciente de Cuidados de Saúde , Atenção Primária à SaúdeRESUMO
BACKGROUND: During the COVID-19 pandemic, telemedicine quickly expanded. Broadband speeds may impact equitable access to video-based mental health (MH) services. OBJECTIVE: To identify access disparities in Veterans Health Administration (VHA) MH services based on broadband speed availability. DESIGN: Instrumental variable difference-in-differences study using administrative data to identify MH visits prior to (October 1, 2015-February 28, 2020) and after COVID-19 pandemic onset (March 1, 2020-December 31, 2021) among 1176 VHA MH clinics. The exposure is broadband download and upload speeds categorized as inadequate (download ≤25 Megabits per second - Mbps; upload ≤3 Mbps), adequate (download ≥25 Mbps and <100 Mbps; upload ≥5 Mbps and <100 Mbps), or optimal (download and upload ≥100/100 Mbps) based on data reported to the Federal Communications Commission at the census block and spatially merged to each veteran's residential address. PARTICIPANTS: All veterans receiving VHA MH services during study period. MAIN MEASURES: MH visits were categorized as in-person or virtual (i.e., telephone or video). By patient, MH visits were counted quarterly by broadband category. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient's broadband speed category and quarterly MH visit count by visit type, adjusted for patient demographics, residential rurality, and area deprivation index. KEY RESULTS: Over the 6-year study period, 3,659,699 unique veterans were seen. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in patients' quarterly MH visit count; patients living in census blocks with optimal versus inadequate broadband increased video visit use (incidence rate ratio (IRR) = 1.52, 95% CI = 1.45-1.59; P < 0.001) and decreased in-person visits (IRR = 0.92, 95% CI = 0.90-0.94; P < 0.001). CONCLUSIONS: This study found patients with optimal versus inadequate broadband availability had more video-based and fewer in-person MH visits after pandemic onset, suggesting broadband availability is an important determinant of access-to-care during public health emergencies requiring remote care.
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COVID-19 , Exclusão Digital , Telemedicina , Humanos , COVID-19/epidemiologia , Saúde Mental , Pandemias , InternetRESUMO
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.
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Portais do Paciente , Veteranos , Humanos , Atenção Primária à Saúde , Estudos Retrospectivos , TelefoneRESUMO
PURPOSE: The authors examined the relationship between mother and child activity. METHODS: The authors compared moderate-vigorous physical activity (MVPA) and sedentary time of low-income mothers with obesity and their 6- to 12-year-old children on week (WD) and weekend (WE) days. A total of 196 mother-child pairs wore accelerometers simultaneously for a week. Mothers completed questionnaires. Spearman correlation and multivariate regression were used. RESULTS: WE MVPA (accelerometry) was significantly correlated between mothers with children aged 6-7 (rs = .35) and daughters (rs = .27). Self-reported maternal PA time spent with one of their children was significantly correlated with the WE MVPA of all children (rs = .21) and children aged 8-10 (rs = .22) and with the WD MVPA of all children (rs = .15), children aged 8-10 (rs = .23), aged 11-12 (rs = .52), and daughters (rs = .37), and inversely correlated to the WD sedentary time of all children (rs = -.21), children aged 8-10 (rs = -.30), aged 11-12 (rs = -.34), daughters (rs = -.26), and sons (rs = -.22). In multivariate regression, significant associations were identified between reported child-mother PA time together and child MVPA and sedentary time (accelerometry). CONCLUSIONS: Mothers may influence the PA levels of their children with the strongest associations found in children aged 6-7 and daughters. Mother-child coparticipation in PA may lead to increased child MVPA and decreased sedentary behavior.
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Mães , Comportamento Sedentário , Acelerometria , Criança , Comportamento Infantil , Exercício Físico , Feminino , Humanos , AutorrelatoRESUMO
BACKGROUND: Kidney disease accounts for more than 49 billion dollars in healthcare expenditures annually. Early detection and intervention may reduce the burden of disease. We describe a quality improvement project to develop a telenephrology dashboard that proactively monitors kidney disease. METHODS: One hundred eighty-four thousands Veterans within the Iowa City Veterans Affairs Health Care System were eligible for telenephrology consultation. The dashboard accessed the charts of 53,085 Veterans at risk for kidney disease. We utilized Lean-Six Sigma tools and principles and the Define-Measure-Analyze-Improve-Control Framework to develop and deploy a telenephrology dashboard in 4 community-based outpatient clinics (CBOCs). The primary measure was the number of days to complete consultation. Secondary measures included number of electronic consultations per month, distance and cost of Veteran travel saved, and number of steps for completion of consult. RESULTS: The data of 1384 Veterans at the 4 CBOCs were analyzed by the telenephrology dashboard, of which 459 generated telenephrology consults. The number of days to complete any type of consultation was unchanged (48.9 days in 2019, compared to 41.6 days in 2017). The average Veteran saved between $21.60 to $63.90 per trip to Iowa City. Between March 2019 and August 2019, there were 27.3 telenephrology consults per month. The number of steps needed to complete the consult request was decreased from 13 to 9. CONCLUSIONS: Utilization of the telenephrology dashboard system contributed to an increase in consultations completed through electronic means without decreasing face-to-face consults. Electronic consults now outnumber traditional face-to-face consultations at our institution. Telenephrology consultation improved early detection and identification of kidney disease and saved time and costs for Veterans in travel, but did not decrease the average number of days to complete consultation requests.
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Apresentação de Dados , Nefropatias , Melhoria de Qualidade , Telemedicina , Interface Usuário-Computador , Veteranos , Atitude Frente aos Computadores , Atenção à Saúde , Humanos , Nefrologia , Serviços de Saúde Rural , Gestão da Qualidade Total , Estados Unidos , United States Department of Veterans AffairsRESUMO
Background: To treat patients with methicillin-susceptible Staphylococcus aureus (MSSA) infections, ß-lactams are recommended for definitive therapy; however, the comparative effectiveness of individual ß-lactams is unknown. This study compared definitive therapy with cefazolin vs nafcillin or oxacillin among patients with MSSA infections complicated by bacteremia. Methods: This retrospective study included patients admitted to 119 Veterans Affairs hospitals from 2003 to 2010. Patients were included if they had a blood culture positive for MSSA and received definitive therapy with cefazolin, nafcillin, or oxacillin. Cox proportional hazards regression and ordinal logistic regression were used to identify associations between antibiotic therapy and mortality or recurrence. A recurrent infection was defined as a MSSA blood culture between 45 and 365 days after the first MSSA blood culture. Results: Of 3167 patients, 1163 (37%) patients received definitive therapy with cefazolin. Patients who received cefazolin had a 37% reduction in 30-day mortality (hazard ratio [HR], 0.63; 95% confidence interval [CI], .51-.78) and a 23% reduction in 90-day mortality (HR, 0.77; 95% CI, .66-.90) compared with patients receiving nafcillin or oxacillin, after controlling for other factors. The odds of recurrence (odds ratio, 1.13; 95% CI, .94-1.36) were similar among patients who received cefazolin compared with patients who received nafcillin or oxacillin, after controlling for other factors. Conclusions: In this large, multicenter study, patients who received cefazolin had a lower risk of mortality and similar odds of recurrent infections compared with nafcillin or oxacillin for MSSA infections complicated by bacteremia. Physicians might consider definitive therapy with cefazolin for these infections.
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Antibacterianos/uso terapêutico , Bacteriemia , Infecções Estafilocócicas , Staphylococcus aureus , beta-Lactamas/uso terapêutico , Idoso , Bacteriemia/complicações , Bacteriemia/tratamento farmacológico , Bacteriemia/epidemiologia , Bacteriemia/microbiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Infecções Estafilocócicas/complicações , Infecções Estafilocócicas/tratamento farmacológico , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/microbiologia , Resultado do TratamentoRESUMO
OBJECTIVES: To determine if military leader behaviors are associated with active component and Reserve-National Guard servicewomen's risk of sexual assault in the military (SAIM) for nondeployed locations. METHODS: A community sample of 1337 Operation Enduring Freedom and Operation Iraqi Freedom-era Army and Air Force servicewomen completed telephone interviews (March 2010-December 2011) querying sociodemographic and military characteristics, sexual assault histories, and leader behaviors. We created 2 factor scores (commissioned and noncommissioned) to summarize behaviors by officer rank. RESULTS: A total of 177 servicewomen (13%) experienced SAIM in nondeployed locations. Negative leader behaviors were associated with increased assault risk, at least doubling servicewomen's odds of SAIM (e.g., noncommissioned officers allowed others in unit to make sexually demeaning comments; odds ratio = 2.7; 95% confidence interval = 1.8, 4.1). Leader behavior frequencies were similar, regardless of service type. Negative leadership behavior risk factors remained significantly associated with SAIM risk even after adjustment for competing risk. Noncommissioned and commissioned officer factor scores were highly correlated (r = 0.849). CONCLUSIONS: The association between leader behaviors and SAIM indicates that US military leaders have a critical role in influencing servicewomen's risk of and safety from SAIM.
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Vítimas de Crime/psicologia , Vítimas de Crime/estatística & dados numéricos , Liderança , Militares/psicologia , Militares/estatística & dados numéricos , Delitos Sexuais/psicologia , Delitos Sexuais/estatística & dados numéricos , Adulto , Campanha Afegã de 2001- , Feminino , Humanos , Entrevistas como Assunto , Guerra do Iraque 2003-2011 , Fatores de Risco , Estados Unidos/epidemiologia , Saúde da MulherRESUMO
BACKGROUND: The Veterans Health Administration (VHA) introduced the Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in March 2007. Although the initiative has been perceived as a vertical intervention focusing on MRSA, it also expanded infection prevention and control programs and resources. We aimed to assess the horizontal effect of the initiative on hospital-onset (HO) gram-negative rod (GNR) bacteremia. METHODS: This retrospective cohort included all patients who had HO bacteremia due to Escherichia coli, Klebsiella species, or Pseudomonas aeruginosa at 130 VHA facilities from January 2003 to December 2013. The effects were assessed using segmented linear regression with autoregressive error models, incorporating autocorrelation, immediate effect, and time before and after the initiative. Community-acquired (CA) bacteremia with same species was also analyzed as nonequivalent dependent controls. RESULTS: A total of 11 196 patients experienced HO-GNR bacteremia during the study period. There was a significant change of slope in HO-GNR bacteremia incidence rates from before the initiative (+0.3%/month) to after (-0.4%/month) (P < .01), while CA GNR incidence rates did not significantly change (P = .08). Cumulative effect of the intervention on HO-GNR bacteremia incidence rates at the end of the study period was estimated to be -43.2% (95% confidence interval, -51.6% to -32.4%). Similar effects were observed in subgroup analyses of each species and antimicrobial susceptibility profile. CONCLUSIONS: Within 130 VHA facilities, there was a sustained decline in HO-GNR bacteremia incidence rates after the implementation of the MRSA Prevention Initiative. As these organisms were not specifically targeted, it is likely that horizontal components of the initiative contributed to this decline.
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Bacteriemia , Infecção Hospitalar , Infecções por Bactérias Gram-Negativas , Veteranos/estatística & dados numéricos , Idoso , Bacteriemia/epidemiologia , Bacteriemia/prevenção & controle , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/prevenção & controle , Feminino , Infecções por Bactérias Gram-Negativas/epidemiologia , Infecções por Bactérias Gram-Negativas/prevenção & controle , Humanos , Controle de Infecções/métodos , Controle de Infecções/estatística & dados numéricos , Masculino , Staphylococcus aureus Resistente à Meticilina , Pessoa de Meia-Idade , Estudos Retrospectivos , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/prevenção & controle , Estados Unidos , United States Department of Veterans AffairsRESUMO
BACKGROUND: To determine the extent to which 30- and 90-day hospital readmission and mortality rates differ as a function of whether a chest pain patient is placed in observation status or admitted to the hospital for a short-stay (<48 h). METHODS: Using 114,043 observation stays and short-stay admissions for chest pain at Veterans Health Administration hospitals between 2005 and 2013, we estimated event-level logistic regression models using a generalized estimating equation framework to predict 30 and 90-day readmissions and mortality as a function of whether the patient had an observation stay or a short-stay admission. We also adjusted for a variety of patient characteristics and unobserved time-invariant hospital factors. RESULTS: Relative to the short-stay inpatient group, veterans with chest pain who were placed in observation status were significantly more likely to be female (7.0 % vs. 6.4 %, White (76.6 % vs. 71.0 %, and from a rural area (28.3 % vs. 20.2 %). There were no other meaningful differences between the groups. Veterans with chest pain who were placed in observation status had 25 % lower odds of dying within 30 days (95 % confidence interval [CI]: 3 % - 43 %) and 12 % lower odds of a 30-day readmission (95 % CI: 6 % - 17 %) compared to those admitted as short-stay inpatients. Neither 90-day outcome was significantly associated with placement in observation status. Patient demographics were also important predictors of mortality and readmissions. CONCLUSIONS: There are clinically observable differences in outcomes between patients admitted to observation and those admitted as short-stay inpatients. We find no evidence that the increase in observation stays reflects a lack of proper care for patients placed in observation status.
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OBJECTIVE: Test an obesity intervention for families with low incomes. METHODS: A total of 208 families were included (a parent with a body mass index [BMI] ≥ 30 and a child aged 6-12 years). A 12-month randomized controlled trial combining family health coaching (motivational interviewing) and connection to community resources. Comparison group: referrals for basic needs, written educational materials. Questionnaires, accelerometry, and anthropometrics. Intention-to-treat analysis of change in outcomes. Two-sided t test with multiple imputation. RESULTS: Parents were 95% female, 31% Black, and 27% Hispanic. Children had a mean BMI-Z score of 1.15. Primary outcomes did not differ between groups at 12 months. Both groups significantly (P < 0.05) improved on the Family Nutrition and Physical Activity Scale for behaviors related to childhood obesity (mean ± SE: comparison, 2.8 ± 1.0; intervention, 2.2 ± 0.9), increased child sedentary activity (comparison, 32.5 ± 12.1; intervention, 39.9 ± 12.4 min/d), and decreased child moderate-vigorous physical activity (comparison, -9.6 ± 3.3; intervention -7.0 ± 3.0 min/d). Parents had no change in BMI. CONCLUSIONS AND IMPLICATIONS: We successfully embedded screening and referral to address social needs within an obesity intervention. The coaching intervention did not provide additional benefits. Future research could explore ways to make these interventions more accessible, valuable, and effective for families.
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Primary care providers (PCPs), including physicians and advanced practice providers, are the front line of medical care. Patient access must balance PCP availability and patient needs. This work develops a new PCP staffing metric using panel size and full-time equivalent data to determine whether a clinic is adequately staffed and describes variation by clinic rurality. Data were from the Veterans Health Administration, 2017-2021. Results describe the gap staffing metric, provide summary graphics, and compare the gap staffing between rural and urban clinics. This novel gap staffing metric can inform strategic clinic staffing in health care systems.
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População Rural , Saúde dos Veteranos , Humanos , Estados Unidos , Recursos Humanos , Atenção à Saúde , Atenção Primária à Saúde , United States Department of Veterans AffairsRESUMO
BACKGROUND: The expansion of telemedicine (e.g., telephone or video) in the Veterans Health Administration (VA) raises concerns for health care disparities between rural and urban veterans. Factors impeding telemedicine use (e.g., broadband, digital literacy, age) disproportionally affect rural veterans. PURPOSE: To examine veteran-reported broadband access, internet use, familiarity with, and preferences for telemedicine stratified by residential rurality. METHODS: Three hundred fifty veterans with a VA primary care visit in March 2022 completed a 30-min computer-assisted telephone interview. The sampling design stratified veterans by residential rurality (i.e., rural or urban) and how primary care was delivered (i.e., in-person or by video). Counts and weighted percentages are reported. FINDINGS: After accounting for survey weights, 96.2% of respondents had in-home internet access and 89.5% reported functional connection speeds. However, rural- compared to urban-residing veterans were less likely to experience a telemedicine visit in the past year (74.1% vs. 85.2%; p = 0.02). When comparing telemedicine to in-person visits, rural versus urban-residing veterans rated them not as good (45.3% vs. 36.8%), just as good (51.1% vs. 53.1%), or better (3.5% vs. 10.0%) (p = 0.05). To make telemedicine visits easier, veterans, regardless of where they lived, recommended technology training (46.4%), help accessing the internet (26.1%), or provision of an internet-enabled device (25.9%). CONCLUSIONS: Though rural-residing veterans were less likely to experience a telemedicine visit, the same actionable facilitators to improve telemedicine access were reported regardless of residential rurality. Importantly, technology training was most often recommended. Policy makers, patient advocates, and other stakeholders should consider novel initiatives to provide training resources.
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Importance: While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions may need to be modified to address facility-level factors. Objective: To assess the association between implementation of an SSI prevention bundle allowing for facility discretion regarding specific component interventions and S aureus deep incisional or organ space SSI rates. Design, Setting, and Participants: This quality improvement study was conducted among all patients who underwent coronary artery bypass grafting, cardiac valve replacement, or total joint arthroplasty (TJA) at 11 Veterans Administration hospitals. Implementation of the bundle was on a rolling basis with the earliest implementation occurring in April 2012 and the latest implementation occurring in July 2017. Data were collected from January 2007 to March 2018 and analyzed from October 2020 to June 2023. Interventions: Nasal screening for S aureus; nasal decolonization of S aureus carriers; chlorhexidine bathing; and appropriate perioperative antibiotic prophylaxis according to S aureus carrier status. Facility discretion regarding how to implement the bundle components was allowed. Main Outcomes and Measures: The primary outcome was deep incisional or organ space SSI caused by S aureus. Multivariable logistic regression with generalized estimating equation (GEE) and interrupted time-series (ITS) models were used to compare SSI rates between preintervention and postintervention periods. Results: Among 6696 cardiac surgical procedures and 16â¯309 TJAs, 95 S aureus deep incisional or organ space SSIs were detected (25 after cardiac operations and 70 after TJAs). While the GEE model suggested a significant association between the intervention and decreased SSI rates after TJAs (adjusted odds ratio, 0.55; 95% CI, 0.31-0.98), there was not a significant association when an ITS model was used (adjusted incidence rate ratio, 0.88; 95% CI, 0.32-2.39). No significant associations after cardiac operations were found. Conclusions and Relevance: Although this quality improvement study suggests an association between implementation of an SSI prevention bundle and decreased S aureus deep incisional or organ space SSI rates after TJAs, it was underpowered to see a significant difference when accounting for changes over time.
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Infecções Estafilocócicas , Veteranos , Humanos , Staphylococcus aureus , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Infecção da Ferida Cirúrgica/etiologia , Antibacterianos/uso terapêutico , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/prevenção & controleRESUMO
Low-income, racially diverse families with one parent with obesity are at high risk for child obesity. Effective approaches to promote healthy behaviors and prevent additional weight gain in family members are needed. Motivational interviewing (MI) may assist families to engage, identify motivations for change and establish goals. However, families with limited resources face other barriers to goal achievement that may be addressed through connection with community organizations. This paper describes a unique protocol combining MI and community connection. This randomized controlled trial includes low-income families with one parent with obesity and at least one child aged 6 to 12â¯years. Families in the intervention group receive an innovative, 12-month intervention combining health coaching using MI to promote lifestyle behavior change goals and community resource mobilization to assist with basic needs and resources to aid goals. The study protocol is modeled on community-based participatory research principles. Data is collected at baseline, 6â¯months, 12â¯months, and 18â¯months include questionnaires, body measurements, and accelerometer data. For adults, primary outcomes are Body Mass Index (BMI), minutes of moderate to vigorous physical activity (MVPA), and hours of sedentary time per day. For children, primary outcomes are sedentary time, MVPA, and the Family Nutrition and Physical Activity Score. From this hard-to-reach population, 236 diverse families were recruited. If the study is deemed effective, it has the potential to demonstrate that the combination of MI, resource mobilization, and utilization of existing community organizations is a sustainable model to assist families at risk for obesity.
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Entrevista Motivacional , Obesidade Infantil , Adulto , Índice de Massa Corporal , Criança , Recursos Comunitários , Exercício Físico , Humanos , Entrevista Motivacional/métodos , Obesidade Infantil/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Importance: Although telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access. Objective: To identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality. Design, Setting, and Participants: This cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021). Exposures: Federal Communications Commission-reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 <100 MB/s; upload speed, ≥5 and <100 MB/s), or optimal (download and upload speeds, ≥100 MB/s) based on data reported at the census block by internet providers and was spatially merged to the latitude and longitude of each veteran's home address using US Census Bureau shapefiles. Main Outcomes and Measures: All visits were coded as in-person or virtual (ie, telephone or video) and counted for each patient, quarterly by visit modality. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient's broadband availability category and the quarterly primary care visit count by visit type, adjusted for covariates. Results: In primary care, 6â¯995â¯545 veterans (91.8% men; mean [SD] age, 63.9 [17.2] years; 71.9% White; and 63.0% residing in an urban area) were seen. Adjusted regression analyses estimated the change after the onset of the pandemic vs before the pandemic in patients' quarterly primary care visit count; patients living in census blocks with optimal vs inadequate broadband had increased video visit use (incidence rate ratio [IRR], 1.33; 95% CI, 1.21-1.46; P < .001) and decreased in-person visits (IRR, 0.84; 95% CI, 0.84-0.84; P < .001). The increase in the rate of video visits before vs after the onset of the pandemic was greatest among patients in the lowest Area Deprivation Index category (indicating least social disadvantage) with availability of optimal vs inadequate broadband (IRR, 1.73; 95% CI, 1.42-2.09). Conclusions and Relevance: This cohort study found that patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the COVID-19 pandemic, suggesting that broadband availability was associated with video-based telemedicine use. Future work should assess the association of telemedicine access with clinical outcomes.
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COVID-19 , COVID-19/epidemiologia , Estudos de Coortes , Feminino , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Pandemias , Atenção Primária à Saúde , Saúde dos VeteranosRESUMO
PURPOSE: Visual assessment of computed tomography (CT) of the lung is routinely employed in the diagnosis of emphysema. Quantitative CT (QCT) can complement visual CT but must be well validated. QCT emphysema is defined as ≥5% of lung volume occupied by low attenuation areas ≤-950 Hounsfield units (LAA-950). Discordant visual and QCT assessments are not uncommon. We examined the association between visual and quantitative chest CT evaluation within a large cohort of subjects to identify variables that may explain discordant visual and QCT findings. MATERIALS AND METHODS: Volumetric inspiratory CT scans of 1221 subjects enrolled in phase 1 of the COPDGene study conducted at the University of Iowa were reviewed. Participants included never smokers, smokers with normal spirometry, preserved ratio impaired spirometry, and Global Initiative for Obstructive Lung Disease (GOLD) stages I-IV. CT scans were quantitatively scored and visually interpreted by both the COPDGene Imaging Center and the University of Iowa radiologists. Individual-level visual assessments were compared with QCT measurements. Agreement between the two sets of radiologists was calculated using kappa statistic. We assessed variables associated with discordant results using regression methods. RESULTS: There was a fair agreement for the presence or absence of emphysema between our center's radiologists and QCT (61% concordance, kappa 0.22 [0.17-0.28]). Similar comparisons showed a slight agreement between the COPDGene Imaging Center and QCT (56% concordance, kappa 0.16 [0.11-0.21]), and a moderate agreement between both sets of visual assessments (80% concordance, kappa 0.60 [0.54-0.65]). Current smoking and female gender were significantly associated with QCT-negative but visually detectable emphysema. CONCLUSION: The slight-to-fair agreement between visual and quantitative CT assessment of emphysema highlights the need to utilize both modalities for a comprehensive radiologic evaluation. Discordant results may be attributable to one or more factors that warrant further exploration in larger studies. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT000608764.
Assuntos
Enfisema , Doença Pulmonar Obstrutiva Crônica , Enfisema Pulmonar , Feminino , Humanos , Pulmão/diagnóstico por imagem , Doença Pulmonar Obstrutiva Crônica/diagnóstico por imagem , Enfisema Pulmonar/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Non-invasive mechanical ventilation (NIV) use in patients admitted with acute respiratory failure due to COPD exacerbations (AECOPDs) varies significantly between hospitals. However, previous literature did not account for patients' illness severity. Our objective was to examine the variation in risk-standardized NIV use after adjusting for illness severity. METHODS: We retrospectively analyzed AECOPD hospitalizations from 2011 to 2017 at 106 acute-care Veterans Health Administration (VA) hospitals in the USA. We stratified hospitals based on the percentage of NIV use among patients who received ventilation support within the first 24 hours of admission into quartiles, and compared patient characteristics. We calculated the risk-standardized NIV % using hierarchical models adjusting for comorbidities and severity of illness. We then stratified the hospitals by risk-standardized NIV % into quartiles and compared hospital characteristics between quartiles. We also compared the risk-standardized NIV % between rural and urban hospitals. RESULTS: In 42,048 admissions for AECOPD over 6 years, the median risk-standardized initial NIV % was 57.3% (interquartile interval [IQI]=41.9-64.4%). Hospitals in the highest risk-standardized NIV % quartiles cared for more rural patients, used invasive ventilators less frequently, and had longer length of hospital stay, but had no difference in mortality relative to the hospitals in the lowest quartiles. The risk-standardized NIV % was 65.3% (IQI=34.2-84.2%) in rural and 55.1% (IQI=10.8-86.6%) in urban hospitals (p=0.047), but hospital mortality did not differ between the two groups. CONCLUSION: NIV use varied significantly across hospitals, with rural hospitals having higher risk-standardized NIV % rates than urban hospitals. Further research should investigate the exact mechanism of variation in NIV use between rural and urban hospitals.
Assuntos
Ventilação não Invasiva , Doença Pulmonar Obstrutiva Crônica , Insuficiência Respiratória , Mortalidade Hospitalar , Hospitais , Humanos , Ventilação não Invasiva/efeitos adversos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Doença Pulmonar Obstrutiva Crônica/terapia , Respiração Artificial/efeitos adversos , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/terapia , Estudos RetrospectivosRESUMO
BACKGROUND: We explored the relationship between rural residency and in-hospital mortality in patients hospitalized with COPD exacerbations. METHODS: We retrospectively analyzed COPD hospitalizations from 2011 to 2017 at 124 acute care Veterans Health Administration (VHA) hospitals in the US. Patient residence was classified using Rural Urban Commuting Area codes as urban, rural, or isolated rural. We stratified patient hospitalizations into quartiles by travel time from patient residence to the nearest VHA primary care provider clinic and hospital. Multivariate analyses utilized generalized estimating equations with a logit link accounting for repeated hospitalizations among patients and adjusting for patient- and hospital-level characteristics. RESULTS: Of 64,914 COPD hospitalizations analyzed, 43,549 (67.1%) were for urban, 18,673 (28.8%) for rural, and 2,692 (4.1%) for isolated rural veterans. In-hospital mortality was 4.9% in urban, 5.5% in rural, and 5.2% in isolated rural veterans (P=0.008). Thirty-day mortality was 8.3% in urban, 9.9% in rural, and 9.2% in isolated rural veterans (P<0.001). Travel time to a primary care provider and VHA hospital was not associated with in-hospital mortality among isolated rural and rural veterans. In the multivariable analysis, compared to urban veterans, isolated rural patients did not have increased mortality. Rural residence was not associated with in-hospital (OR=0.87; 95% CI=0.67-1.12, P=0.28) but was associated with increased 30-day mortality (OR=1.13; 95% CI=1.04-1.22, P=0.002). Transfer from another acute care hospital (OR=14.97; 95% CI=9.80-17.16, P<0.001) or an unknown/other facility (OR=33.05; 95% CI=22.66-48.21, P<0.001) were the strongest predictors of increased in-hospital mortality compared to patients coming from the outpatient sector. Transfer from another acute care facility was also a risk factor for 30-day mortality. CONCLUSION: Potential gaps in post-discharge care of rural veterans may be responsible for the rural-urban disparities. Further research should investigate the exact mechanism that inter-hospital transfers affect mortality.
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Doença Pulmonar Obstrutiva Crônica , Veteranos , Assistência ao Convalescente , Hospitais , Humanos , Alta do Paciente , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/terapia , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Veterans AffairsRESUMO
PURPOSE: To create a simplified critical illness severity scoring system with high prediction accuracy for 30-day mortality using only commonly available variables. MATERIALS AND METHODS: This is a retrospective cohort study of ICU admissions 2010-2015 in 306 ICUs in 117 Veterans Affairs (VA) hospitals. We randomly divided our cohort into a training dataset (75%) and a validation dataset (25%). We created a critical illness severity scoring system (CISSS) using age, comorbidities, heart rate, mean arterial blood pressure, temperature, respiratory rate, hematocrit, white blood cell count, creatinine, sodium, glucose, albumin, bilirubin, bicarbonate, use of invasive mechanical ventilation, and whether the admission was surgical or not. We validated the performance of CISSS to predict 30-day mortality internally. RESULTS: After excluding 31,743 re-admissions, we divided our sample (n = 534,001) into a training (n = 400,613) and a validation dataset (n = 133,388). In the training dataset, the area under the curve (AUC) of CISSS was 0.847(95%CI = 0.845-0.850). In the validation dataset, the AUC was 0.848 (95%CI = 0.844-0.852), the standardized mortality ratio (SMR) was 1.00 (95%CI = 0.98-1.02), and Brier's score for 30-day mortality was 0.058 (95%CI = 0.057-0.059). CISSS calibration was acceptable. CONCLUSIONS: CISSS has very good performance and requires only commonly used variables that can be easily extracted by electronic health records.