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1.  A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months 
“Partners in Dementia Care” (PDC) tested the effectiveness of a care-coordination program integrating healthcare and community services and supporting veterans with dementia and their caregivers. Delivered via partnerships between Veterans Affairs medical centers and Alzheimer’s Association chapters, PDC targeted both patients and caregivers, distinguishing it from many non-pharmacological interventions. Hypotheses posited PDC would improve five veteran self-reported outcomes: 1) unmet need, 2) embarrassment about memory problems, 3) isolation, 4) relationship strain and 5) depression. Greater impact was expected for more impaired veterans. A unique feature was self-reported research data collected from veterans with dementia.
Methods and Findings
Five matched communities were study sites. Two randomly selected sites received PDC for 12 months; comparison sites received usual care. Three structured telephone interviews were completed every 6 months with veterans who could participate.
Of 508 consenting veterans, 333 (65.6%) completed baseline interviews. Among those who completed baseline interviews, 263 (79.0%) completed 6-month follow-ups and 194 (58.3%) completed 12-month follow-ups. Regression analyses showed PDC veterans had significantly less adverse outcomes than those receiving usual care, particularly for more impaired veterans after 6 months, including reduced relationship strain (B = −0.09; p = 0.05), depression (B = −0.10; p = 0.03), and unmet need (B = −0.28; p = 0.02; and B = −0.52; p = 0.08). PDC veterans also had less embarrassment about memory problems (B = −0.24; p = 0.08). At 12 months, more impaired veterans had further reductions in unmet need (B = −0.96; p < 0.01) and embarrassment (B = −0.05; p = 0.02). Limitations included use of matched comparison sites rather than within-site randomization and lack of consideration for variation within the PDC group in amounts and types of assistance provided.
Partnerships between community and health organizations have the potential to meet the dementia-related needs and improve the psychosocial functioning of persons with dementia.
Trial Registry
PMCID: PMC3978714  PMID: 24764496
2.  Predictors of Inpatient Utilization among Veterans with Dementia 
Dementia is prevalent and costly, yet the predictors of inpatient hospitalization are not well understood. Logistic and negative binomial regressions were used to identify predictors of inpatient hospital utilization and the frequency of inpatient hospital utilization, respectively, among veterans. Variables significant at the P < 0.15 level were subsequently analyzed in a multivariate regression. This study of veterans with a diagnosis of dementia (n = 296) and their caregivers found marital status to predict hospitalization in the multivariate logistic model (B = 0.493, P = 0.029) and personal-care dependency to predict hospitalization and readmission in the multivariate logistic model and the multivariate negative binomial model (B = 1.048, P = 0.007, B = 0.040, and P = 0.035, resp.). Persons with dementia with personal-care dependency and spousal caregivers have more inpatient admissions; appropriate care environments should receive special care to reduce hospitalization. This study was part of a larger clinical trial; this trial is registered with NCT00291161.
PMCID: PMC4058849  PMID: 24982674
3.  Utilization of Surveillance for Hepatocellular Carcinoma among Patients with Cirrhosis in the United States 
Hepatology (Baltimore, Md.)  2010;52(1):10.1002/hep.23615.
Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is recommended but may not be performed. The extent and determinants of HCC surveillance are unknown.
We conducted a population-based US cohort study of those over 65 years of age to examine utilization and determinants of pre-diagnosis surveillance in patients with HCC who were previously diagnosed with cirrhosis. Patients diagnosed with HCC during 1994-2002 were identified from the linked Surveillance, Epidemiology, and End-Results registry-Medicare databases. We identified alpha-fetoprotein and ultrasound tests performed for HCC surveillance, and examined factors associated with surveillance.
We identified 1,873 HCC patients with a prior diagnosis of cirrhosis. In the 3 years before HCC, 17% received regular surveillance and 38% received inconsistent surveillance. In a subset of 541 patients in whom cirrhosis was recorded for 3 or more years prior to HCC, only 29% received routine surveillance and 33% inconsistent surveillance. Among all patients who received regular surveillance, approximately 52% received both alpha-fetoprotein and ultrasound, 46% received alpha-fetoprotein only, and 2% received ultrasound only. Patients receiving regular surveillance were more likely to have lived in urban areas and had higher incomes than those who did not receive surveillance. Before diagnosis, approximately 48% of patients were seen by a gastroenterologist/hepatologist or by a physician with an academic affiliation; they were approximately 4.5-fold and 2.8-fold, respectively, more likely to receive regular surveillance than those seen by a primary care physician only. Geographic variation in surveillance was observed and explained by patient and physician factors.
Less than 20% of patients with cirrhosis who developed HCC received regular surveillance. Gastroenterologists/hepatologists or physicians with an academic affiliation are more likely to perform surveillance.
PMCID: PMC3835698  PMID: 20578139
Hepatocellular carcinoma; cirrhosis; AFP; ultrasound; surveillance
4.  Measurement in Veterans Affairs Health Services Research: Veterans as a Special Population 
Health Services Research  2005;40(5 Pt 2):1573-1583.
To introduce this supplemental issue on measurement within health services research by using the population of U.S. veterans as an illustrative example of population and system influences on measurement quality.
Principal Findings
Measurement quality may be affected by differences in demographic characteristics, illness burden, psychological health, cultural identity, or health care setting. The U.S. veteran population and the VA health system represent a microcosm in which a broad range of measurement issues can be assessed.
Measurement is the foundation on which health decisions are made. Poor measurement quality can affect both the quality of health care decisions and decisions about health care policy. The accompanying articles in this issue highlight a subset of measurement issues that have applicability to the broad community of health services research. It is our hope that they stimulate a broad discussion of the measurement challenges posed by conducting “state-of-the-art” health services research.
PMCID: PMC1361220  PMID: 16178996
Measurement; special populations; veterans
5.  Is a prostate cancer screening anxiety measure invariant across two different samples of age-appropriate men? 
In order to explore the influence of anxiety on decision–making processes, valid anxiety measures are needed. We evaluated a prostate cancer screening (PCS) anxiety scale that measures anxiety related to the prostate–specific antigen (PSA) test, the digital rectal examination (DRE), and the decision to undergo PCS (PCS-D) using two samples in different settings.
We assessed four psychometric properties of the scale using baseline data from a randomized, controlled decision aid trial (n = 301, private clinic; n = 149, public).
The 3-factor measure had adequate internal consistency reliability, construct validity, and discriminant validity. Confirmatory factor analyses indicated that the 3–factor model did not have adequate fit. When subscales were considered separately, only the 6–item PCS-D anxiety measure had adequate fit and was invariant across clinics.
Our results support the use of a 6–item PCS-D anxiety measure with age-appropriate men in public and private settings. The development of unique anxiety items relating to the PSA test and DRE is still needed.
PMCID: PMC3408324  PMID: 22681782
6.  Proxies and Other External Raters: Methodological Considerations 
Health Services Research  2005;40(5 Pt 2):1676-1693.
The purpose of this paper is to introduce researchers to the measurement and subsequent analysis considerations involved when using externally rated data. We will define and describe two categories of externally rated data, recommend methodological approaches for analyzing and interpreting data in these two categories, and explore factors affecting agreement between self-rated and externally rated reports. We conclude with a discussion of needs for future research.
Data Sources/Study Setting
Data sources for this paper are previous published studies and reviews comparing self-rated with externally rated data.
Study Design/Data Collection/Extraction Methods
This is a psychometric conceptual paper.
Principal Findings
We define two types of externally rated data: proxy data and other-rated data. Proxy data refer to those collected from someone who speaks for a patient who cannot, will not, or is unavailable to speak for him or herself, whereas we use the term other-rater data to refer to situations in which the researcher collects ratings from a person other than the patient to gain multiple perspectives on the assessed construct. These two types of data differ in the way the measurement model is defined, the definition of the gold standard against which the measurements are validated, the analysis strategies appropriately used, and how the analyses are interpreted. There are many factors affecting the discrepancies between self- and external ratings, including characteristics of the patient, the proxy, and of the rated construct. Several psychological theories can be helpful in predicting such discrepancies.
Externally rated data have an important place in health services research, but use of such data requires careful consideration of the nature of the data and how it will be analyzed and interpreted.
PMCID: PMC1361219  PMID: 16179002
Validity; proxy; self-report
7.  Statins Are Associated with a Reduced Risk of Hepatocellular Carcinoma in a Large Cohort of Patients with Diabetes 
Gastroenterology  2009;136(5):1601-1608.
Experimental studies indicate a potential cancer prevention effect for statins. Given the increasing prevalence of statin use, and the rising incidence of hepatocellular carcinoma (HCC), the potential association between statins and HCC is an important issue to examine.
We conducted a matched case-control study nested within a cohort of patients with diabetes. Cases comprised incident HCC as defined by those occurring at least 6 months following entry in the cohort. Controls were identified by incidence density sampling from patients who remained at risk at the date of the HCC diagnosis matched on age and gender. We identified filled statin prescriptions as well as several potential confounding conditions, medications as well as propensity score to use statins. Odds ratios (OR) as estimates of the relative risk for HCC associated with statin use and 95% CIs were obtained using conditional logistic regression.
We examined 1303 cases and 5212 controls. The mean age was 72 years and 99% were men. A significantly smaller proportion of cases (34.3%) had at least one filled prescriptions for statins than controls (53.1%). There were no significant associations between HCC and non statin cholesterol or triglyceride lowering medications. The unadjusted OR for any statin prescription was 0.46 (95% CI: 0.40–0.517) and the adjusted OR was 0.74 (0.64, 0.87). To reduce the potential confounding effect of existing liver disease, we ran the analyses in a subgroup of patients without recorded liver disease; the ORs were slightly attenuated but remained highly significant both for any statin prescription (0.63 (0.50–0.78).
Statin use is associated with a significant reduction in the risk of hepatocellular carcinoma among patients with diabetes.
PMCID: PMC2677134  PMID: 19208359
8.  Using a Spanish Surname Match to Improve Identification of Hispanic Women in Medicare Administrative Data 
Health Services Research  2006;41(4 Pt 1):1469-1481.
To assess the effectiveness of a Spanish surname match for improving the identification of Hispanic women in Medicare administrative data in which Hispanics are historically underrepresented.
Data Sources
We collected self-identified race/ethnicity data (N = 2,997) from a mailed survey sent to elderly Medicare beneficiaries who resided in 11 geographic areas consisting of eight metropolitan counties and three nonmetropolitan areas (171 counties) in the fall of 2004. The 1990 Census Spanish Surname list was used to identify Hispanics in the Medicare data. In addition, we used data published on the U.S. Census Bureau website to obtain estimates of elderly Hispanics.
Study Design
We used self-identified race/ethnicity as the gold standard to examine the agreement with Medicare race code alone, and with Medicare race code+Spanish surname match. Additionally, we estimated the proportions of Hispanic women and men, in each of the 11 geographic areas in our survey, using the Medicare race code alone and the Medicare race code+Spanish surname match, and compared those estimates with estimates derived from U.S. Census 2000 data.
Principal Findings
The Spanish surname match dramatically increased the accuracy of the Medicare race code for identifying both Hispanic and white women, producing improvements comparable with those seen for men.
We recommend the addition of a proxy race code in the Medicare data using the Spanish surname match to improve the accuracy of racial/ethnic representation.
PMCID: PMC1797094  PMID: 16899019
Women; minorities; Medicare race code; Spanish surname; sensitivity and specificity
9.  Is There a Race-Based Disparity in the Survival of Veterans with HIV? 
Disparities in survival for black patients with HIV in the United States have been reported. The VA is an equal access health care system.
To determine whether such disparities are present in the VA health care system.
Retrospective cohort study using national VA administrative databases.
Two thousand three hundred and four white and 3,641 black HIV-infected patients first hospitalized for HIV between October 1, 1996 and September 30, 2000.
Thirty-day mortality after first hospitalization with HIV, and subsequent long-term survival. Follow-up ended at death or September 30, 2002. Data were adjusted for age, sex, HIV disease severity, non-HIV-related comorbidities, primary discharge diagnosis, hepatitis C status, and facility effects.
The mean follow-up was 3.2 years. Overall survival was similar for black patients compared with white patients (adjusted hazard ratio 1.09, P =.09). Hospital mortality was 7.0% for black and 6.4% for white patients (P =.35). Adjusted hospital mortality for black patients was similar to that of white patients (odds ratio 1.20, P =.10). Long-term survival after hospitalization did not significantly differ by race (adjusted hazard ratio 1.07, P =.21, for black patients compared with white patients).
Survival during and after first hospitalization with HIV in the VA did not significantly differ for white and black patients, possibly indicating similar effectiveness of care for HIV. Further research is needed to understand the reasons for the lack of disparities for VA patients with HIV and whether the VA's results could be replicated.
PMCID: PMC1924608  PMID: 16808745
HIV/AIDS; race; survival; veterans affairs; health disparities; cohort study
10.  Validity of a Low Literacy Version of the Decisional Conflict Scale 
Patient education and counseling  2011;85(3):521-524.
To evaluate the psychometric properties of the 4-factor low literacy Decisional Conflict Scale (DCS-LL) with men eligible for prostate cancer screening (PCS).
We used baseline (T0; n = 149) and post-intervention (T2; n = 89) data from a randomized, controlled trial of a PCS decision aid to assess internal consistency reliability and construct, discriminant, and factor validity.
There was evidence of excellent internal consistency reliability (α’s ≥ .80) and fair construct validity (most r’s ≥ .40) for the DCS-LL except for the Supported subscale. The DCS-LL was able to discriminate between men who had decided and those who had not. There was evidence for the original 4-factor model at T0 but exploratory analysis suggested a 3-factor solution at T0 and T2 with Informed and Value Clarity as one factor.
For men eligible for PCS, feeling informed and feeling clear about values may not reflect distinct cognitive processes. Feeling supported may not be a factor contributing to uncertainty. Research should address whether current DCS subscales best represent the factors that contribute to uncertainty for PCS and for other screening decisions. Research should also explore the influence of health literacy on the factor structure of the DCS-LL.
PMCID: PMC3121898  PMID: 21300518
decisional conflict; decision making; prostate cancer screening; measurement; validity; psychometrics

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