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1.  Risk of Heart Failure With Human Immunodeficiency Virus in the Absence of Prior Diagnosis of Coronary Heart Disease 
Archives of internal medicine  2011;171(8):737-743.
Background
Whether human immunodeficiency virus (HIV) infection is a risk factor for heart failure (HF) is not clear. The presence of coronary heart disease and alcohol consumption in this population may confound this association.
Methods
To determine whether HIV infection is a risk factor for incident HF, we conducted a population-based, retrospective cohort study of HIV-infected and HIV-uninfected veterans enrolled in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC) and the 1999 Large Health Study of Veteran Enrollees (LHS) from January 1, 2000, to July 31, 2007.
Results
There were 8486 participants (28.2% HIV-infected) enrolled in the VACS-VC who also participated in the 1999 LHS. During the median 7.3 years of follow-up, 286 incident HF events occurred. Age- and race/ethnicity–adjusted HF rates among HIV-infected and HIV-uninfected veterans were 7.12 (95% confidence interval [CI],6.90-7.34) and 4.82 (95% CI, 4.72-4.91) per 1000 person-years, respectively. Compared with HIV-uninfected veterans, those who were HIV infected had an increased risk ofHF (adjusted hazard ratio [HR], 1.81; 95% CI, 1.39-2.36). This association persisted among veterans who did not have a coronary heart disease event or a diagnosis related to alcohol abuse or dependence before the incident HF event (adjusted HR, 1.96; 95% CI, 1.29-2.98). Compared with HIV-uninfected veterans, those who were HIV infected with a baseline Human immunodeficiency virus 1 (HIV-1) RNA level of 500 or more copies/mL had a higher risk of HF (adjusted HR, 2.28; 95% CI, 1.57-3.32), while those with baseline and a recent HIV-1 RNA level less than 500 copies/mL did not (adjusted HR, 1.10; 95% CI, 0.64-1.89; P< .001 for comparison between high and low HIV-1 RNA groups).
Conclusions
Our data suggest that HIV infection is a risk factor for HF. Ongoing viral replication is associated with a higher risk of developing HF.
doi:10.1001/archinternmed.2011.151
PMCID: PMC3687533  PMID: 21518940
2.  Choices in the use of ICD-9 codes to identify stroke risk factors can affect the apparent population-level risk factor prevalence and distribution of CHADS2 scores 
While developed for managing individuals with atrial fibrillation, risk stratification schemes for stroke, such as CHADS2, may be useful in population-based studies, including those assessing process of care. We investigated how certain decisions in identifying diagnoses from administrative data affect the apparent prevalence of CHADS2-associated diagnoses and distribution of scores. Two sets of ICD-9 codes (more restrictive/ more inclusive) were defined for each CHADS2-associated diagnosis. For stroke/transient ischemic attack (TIA), the more restrictive set was applied to only inpatient data. We varied the number of years (1-3) in searching for relevant codes, and, except for stroke/TIA, the number of instances (1 vs. 2) that diagnoses were required to appear. The impact of choices on apparent disease prevalence varied by type of choice and condition, but was often substantial. Choices resulting in substantial changes in prevalence also tended to be associated with more substantial effects on the distribution of CHADS2 scores.
PMCID: PMC3427978  PMID: 22937488
Stroke; atrial fibrillation; risk stratification; CHADS2; ICD-9-CM codes
3.  The Risk of Incident Coronary Heart Disease Among Veterans with and without HIV and Hepatitis C 
Background
Whether hepatitis C (HCV) confers additional coronary heart disease (CHD) risk among Human Immunodeficiency Virus (HIV) infected individuals is unclear. Without appropriate adjustment for antiretroviral therapy, CD4 count, and HIV-1 RNA, and substantially different mortality rates among those with and without HIV and HCV infection, the association between HIV, HCV, and CHD may be obscured.
Methods and Results
We analyzed data on 8579 participants (28% HIV+, 9% HIV+HCV+) from the Veterans Aging Cohort Study Virtual Cohort who participated in the 1999 Large Health Study of Veteran Enrollees. We analyzed data collected on HIV and HCV status, risk factors for and the incidence of CHD, and mortality from 1/2000–7/2007. We compared models to assess CHD risk when death was treated as a censoring event and as a competing risk. During the median 7.3 years of follow-up, there were 194 CHD events and 1186 deaths. Compared with HIV−HCV− Veterans, HIV+ HCV+ Veterans had a significantly higher risk of CHD regardless of whether death was adjusted for as a censoring event (adjusted hazard ratio (HR)=2.03, 95% CI=1.28–3.21) or a competing risk (adjusted HR=2.45, 95% CI=1.83–3.27 respectively). Compared with HIV+HCV− Veterans, HIV+ HCV+ Veterans also had a significantly higher adjusted risk of CHD regardless of whether death was treated as a censored event (adjusted HR=1.93, 95% CI=1.02–3.62) or a competing risk (adjusted HR =1.46, 95% CI=1.03–2.07).
Conclusions
HIV+HCV+ Veterans have an increased risk of CHD compared to HIV+HCV−, and HIV−HCV− Veterans.
doi:10.1161/CIRCOUTCOMES.110.957415
PMCID: PMC3159506  PMID: 21712519
viruses; coronary disease; mortality; multi morbidity
4.  Association of Psychiatric Illness and Obesity, Physical Inactivity and Smoking among a National Sample of Veterans 
Psychosomatics  2011;52(3):230-236.
Background
Increased cardiovascular morbidity and mortality has been reported across a number of chronic psychiatric illnesses. Interventions to decrease cardiovascular risk have focused on single health behaviors.
Objective
To evaluate the co-occurrence of multiple poor health behaviors which increase cardiovascular risk among veterans with psychiatric diagnoses.
Methods
Using data from the 1999 Large Health Survey of Veterans (n=501,161), multivariate logistic regression was used to evaluate the associations between current smoking, no regular exercise, and obesity with each of six Axis I diagnoses.
Results
There were statistically increased odds of co-occurrence of obesity, current tobacco use and no regular exercise among veterans with each of the psychiatric diagnoses, with the exception of drug use disorders (which was not significantly different from 1). The highest odds were among veterans with schizophrenia, PTSD, and bipolar disorder [OR (95% CI) of 1.37 (1.29, 1.45); 1.26 (1.20, 1.32); and 1.19 (1.11, 1.25), respectively]. The OR for depression was not significant after adjustment for medical co-morbidity.
Conclusions
Veterans with psychiatric illnesses, and particularly those with schizophrenia, PTSD, and bipolar disorder, are much more likely to have multiple poor health behaviors that increase their cardiovascular risk. Interventions to decrease cardiovascular risk among veterans with serious mental illness need to target multiple health behaviors.
doi:10.1016/j.psym.2010.12.009
PMCID: PMC3094543  PMID: 21565594
5.  Comparison of Health Outcomes for Male Seniors in the Veterans Health Administration and Medicare Advantage Plans 
Health Services Research  2010;45(2):376-396.
Objectives
To compare the Veterans Health Administration (VHA) with the Medicare Advantage (MA) plans with regard to health outcomes.
Data Sources
The Medicare Health Outcome Survey, the 1999 Large Health Survey of Veteran Enrollees, and the Ambulatory Care Survey of Healthcare Experiences of Patients (Fiscal Years 2002 and 2003).
Study Design
A retrospective study.
Extraction Methods
Men 65+ receiving care in MA (N=198,421) or in VHA (N=360,316). We compared the risk-adjusted probability of being alive with the same or better physical (PCS) and mental (MCS) health at 2-years follow-up. We computed hazard ratio (HR) for 2-year mortality.
Principal Findings
Veterans had a higher adjusted probability of being alive with the same or better PCS compared with MA participants (VHA 69.2 versus MA 63.6 percent, p<.001). VHA patients had a higher adjusted probability than MA patients of being alive with the same or better MCS (76.1 versus 69.6 percent, p<.001). The HRs for mortality in the MA were higher than in the VHA (HR, 1.26 [95 percent CI 1.23–1.29]).
Conclusions
Our findings indicate that the VHA has better patient outcomes than the private managed care plans in Medicare. The VHA's performance offers encouragement that the public sector can both finance and provide exemplary health care.
doi:10.1111/j.1475-6773.2009.01068.x
PMCID: PMC2838151  PMID: 20050934
Health outcomes; system comparison; quality of care
6.  Patient-Provider Language Concordance and Colorectal Cancer Screening 
ABSTRACT
Background and Objective
Patient-provider language barriers may play a role in health-care disparities, including obtaining colorectal cancer (CRC) screening. Professional interpreters and language-concordant providers may mitigate these disparities.
Design, Subjects, and Main Measures
We performed a retrospective cohort study of individuals age 50 years and older who were categorized as English-Concordant (spoke English at home, n = 21,594); Other Language-Concordant (did not speak English at home but someone at their provider’s office spoke their language, n = 1,463); or Other Language-Discordant (did not speak English at home and no one at their provider’s spoke their language, n = 240). Multivariate logistic regression assessed the association of language concordance with colorectal cancer screening.
Key Results
Compared to English speakers, non-English speakers had lower use of colorectal cancer screening (30.7% vs 50.8%; OR, 0.63; 95% CI, 0.51–0.76). Compared to the English-Concordant group, the Language-Discordant group had similar screening (adjusted OR, 0.84; 95% CI, 0.58–1.21), while the Language-Concordant group had lower screening (adjusted OR, 0.57; 95% CI, 0.46–0.71).
Conclusions
Rates of CRC screening are lower in individuals who do not speak English at home compared to those who do. However, the Language-Discordant cohort had similar rates to those with English concordance, while the Language-Concordant cohort had lower rates of CRC screening. This may be due to unmeasured differences among the cohorts in patient, provider, and health care system characteristics. These results suggest that providers should especially promote the importance of CRC screening to non-English speaking patients, but that language barriers do not fully account for CRC screening rate disparities in these populations.
doi:10.1007/s11606-010-1512-9
PMCID: PMC3019323  PMID: 20857340
language concordance; cancer screening; disparities
7.  The Association of Psychiatric Illness and All-Cause Mortality in the National Department of Veterans Affairs Health Care System 
Psychosomatic medicine  2010;72(8):817-822.
Objective
This study aims to assess the independent association of seven psychiatric illnesses with all-cause mortality in a representative national sample of veterans, after adjustment for demographic factors, psychiatric and medical co-morbidity, obesity, tobacco use and exercise frequency.
Methods
Analyses were conducted using data from the 1999 Large Health Survey of Veteran Enrollees (n = 559,985). Cox proportional hazards models were used to examine the relationship of seven psychiatric diagnoses with mortality. Date of all-cause mortality was determined from the Department of Veterans Affairs' Beneficiary Identification and Records Locator System. All-cause mortality rates were calculated as the total number of deaths in each group divided by the person-years of follow-up time in each group.
Results
27% of the subjects (n=131,396) died during the 9-year study period. Each of the psychiatric diagnoses was associated with significantly increased hazard ratio for all-cause mortality after adjusting for age, race and gender. Hazard ratios (95% CI) ranged from 1.02 (1.01, 1.04) for PTSD to 1.97 (1.89, 2.04) for alcohol use disorders. After adjustment for psychiatric and medical co-morbidity, obesity, current smoking and exercise frequency, alcohol and drug abuse and dependence and schizophrenia were statistically significantly associated with an increased risk of mortality.
Conclusions
In this study of a large representative national sample of veterans, schizophrenia and alcohol and drug use disorders were independently associated with an increased risk of all-cause mortality over a 9-year period.
doi:10.1097/PSY.0b013e3181eb33e9
PMCID: PMC2950891  PMID: 20639387
Mortality; Psychiatric Illness; Medical Co-morbidity; Veterans
8.  The quality of care for adults with epilepsy: an initial glimpse using the QUIET measure 
Background
We examined the quality of adult epilepsy care using the Quality Indicators in Epilepsy Treatment (QUIET) measure, and variations in quality based on the source of epilepsy care.
Methods
We identified 311 individuals with epilepsy diagnosis between 2004 and 2007 in a tertiary medical center in New England. We abstracted medical charts to identify the extent to which participants received quality indicator (QI) concordant care for individual QI's and the proportion of recommended care processes completed for different aspects of epilepsy care over a two year period. Finally, we compared the proportion of recommended care processes completed for those receiving care only in primary care, neurology clinics, or care shared between primary care and neurology providers.
Results
The mean proportion of concordant care by indicator was 55.6 (standard deviation = 31.5). Of the 1985 possible care processes, 877 (44.2%) were performed; care specific to women had the lowest concordance (37% vs. 42% [first seizure evaluation], 44% [initial epilepsy treatment], 45% [chronic care]). Individuals receiving shared care had more aspects of QI concordant care performed than did those receiving neurology care for initial treatment (53% vs. 43%; X2 = 9.0; p = 0.01) and chronic epilepsy care (55% vs. 42%; X2 = 30.2; p < 0.001).
Conclusions
Similar to most other chronic diseases, less than half of recommended care processes were performed. Further investigation is needed to understand whether a shared-care model enhances quality of care, and if so, how it leads to improvements in quality.
doi:10.1186/1472-6963-11-1
PMCID: PMC3024216  PMID: 21199575
9.  The Impact of Private Insurance Coverage on Veterans' Use of VA Care: Insurance and Selection Effects 
Health Services Research  2008;43(1 Pt 1):267-286.
Objective
To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage.
Data Sources
The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File.
Study Design
We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care).
Principal Findings
VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect.
Conclusions
Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services.
doi:10.1111/j.1475-6773.2007.00743.x
PMCID: PMC2323148  PMID: 18211529
VA health care system; insurance effect; selection effect; access/demand/utilization of services; instrumental variables
10.  Use of angiotensin receptor blockers and risk of dementia in a predominantly male population: prospective cohort analysis 
Objective To investigate whether angiotensin receptor blockers protect against Alzheimer’s disease and dementia or reduce the progression of both diseases.
Design Prospective cohort analysis.
Setting Administrative database of the US Veteran Affairs, 2002-6.
Population 819 491 predominantly male participants (98%) aged 65 or more with cardiovascular disease.
Main outcome measures Time to incident Alzheimer’s disease or dementia in three cohorts (angiotensin receptor blockers, lisinopril, and other cardiovascular drugs, the “cardiovascular comparator”) over a four year period (fiscal years 2003-6) using Cox proportional hazard models with adjustments for age, diabetes, stroke, and cardiovascular disease. Disease progression was the time to admission to a nursing home or death among participants with pre-existing Alzheimer’s disease or dementia.
Results Hazard rates for incident dementia in the angiotensin receptor blocker group were 0.76 (95% confidence interval 0.69 to 0.84) compared with the cardiovascular comparator and 0.81 (0.73 to 0.90) compared with the lisinopril group. Compared with the cardiovascular comparator, angiotensin receptor blockers in patients with pre-existing Alzheimer’s disease were associated with a significantly lower risk of admission to a nursing home (0.51, 0.36 to 0.72) and death (0.83, 0.71 to 0.97). Angiotensin receptor blockers exhibited a dose-response as well as additive effects in combination with angiotensin converting enzyme inhibitors. This combination compared with angiotensin converting enzyme inhibitors alone was associated with a reduced risk of incident dementia (0.54, 0.51 to 0.57) and admission to a nursing home (0.33, 0.22 to 0.49). Minor differences were shown in mean systolic and diastolic blood pressures between the groups. Similar results were observed for Alzheimer’s disease.
Conclusions Angiotensin receptor blockers are associated with a significant reduction in the incidence and progression of Alzheimer’s disease and dementia compared with angiotensin converting enzyme inhibitors or other cardiovascular drugs in a predominantly male population.
doi:10.1136/bmj.b5465
PMCID: PMC2806632  PMID: 20068258
11.  Utilization of Primary Care by Veterans with Psychiatric Illness in the National Department of Veterans Affairs Health Care System 
Journal of General Internal Medicine  2008;23(11):1835-1840.
BACKGROUND
Psychiatric illness is associated with increased medical morbidity and mortality. Studies of primary care utilization by patients with psychiatric disorders have been limited by nonrepresentative samples and confounding by medical co-morbidity.
OBJECTIVE
To determine whether patients with psychiatric disorders use primary care services differently than patients without these disorders, after controlling for medical co-morbidity.
DESIGN
Data from the 1999 Large Health Survey of Veterans (LHS) ( = 559,985) were linked to VA administrative data in order to identify veterans who received primary care. After adjusting for sociodemographic and clinical characteristics, medical co-morbidity, and facility characteristics, multivariate logistic regression was used to evaluate whether seven psychiatric diagnoses were associated with an increased or decreased likelihood of any primary care visit over 12 months.
RESULTS
Veterans with either schizophrenia, bipolar disorder or a drug use disorder were less likely to have had any primary care visit during the study period: [OR 0.61, 95% CI 0.59 to 0.63], [OR 0.63, 95% CI 0.60 to 0.67] and [OR 0.88, 95% CI 0.83 to 0.92], respectively, than veterans without these diagnoses, even after controlling for medical co-morbidity. Among patients with any primary care utilization, those with six of the seven psychiatric diagnoses had fewer visits in the study period.
CONCLUSIONS
Patients with schizophrenia, bipolar disorder or drug use disorders use less primary care than patients without these disorders. Interventions are needed to increase engagement in primary care by these vulnerable groups.
doi:10.1007/s11606-008-0786-7
PMCID: PMC2585662  PMID: 18795371
primary care; psychiatric illness; Axis I psychiatric disorders; Veterans Affairs Health Care System
12.  A Web-Based Nutrition Program Reduces Health Care Costs in Employees With Cardiac Risk Factors: Before and After Cost Analysis 
Background
Rising health insurance premiums represent a rapidly increasing burden on employer-sponsors of health insurance and their employees. Some employers have become proactive in managing health care costs by providing tools to encourage employees to directly manage their health and prevent disease. One example of such a tool is DASH for Health, an Internet-based nutrition and exercise behavior modification program. This program was offered as a free, opt-in benefit to US-based employees of the EMC Corporation.
Objective
The aim was to determine whether an employer-sponsored, Internet-based diet and exercise program has an effect on health care costs.
Methods
There were 15,237 total employees and spouses who were included in our analyses, of whom 1967 enrolled in the DASH for Health program (DASH participants). Using a retrospective, quasi-experimental design, study year health care costs among DASH participants and non-participants were compared, controlling for baseline year costs, risk, and demographic variables. The relationship between how often a subject visited the DASH website and health care costs also was examined. These relationships were examined among all study subjects and among a subgroup of 735 subjects with cardiovascular conditions (diabetes, hypertension, hyperlipidemia). Multiple linear regression analysis examined the relationship of program use to health care costs, comparing study year costs among DASH participants and non-participants and then examining the effects of increased website use on health care costs. Analyses were repeated among the cardiovascular condition subgroups.
Results
Overall, program use was not associated with changes in health care costs. However, among the cardiovascular risk study subjects, health care costs were US$827 lower, on average, during the study year (P = .05; t 729 = 1.95). Among 1028 program users, increased website use was significantly associated with lower health care costs among those who visited the website at least nine times during the study year (US$14 decrease per visit; P = .04; t 1022 = 2.05), with annual savings highest among 80 program users with targeted conditions (US$55 decrease per visit; P < .001; t 74 = 2.71).
Conclusions
An employer-sponsored, Internet-based diet and exercise program shows promise as a low-cost benefit that contributes to lower health care costs among persons at higher risk for above-average health care costs and utilization.
doi:10.2196/jmir.1263
PMCID: PMC2802558  PMID: 19861297
Employer health costs; disease management; health promotion; wellness programs; costs and cost analysis
13.  Measurement of treatment adherence with antipsychotic agents in patients with schizophrenia 
The importance of medication adherence in sustaining control of schizophrenic symptoms has generated a great deal of interest in comparing levels of treatment adherence with different antipsychotic agents. However, the bulk of the research has yielded results that are often inconsistent. In this prospective, observational study, we assessed the measurement properties of 3 commonly used, pharmacy-based measures of treatment adherence with antipsychotic agents in schizophrenia using data from the Veterans Health Administration during 2000 to 2005. Patients were selected if they were on antipsychotics and diagnosed with schizophrenia (N = 18,425). A gap of ≥30 days (with no filled index medication) was used to define discontinuation of treatment as well as medication “episodes,” or the number of times a patient returned to the same index agent after discontinuation of treatment within a 1-year period. The study found that the 3 existing measures differed in their approaches in measuring treatment adherence, suggesting that studies using these different measures would generate different levels of treatment adherence across antipsychotic agents. Considering the measurement problems associated with each existing approach, we offered a new, medication episode-specific approach, which would provide a fairer comparison of the levels of treatment adherence across different antipsychotic agents.
PMCID: PMC2762365  PMID: 19851516
medication adherence; antipsychotic agents; schizophrenia
14.  PREDICTORS OF CARDIOPULMONARY HOSPITALIZATION IN CHRONIC SPINAL CORD INJURY 
Objective
We investigated longitudinal risk factors of hospitalization for circulatory and pulmonary diseases among veterans with chronic spinal cord injury (SCI). Circulatory and respiratory system illnesses are leading causes of death in chronic SCI patients, yet risk factors for related hospitalizations have not been characterized.
Design
Prospective cohort study.
Setting
Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts.
Participants / Data Source(s)
309 veterans ≥ 1 year post-SCI from the VA-Boston Chronic SCI cohort who completed a health questionnaire and underwent spirometry at study entry. Baseline data was linked to 1996–2003 hospitalization records from the VA National Patient Care Database.
Interventions
Not applicable.
Main Outcome Measure(s)
Cardiopulmonary hospital admissions, the predictors of which were assessed by Multivariate Cox regression.
Results
Of 1,478 admissions observed, 143 were due to cardiopulmonary (77 circulatory and 66 respiratory) illnesses. Independent predictors were greater age (3% increase /year), hypertension, and if in the lowest BMI quintile (<22.4 kg/m2). A greater %-predicted FEV1 was associated with reduced risk. SCI level and completeness of injury was not statistically significant after adjusting for these risk factors.
Conclusion
Cardiopulmonary hospitalization risk in persons with chronic SCI is related to greater age and medical factors that, if recognized, may result in strategies for reducing future hospitalizations.
doi:10.1016/j.apmr.2008.07.026
PMCID: PMC2648127  PMID: 19236973
Spinal Cord Injury; Hospitalization; Circulatory; Respiratory; Proportional Hazards Regression
15.  Factors Associated with Health-Related Quality of Life in Chronic Spinal Cord Injury 
Objective
An important goal of rehabilitation and treatment after spinal cord injury (SCI) is to improve function and enhance health-related quality of life (HRQoL). However, previous assessments are limited by use of HRQoL instruments not specific to SCI. Although respiratory dysfunction is common in SCI, it has not been possible to assess the association of comorbid medical conditions, including respiratory symptoms and pulmonary function, to HRQoL. Therefore, we assessed whether these factors were associated with HRQoL in SCI using an SCI-specific HRQoL questionnaire.
Design
In our cross-sectional study, 356 participants ≥ 1 yr post-SCI completed a 23-item SCI-specific HRQoL questionnaire and a detailed health questionnaire, and underwent pulmonary function testing and a neurological exam at VA Boston between 1998 and June 2003.
Results
In a multivariate regression model, age, employment status, motor level and completeness of injury, and ambulatory mode (use of hand-propelled or motorized wheelchair, use of crutches or canes, or walking independently) were independently associated with HRQoL. After adjusting for these factors, chronic cough, chronic phlegm, persistent wheeze, dyspnea with activities of daily living, and lower forced expiratory volume in 1 sec and forced vital capacity were each associated with a lower HRQoL.
Conclusions
These results provide evidence for the clinical validity of our SCI-specific HRQoL instrument. We also identify potentially modifiable factors that, if addressed, may lead to HRQoL improvement in SCI.
doi:10.1097/PHM.0b013e31804a7d00
PMCID: PMC2292343  PMID: 17449983
Quality Of Life; Spinal Cord Injuries; Pulmonary Function Tests; Comorbidity
16.  The Challenges of Multimorbidity from the Patient Perspective 
Journal of General Internal Medicine  2007;22(Suppl 3):419-424.
Background
Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective.
Objective
The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses.
Design
This research is designed as a cross-sectional survey.
Participants
Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients.
Measurements
Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers.
Results
Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were “definitely” willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were “definitely” willing to see 6 of 11 non-physician healthcare providers.
Conclusions
Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients.
doi:10.1007/s11606-007-0308-z
PMCID: PMC2150619  PMID: 18026811
multimorbidity; multiple chronic illness; self-management skills
17.  The Challenges of Multimorbidity from the Patient Perspective 
Journal of General Internal Medicine  2007;22(Suppl 3):419-424.
Background
Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective.
Objective
The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses.
Design
This research is designed as a cross-sectional survey.
Participants
Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients.
Measurements
Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers.
Results
Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were “definitely” willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were “definitely” willing to see 6 of 11 non-physician healthcare providers.
Conclusions
Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients.
doi:10.1007/s11606-007-0308-z
PMCID: PMC2150619  PMID: 18026811
multimorbidity; multiple chronic illness; self-management skills
18.  An alternative approach to measuring treatment persistence with antipsychotic agents among patients with schizophrenia in the Veterans Health Administration 
Prior studies have demonstrated the importance of treatment persistence with anti-psychotic agents in sustaining control of schizophrenic symptoms. However, the conventional approach in measuring treatment persistence tended to use only the first prescription episode even though some patients received multiple prescriptions (or multiple treatment episodes) of the same medication within one year following the initiation of the index drug. In this study, we used data from the Veterans Health Administration in the United States to assess the extent to which patients received multiple prescriptions. The study found that about a quarter of the patients had two or more treatment episodes and that levels of treatment persistence tended to vary across treatment episodes. Based on these results, we offered an alternative approach in which we calculated treatment persistence with typical and atypical antipsychotic agents separately for patients with one, two, or three treatment episodes. Considering that patients with different number of treatment episodes might differ in disease profiles, this treatment episode-specific approach offered a fair comparison of the levels of treatment persistence across patients with different number of treatment episodes. Future research needs to extend the analyses beyond two antipsychotic classes to individual antipsychotic agents. A more comprehensive assessment using appropriate analytic methods should help physicians make prescription choices that will ultimately improve the care of patients with schizophrenia.
PMCID: PMC2654631  PMID: 19300560
treatment persistence (or discontinuation); treatment episode; antipsychotic agents; schizophrenia
19.  Simvastatin is associated with a reduced incidence of dementia and Parkinson's disease 
BMC Medicine  2007;5:20.
Background
Statins are a class of medications that reduce cholesterol by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A reductase. Whether statins can benefit patients with dementia remains unclear because of conflicting results. We hypothesized that some of the confusion in the literature might arise from differences in efficacy of different statins. We used a large database to compare the action of several different statins to investigate whether some statins might be differentially associated with a reduction in the incidence of dementia and Parkinson's disease.
Methods
We analyzed data from the decision support system of the US Veterans Affairs database, which contains diagnostic, medication and demographic information on 4.5 million subjects. The association of lovastatin, simvastatin and atorvastatin with dementia was examined with Cox proportional hazard models for subjects taking statins compared with subjects taking cardiovascular medications other than statins, after adjusting for covariates associated with dementia or Parkinson's disease.
Results
We observed that simvastatin is associated with a significant reduction in the incidence of dementia in subjects ≥65 years, using any of three models. The first model incorporated adjustment for age, the second model included adjusted for three known risk factors for dementia, hypertension, cardiovascular disease or diabetes, and the third model incorporated adjustment for the Charlson index, which is an index that provides a broad assessment of chronic disease. Data were obtained for over 700000 subjects taking simvastatin and over 50000 subjects taking atorvastatin who were aged >64 years. Using model 3, the hazard ratio for incident dementia for simvastatin and atorvastatin are 0.46 (CI 0.44–0.48, p < 0.0001) and 0.91 (CI 0.80–1.02, p = 0.11), respectively. Lovastatin was not associated with a reduction in the incidence of dementia. Simvastatin also exhibited a reduced hazard ratio for newly acquired Parkinson's disease (HR 0.51, CI 0.4–0.55, p < 0.0001).
Conclusion
Simvastatin is associated with a strong reduction in the incidence of dementia and Parkinson's disease, whereas atorvastatin is associated with a modest reduction in incident dementia and Parkinson's disease, which shows only a trend towards significance.
doi:10.1186/1741-7015-5-20
PMCID: PMC1955446  PMID: 17640385
20.  Health Status Among 28,000 Women Veterans 
Journal of General Internal Medicine  2006;21(Suppl 3):S40-S46.
BACKGROUND
Male veterans receiving Veterans Health Administration (VA) care have worse health than men in the general population. Less is known about health status in women veteran VA patients, a rapidly growing population.
OBJECTIVE
To characterize health status of women (vs men) veteran VA patients across age cohorts, and assess gender differences in the effect of social support upon health status.
DESIGN AND PATIENTS
Data came from the national 1999 Large Health Survey of Veteran Enrollees (response rate 63%) and included 28,048 women and 651,811 men who used VA in the prior 3 years.
MEASUREMENTS
Dimensions of health status from validated Veterans Short Form-36 instrument; social support (married, living arrangement, have someone to take patient to the doctor).
RESULTS
In each age stratum (18 to 44, 45 to 64, and ≥65 years), Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were clinically comparable by gender, except that for those aged ≥65, mean MCS was better for women than men (49.3 vs 45.9, P<.001). Patient gender had a clinically insignificant effect upon PCS and MCS after adjusting for age, race/ethnicity, and education. Women had lower levels of social support than men; in patients aged <65, being married or living with someone benefited MCS more in men than in women.
CONCLUSIONS
Women veteran VA patients have as heavy a burden of physical and mental illness as do men in VA, and are expected to require comparable intensity of health care services. Their ill health occurs in the context of poor social support, and varies by age.
doi:10.1111/j.1525-1497.2006.00373.x
PMCID: PMC1513164  PMID: 16637944
women's health; veterans; health status; quality of life; social support

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