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1.  Physiologic Frailty and Fragility Fracture in HIV-Infected Male Veterans 
Frailty, as measured by the Veterans Aging Cohort Study Index, is an important predictor of fragility fracture in the context of established fracture risk factors. Anemia and increasing age drive this association in a male veteran population.
Background. The Veterans Aging Cohort Study (VACS) Index is associated with all-cause mortality in individuals infected with human immunodeficiency virus (HIV). It is also associated with markers of inflammation and may thus reflect physiologic frailty. This analysis explores the association between physiologic frailty, as assessed by the VACS Index, and fragility fracture.
Methods. HIV-infected men from VACS were included. We identified hip, vertebral, and upper arm fractures using ICD-9-CM codes. We used Cox regression models to assess fragility fracture risk factors including the VACS Index, its components (age, hepatitis C status, FIB-4 score, estimated glomerular filtration rate, hemoglobin, HIV RNA, CD4 count), and previously identified risk factors for fragility fractures.
Results. We included 40 115 HIV-infected male Veterans. They experienced 588 first fragility fractures over 6.0 ± 3.9 years. The VACS Index score (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.11–1.19), white race (HR, 1.92; 95% CI, 1.63–2.28), body mass index (HR, 0.94; 95% CI, .92–.96), alcohol-related diagnoses (HR, 1.65; 95% CI, 1.26–2.17), cerebrovascular disease (HR, 1.95; 95% CI, 1.14–3.33), proton pump inhibitor use (HR, 1.87; 95% CI, 1.54–2.27), and protease inhibitor use (HR, 1.25; 95% CI, 1.04–1.50) were associated with fracture risk. Components of the VACS Index score most strongly associated with fracture risk were age (HR, 1.40; 95% CI, 1.27–1.54), log HIV RNA (HR, 0.91; 95% CI, .88–.94), and hemoglobin level (HR, 0.82; 95% CI, .78–.86).
Conclusions. Frailty, as measured by the VACS Index, is an important predictor of fragility fractures among HIV-infected male Veterans.
doi:10.1093/cid/cit056
PMCID: PMC3634308  PMID: 23378285
HIV; frailty; fragility fractures; Veterans
2.  Receipt of Opioid Analgesics by HIV-Infected and Uninfected Patients 
ABSTRACT
BACKGROUND
Opioids are increasingly prescribed, but there are limited data on opioid receipt by HIV status.
OBJECTIVES
To describe patterns of opioid receipt by HIV status and the relationship between HIV status and receiving any, high-dose, and long-term opioids.
DESIGN
Cross-sectional analysis of the Veterans Aging Cohort Study.
PARTICIPANTS
HIV-infected (HIV+) patients receiving Veterans Health Administration care, and uninfected matched controls.
MAIN MEASURES
Pain-related diagnoses were determined using ICD-9 codes. Any opioid receipt was defined as at least one opioid prescription; high-dose was defined as an average daily dose ≥120 mg of morphine equivalents; long-term opioids was defined as ≥90 consecutive days, allowing a 30 day refill gap. Multivariable models were used to assess the relationship between HIV infection and the three outcomes.
KEY RESULTS
Among the HIV+ (n = 23,651) and uninfected (n = 55,097) patients, 31 % of HIV+ and 28 % of uninfected (p < 0.001) received opioids. Among patients receiving opioids, HIV+ patients were more likely to have an acute pain diagnosis (7 % vs. 4 %), but less likely to have a chronic pain diagnosis (53 % vs. 69 %). HIV+ patients received a higher mean daily morphine equivalent dose than uninfected patients (41 mg vs. 37 mg, p = 0.001) and were more likely to receive high-dose opioids (6 % vs. 5 %, p < 0.001). HIV+ patients received fewer days of opioids than uninfected patients (median 44 vs. 60, p < 0.001), and were less likely to receive long-term opioids (31 % vs. 34 %, p < 0.001). In multivariable analysis, HIV+ status was associated with receipt of any opioids (AOR 1.40, 95 % CI 1.35, 1.46) and high-dose opioids (AOR 1.22, 95 % CI 1.07, 1.39), but not long-term opioids (AOR 0.94, 95 % CI 0.88, 1.01).
CONCLUSIONS
Patients with HIV infection are more likely to be prescribed opioids than uninfected individuals, and there is a variable association with pain diagnoses. Efforts to standardize approaches to pain management may be warranted in this highly complex and vulnerable patient population.
doi:10.1007/s11606-012-2189-z
PMCID: PMC3539026  PMID: 22895747
opioid; pain; HIV; narcotics; veterans
3.  Unhealthy Alcohol and Illicit Drug Use are Associated with Decreased Quality of HIV Care 
Background
HIV-infected patients with substance use experience suboptimal health outcomes, possibly to due to variations in care.
Objectives
To assess the association between substance use and the quality of HIV care (QOC) received.
Research Design
Retrospective cohort study.
Subjects
HIV-infected patients enrolled in the Veterans Aging Cohort Study.
Measures
We collected self-report substance use data and abstracted 9 HIV quality indicators (QIs) from medical records. Independent variables were unhealthy alcohol use (AUDIT-C score ≥4) and illicit drug use (self-report of stimulants, opioids, or injection drug use in past year). Main outcome was the percentage of QIs received, if eligible. We estimated associations between substance use and QOC using multivariable linear regression.
Results
The majority of the 3,410 patients were male (97.4%) and Black (67.0%) with a mean age of 49.1 years (SD 8.8). Overall, 25.8% reported unhealthy alcohol use, 22% illicit drug use, and participants received 81.5% (SD=18.9) of QIs. The mean percentage of QIs received was lower for those with unhealthy alcohol use vs. not (59.3% vs. 70.0%, p<.001) and those using illicit drugs vs. not (57.8% vs. 70.7%, p<.001). In multivariable models, unhealthy alcohol use (adjusted β −2.74; 95% CI −4.23, −1.25) and illicit drug use (adjusted β −3.51 95% CI −4.99, −2.02) remained inversely associated with the percentage of QIs received.
Conclusions
Though the overall QOC for these HIV-infected Veteran patients was high, gaps persist for those with unhealthy alcohol and illicit drug use. Interventions that address substance use in HIV-infected patients may improve the QOC received.
doi:10.1097/QAI.0b013e31826741aa
PMCID: PMC3460799  PMID: 22820808
Alcohol; Quality of Health Care; HIV; Quality Indicators; Health Care; Opioid-Related Disorders
4.  Use of Structured and Unstructured Data to Identify Contraceptive Use in Women Veterans 
Contraceptive use among women Veterans may not be adequately captured using administrative and pharmacy codes. Clinical progress notes may provide a useful alternative. The objectives of this study were to validate the use of administrative and pharmacy codes to identify contraceptive use in Veterans Health Administration data, and to determine the feasibility and validity of identifying contraceptive use in clinical progress notes. The study included women Veterans who participated in the Women Veterans Cohort Study, enrolled in the Veterans Affairs Connecticut Health Care System, completed a baseline survey, and had clinical progress notes from one year prior to survey completion. Contraceptive ICD-9-CM codes, V-codes, CPT codes, and pharmacy codes were identified. Progress notes were annotated to identify contraceptive use. Self-reported contraceptive use was identified from a baseline survey of health habits and healthcare practices and utilization. Sensitivity, specificity, and positive predictive value were calculated comparing administrative and pharmacy contraceptive codes and progress note–based contraceptive information to self-report survey data. Results showed that administrative and pharmacy codes were specific but not sensitive for identifying contraceptive use. For example, oral contraceptive pill codes were highly specific (1.00) but not sensitive (0.41). Data from clinical progress notes demonstrated greater sensitivity and comparable specificity. For example, for oral contraceptive pills, progress notes were both specific (0.85) and sensitive (0.73). Results suggest that the best approach for identifying contraceptive use, through either administrative codes or progress notes, depends on the research question.
PMCID: PMC3709878  PMID: 23861675
contraception; electronic health records; Veterans; clinical coding
5.  Validating Smoking Data From the Veteran’s Affairs Health Factors Dataset, an Electronic Data Source 
Nicotine & Tobacco Research  2011;13(12):1233-1239.
Introduction:
We assessed smoking data from the Veterans Health Administration (VHA) electronic medical record (EMR) Health Factors dataset.
Methods:
To assess the validity of the EMR Health Factors smoking data, we first created an algorithm to convert text entries into a 3-category smoking variable (never, former, and current). We compared this EMR smoking variable to 2 different sources of patient self-reported smoking survey data: (a) 6,816 HIV-infected and -uninfected participants in the 8-site Veterans Aging Cohort Study (VACS-8) and (b) a subset of 13,689 participants from the national VACS Virtual Cohort (VACS-VC), who also completed the 1999 Large Health Study (LHS) survey. Sensitivity, specificity, and kappa statistics were used to evaluate agreement of EMR Health Factors smoking data with self-report smoking data.
Results:
For the EMR Health Factors and VACS-8 comparison of current, former, and never smoking categories, the kappa statistic was .66. For EMR Health Factors and VACS-VC/LHS comparison of smoking, the kappa statistic was .61.
Conclusions:
Based on kappa statistics, agreement between the EMR Health Factors and survey sources is substantial. Identification of current smokers nationally within the VHA can be used in future studies to track smoking status over time, to evaluate smoking interventions, and to adjust for smoking status in research. Our methodology may provide insights for other organizations seeking to use EMR data for accurate determination of smoking status.
doi:10.1093/ntr/ntr206
PMCID: PMC3223583  PMID: 21911825
6.  Delayed Presentation for Human Immunodeficiency Virus (HIV) Care Among Veterans 
Medical care  2007;45(11):1105-1109.
Background
Despite the effectiveness of antiretroviral therapy, nearly half of patients entering human immunodeficiency virus (HIV) care have advanced disease. Many attribute this delay to poor access to healthcare. Others argue that delays will persist until routine screening is adopted. The Veterans Health Administration (VA) is a unique laboratory to examine whether access to comprehensive health benefits results in earlier entry into HIV care.
Methods
Retrospective observational study of 4368 HIV-positive patients entering HIV care during 1998–2002 at VA medical centers nationwide. Outcomes of interest: rates of acquired immune deficiency syndrome in year of presentation; duration of VA utilization before HIV presentation; presence of “clinical triggers,” signaling greater risk of HIV infection, before presentation.
Results
Fifty-one percent (n = 2211) of all patients presented with CD4 counts of <200 cells/mm3. Thirty-nine percent (n = 1697) of all patients used other VA services before presentation for HIV care, with median duration of 3.6 years (interquartile range 25–75: 2.2–5.1 year) and 6 physician visits [interquartile range (IQR), 25–75: 2–18 visits] between first utilization and HIV presentation. No difference existed in the percentage presenting with CD4 counts <200 cells/mm3 among those with and without prior VA healthcare (50% vs. 51%, P = 0.76). Only 13% of those with prior VA healthcare demonstrated a clinical trigger before HIV presentation.
Conclusions
More than half of veterans entered HIV care with an acquired immune deficiency syndrome diagnosis at presentation irrespective of whether they had previously established healthcare in the VA. Access to care does not seem to be the primary cause of delayed HIV presentation. Widespread HIV screening is needed to improve rates of early detection.
doi:10.1097/MLR.0b013e3181271476
PMCID: PMC3460382  PMID: 18049352
HIV; AIDS; diagnosis; screening; access to care
7.  A Comparison of Treatment Eligibility for Hepatitis C Virus in HCV-Monoinfected Versus HCV/HIV-Coinfected Persons in Electronically Retrieved Cohort of HCV-Infected Veterans 
Abstract
Treatment rates for hepatitis C virus (HCV) are low in actual clinical settings. However, the proportion of patients eligible for treatment, especially among those coinfected with HIV, is not well known. Our aim was to determine and compare the rates for HCV treatment eligibility among HCV and HCV-HIV-coinfected persons. We assembled a national cohort of HCV-infected veterans in care from 1998–2003, using the VA National Patient Care Database for demographic/clinical information, the Pharmacy Benefits Management database for pharmacy records, and the Decision Support Systems database for laboratory data. We compared the HCV-monoinfected and HCV-HIV-coinfected subjects for treatment indications and eligibility using current treatment guidelines. Of the 27,452 subjects with HCV and 1225 with HCV-HIV coinfection, 74.0% and 84.6% had indications for therapy and among these, 43.9% of HCV-monoinfected and 28.4% of HCV-HIV-coinfected subjects were eligible for treatment. Anemia, decompensated liver disease (DLD), chronic obstructive pulmonary disease (COPD), recent alcohol abuse, and coronary artery disease were the most common contraindications in the HCV, and anemia, DLD, renal failure, recent drug abuse, and COPD in the HCV-HIV-coinfected group. Among those eligible for treatment, only 23% of the HCV-monoinfected and 15% of the HCV-HIV-coinfected subjects received any treatment for HCV. Most veterans with HCV are not eligible for treatment according to the current guidelines. Even for those who are eligible for treatment, only a minority is prescribed treatment. Several contraindications are modifiable and aggressive management of those may improve treatment prescription rates.
doi:10.1089/aid.2011.0004
PMCID: PMC3719436  PMID: 21338329
8.  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
9.  Pregnancy and Mental Health Among Women Veterans Returning from Iraq and Afghanistan 
Journal of Women's Health  2010;19(12):2159-2166.
Abstract
Background
Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) may experience significant stress during military service that can have lingering effects. Little is known about mental health problems or treatment among pregnant OEF/OIF women veterans. The aim of this study was to determine the prevalence of mental health problems among veterans who received pregnancy-related care in the Veterans Health Administration (VHA) system.
Methods
Data from the Defense Manpower Data Center (DMDC) deployment roster of military discharges from October 1, 2001, through April 30, 2008, were used to assemble an administrative cohort of female OEF/OIF veterans enrolled in care at the VHA (n = 43,078). Pregnancy and mental health conditions were quantified according to ICD-9-CM codes and specifications. Mental healthcare use and prenatal care were assessed by analyzing VHA stop codes.
Results
During the study period, 2966 (7%) women received at least one episode of pregnancy-related care, and 32% of veterans with a pregnancy and 21% without a pregnancy received one or more mental health diagnoses (p < 0.0001). Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or schizophrenia as those without a pregnancy.
Conclusions
Women OEF/OIF veterans commonly experience mental health problems after military service. The burden of mental health conditions is higher among women with an identified instance of pregnancy than among those without. Because women do not receive pregnancy care at the VHA, however, little is known about ongoing concomitant prenatal and mental healthcare or about pregnancy outcomes among these women veterans.
doi:10.1089/jwh.2009.1892
PMCID: PMC3052271  PMID: 21039234
10.  The Burden of Illness in the First Year Home: Do Male and Female VA Users Differ in Health Conditions and Healthcare Utilization 
Background
We sought to describe gender differences in medical and mental health conditions and health care utilization among veterans who used Veterans Health Administration (VA) services in the first year after combat in Iraq and Afghanistan.
Methods
This is an observational study, using VA administrative and clinical data bases, of 163,812 Operation Enduring Freedom/Operation Iraqi Freedom veterans who had enrolled in VA and who had at least one visit within 1 year of last deployment.
Results
Female veterans were slightly younger (mean age, 30 years vs. 32 for men; p <.0001), twice as likely to be African American (30% vs. 15%; p <.0001), and less likely to be married (32% vs. 49%; p < .0001). Women had more visits to primary care (2.6 vs. 2.0; p < .001) and mental health (4.0 vs. 3.6; p < .001) clinics and higher use of community care outside the VA (14% vs. 10%; p < .001). After adjustment for significant demographic differences, women were more likely to have musculoskeletal and skin disorders, mild depression, major depression, and adjustment disorders, whereas men were more likely to have ear disorders and posttraumatic stress disorder. Thirteen percent of women sought care for gynecologic examination, 10% for contraceptive counseling, and 7% for menstrual disorders.
Conclusion
Female veterans had similar rates of physical conditions, but higher rates of some mental health disorders and additionally, used the VA for reproductive health needs. They also had slightly greater rates of health care service use. These findings highlight the complexity of female Veteran health care and support the development of enhanced comprehensive women’s health services within the VA.
doi:10.1016/j.whi.2010.08.001
PMCID: PMC3138124  PMID: 21185994
11.  Rural Residence Is Associated With Delayed Care Entry and Increased Mortality Among Veterans With Human Immunodeficiency Virus Infection 
Medical care  2010;48(12):1064-1070.
Context
Rural persons with human immunodeficiency virus (HIV) face many barriers to care, but little is known about rural-urban variation in HIV outcomes.
Objective
To determine the association between rural residence and HIV outcomes.
Design, Setting, and Patients
Retrospective cohort study of mortality among persons initiating HIV care in Veterans Administration (VA) during 1998–2006, with mortality follow-up through 2008. Rural residence was determined using Rural Urban Commuting Area codes. We identified 8489 persons initiating HIV care in VA with no evidence of combination antiretroviral therapy (cART) use at care entry, of whom 705 (8.3%) were rural.
Outcome Measure
All-cause mortality.
Results
At care entry, rural persons were less likely than urban persons to have drug use problems (10.6% vs. 19.5%, P < 0.001) or hepatitis C (34.3% vs. 41.2%, P = 0.001), but had more advanced HIV infection (median CD4: 186 vs. 246, P < 0.001). By 2 years after care entry, 5874 persons had initiated cART (528 rural [74.9%] and 5346 urban [68.7%], P = 0.001), and there were 1022 deaths (108 rural [15.3%] and 914 urban [11.7%], P = 0.004). The mortality hazard ratio for rural persons compared with urban was 1.34 (95% confidence interval: 1.05–1.69). The hazard ratio decreased to 1.18 (95% confidence interval: 0.93–1.50) after adjustment for HIV severity (CD4 and AIDS-defining illnesses) at care entry, and was 1.17 (95% confidence interval: 0.92–1.50) in a model adjusting for age, HIV severity at care entry, substance use, hepatitis B or C diagnoses, and cART initiation.
Conclusions
Later entry into care drives increased mortality for rural compared with urban veterans with HIV. Future studies should explore the person, care system, and community-level determinants of late care entry for rural persons with HIV.
doi:10.1097/MLR.0b013e3181ef60c2
PMCID: PMC3138500  PMID: 20966783
HIV; rural health; veterans
12.  Hepatitis C treatment completion rates in routine clinical care 
Background
Treatment completion rates for hepatitis C virus (HCV) infection in clinical practice settings are unknown.
Methods
We assembled a national cohort of HCV-infected veterans-in-care from 1998 to 2003, using the VA National Patient Care Database for demographical/clinical information, Pharmacy Benefits Management database for pharmacy records and the Decision Support Systems database for laboratory data. We used logistic regression to determine the factors predicting treatment non-completion for HCV.
Results
We identified 134 934 HCV-infected veterans of whom 16 043 [11.9%; 95% confidence interval (CI) 11.7–12.1] were prescribed treatment for HCV. Among the 10 641 veterans with > 1 year of follow-up, 2396 (22.5%; 95% CI 21.7–23.3) completed a 48-week course. Non-completers were more likely to have pre-treatment anaemia, coronary artery disease, depression, substance abuse, used standard interferon, higher comorbidity count, and been treated at a low-volume treatment site (defined as sites initiating HCV treatment for < 200 individuals). In multivariable analyses, treatment completion was positively associated with pegylated interferon use [odds ratio (OR) 1.59, 95% CI 1.40–1.80] and site treatment volume (OR 1.87, 95% CI 1.56–2.24 for sites initiating treatment for > 200 individuals) and negatively associated with pre-treatment anaemia (OR 0.68, 95% CI 0.58–0.80 for haemoglobin 10–14 g/dl) and depression (OR 0.78, 95% CI 0.69–0.89). Human immunodeficiency virus coinfection and minority race were not associated with failing to complete treatment.
Conclusions
Among veterans-in-care with known HCV, 11.9% initiate therapy of whom 22.5% (one in 56 with known HCV infection) complete a 48-week course of treatment. Higher completion rates among higher volume treatment sites suggest that some factors associated with non-completion (pre-treatment depression and anaemia), may be modifiable with experience.
doi:10.1111/j.1478-3231.2009.02156.x
PMCID: PMC3132089  PMID: 19889081
anaemia; depression; hepatitis C; HIV infection; pegylated interferon; practice variation; treatment completion
13.  Determinants of Hormone Therapy Discontinuation among Female Veterans Nationally 
Military medicine  2008;173(1):91-96.
Purpose
The growing presence of female veterans within the Department of Veterans Affairs (VA) health care system highlights the need to assess the quality of and access to gender-specific care for menopause. We assessed the use of hormone therapy (HT) among female veterans before and after the release of the Women’s Health Initiative clinical trial results and evaluated whether the structure of women’s health care services within the VA system affects the use of HT.
Methods
We identified all female veterans using HT in 2001 by using the VA pharmacy benefits management database and administrative data. Subjects identified as using HT in 2001 were evaluated to determine estrogen use status in 2003 and 2004. We calculated the change in HT use over time and performed multivariate analyses to identify patient and utilization determinants of HT discontinuation.
Results
In 2001, 36,222 female veterans used HT. By 2004, 23,924 (66%) had discontinued HT. Subjects who had used a VA women’s clinic or were younger (40–54 years of age) were significantly less likely to discontinue HT. However, Hispanic ethnicity, African American race, and clinical diagnoses such as heart disease and mastectomy were significantly associated with discontinuation.
Conclusion
Discontinuation rates in the VA system parallel those in the private sector. However, patients with any use of VA women’s clinics were less likely to discontinue HT, indicating a practice setting variation that may indicate either more specific care or differential implementation of the new HT guidelines. Further research is warranted to assess whether a disparity occurs according to practice setting (or provider factors) with rapid shifts in guidelines.
PMCID: PMC3115618  PMID: 18251338
14.  Comparison of Two VA Laboratory Data Repositories Indicates That Missing Data Vary Despite Originating From the Same Source 
Medical care  2009;47(1):121-124.
Background
Assessing accuracy and completeness of data is an important component of conducting research. VA Healthcare System benefits from a highly developed electronic medical information system. The Immunology Case Registry was designed to monitor costs and quality of HIV care. The Decision Support System was developed to monitor utilization and costs of veterans in care. Because these systems extract data from the same source using independent methods, they provide an opportunity to compare the accuracy and completeness of each.
Objective
To compare overlapping laboratory data from the Veterans Affairs Health Information System between 2 data repositories.
Research Design
For hemoglobin, CD4+ lymphocyte counts (CD4), HIV RNA viral load, aspartate aminotransferase, alanine aminotransferase, glycosylated hemoglobin, creatinine, and white blood count, we calculated the percent of individuals with a value from each source. For results in both repositories, we calculated Pearson’s correlation coefficients.
Subjects
A total of 22,647 HIV + veterans in the Virtual Cohort with a visit in fiscal year 2002.
Results
For 6 out of 9 tests, 68% to 72% of the observations overlapped. For CD4, viral load, and glycosylated hemoglobin less than 31% of observations overlapped. Overlapping results were nearly perfectly correlated except for CD4.
Conclusions
Six of the laboratory tests demonstrated remarkably similar amounts of overlap, though Immunology Case Registry and Decision Support System both have missing data. Findings indicate that validation of laboratory data should be conducted before its use in quality and efficiency projects. When 2 databases are not available for comparison, other methods of validation should be implemented.
doi:10.1097/MLR.0b013e31817d69c2
PMCID: PMC3032537  PMID: 19106740
laboratory; DSS; ICR; VA
15.  Hepatitis C Progressing to Hepatocellular Carcinoma: The HCV Dialysis Patient in Dilemma 
Journal of viral hepatitis  2009;17(1):59-64.
Background
Approximately 3.2 million people in the United States have chronic hepatitis C virus (HCV) infection; the primary cause for adult liver transplantation and a significant burden on healthcare resources. The role of HCV and other risk factors in development of HCC in patients with chronic kidney disease is not well defined.
Aim
To identify specific predictors of hepatocellular carcinoma (HCC) in dialysis patients with chronic HCV.
Methods
This study assessed factors associated with the development of HCC in dialysis patients with chronic HCV. Data were extracted from the United States Renal Database System (USRDS) using ICD-9 codes. Variables included were gender, race, duration on dialysis, and comorbidities (alcohol abuse, drug abuse, HIV, hepatitis B, diabetes and/or presence of cirrhosis).
Results
Among the 32,806 HCV infected subjects, 262 cases had HCC. HCC was 12 times more likely in subjects with cirrhosis (p<.001), 3 times more likely in subjects with alcohol abuse (p<.001), and 1.3 times more likely in subjects with diabetes (p=.04). Asians were 3 times more likely (p<.001) to have HCC. Females were less likely to have HCC compared to males (p=.002). The likelihood of having HCC increased with age (p=.001).
Implications
This population-based study demonstrates that among subjects with HCV on dialysis, those with cirrhosis, Asian race and history of alcohol abuse are at highest risk for development of HCC. Furthermore, these findings indicate links between HCV and HCC which are valuable in case management for identifying; monitoring, and managing dialysis patients with HCC.
doi:10.1111/j.1365-2893.2009.01151.x
PMCID: PMC2956610  PMID: 19566787
hepatitis C; hepatocellular carcinoma; dialysis; co-morbidity; end stage renal disease
16.  Rate and predictors of treatment prescription for hepatitis C 
Gut  2006;56(3):385-389.
Background
The true treatment rate for hepatitis C virus (HCV) in veterans is unknown.
Aim
To determine the treatment prescription rates and predictors of treatment prescription for HCV in a large national population.
Methods
The Department of Veterans Affairs National Patient Care Database (NPCD) was used to identify all HCV‐infected people between the fiscal years 1999 and 2003 using the International classification of diseases, 9th revision codes. Demographic information, medical and psychiatric comorbidities, and drug and alcohol use diagnoses were retrieved. Pharmacy data were retrieved from the Department of Veterans Affairs Pharmacy Benefits Management (PBM) database. Logistic regression analysis was used to determine the predictors of treatment for HCV in HCV.
Results
113 927 veterans in the Department of Veterans Affairs care with a diagnosis of HCV were identified. The treatment prescription rate for HCV was 11.8%. Patients not prescribed treatment were older, more likely to be from minority races, have more alcohol and drug misuse, and have medical and psychiatric comorbid conditions. In a multivariate logistic regression model, the following factors were predictive of non‐treatment for HCV: increasing age (odds ratio (OR) 0.77 for each 5‐year increase in age; 95% confidence interval (CI) 0.76 to 0.78); black race (OR 0.64; 95% CI 0.6 to 0.68); Hispanic race (OR 0.88; 95% CI 0.8 to 0.96); alcohol abuse and dependence (OR 0.62; 95% CI 0.59 to 0.65); drug abuse and dependence (OR 0.78; 95% CI 0.74 to 0.82); anaemia (OR 0.18; 95% CI 0.16 to 0.21); hepatitis B infection (OR 0.72; 95% CI 0.62 to 0.83); coronary artery disease (OR 0.9; 95% CI 0.85 to 0.97); stroke (OR 0.75; 95% CI 0.67 to 0.85); bipolar disorder (OR 0.64; 95% CI 0.58 to 0.70); major depression (OR 0.72; 95% CI 0.67 to 0.77); mild depression (OR 0.56; 95% CI 0.53 to 0.59); and schizophrenia (OR 0.71; 95% CI 0.65 to 0.77). The following factors were associated with a higher likelihood of treatment prescription for HCV: liver cirrhosis (OR 1.6; 95% CI 1.5 to 1.7); and diabetes (OR 1.07; 95% CI 1.02 to 1.12).
Conclusions
A small number of HCV‐infected veterans were prescribed treatment for HCV. Non‐treatment is associated with increasing age, non‐white race, drug and alcohol abuse, and dependence and comorbid illnesses. Reasons for non‐treatment need further study.
doi:10.1136/gut.2006.099150
PMCID: PMC1856823  PMID: 17005764

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