OBJECTIVE:Alcohol use disorders worsen the course of schizophrenia. Although the atypical antipsychotic clozapine appears to decrease alcohol use in schizophrenia, risperidone does not. We have proposed that risperidone's relatively potent dopamine D2 receptor blockade may partly underlie its lack of effect on alcohol use. Since long-acting injectable (LAI) risperidone both results in lower average steady-state plasma concentrations than oral risperidone (with lower D2 receptor occupancy) and encourages adherence, it may be more likely to decrease heavy alcohol use (days per week of drinking 5 or more drinks per day) than oral risperidone.METHOD:Ninety-five patients with DSM-IV-TR diagnoses of schizophrenia and alcohol use disorder were randomized to 6 months of oral or LAI risperidone between 2005 and 2008. Explanatory (efficacy) analyses were carried out to evaluate the potential benefits of LAI under suitably controlled conditions (in contrast to real-world settings), with intent-to-treat analyses being secondary.RESULTS:Explanatory analyses showed that heavy drinking in the oral group worsened over time (P = .024) and that there was a statistical trend toward significance in the difference between the changes in heavy drinking days in the oral and LAI groups (P = .054). Furthermore, the 2 groups differed in the mean number of drinking days per week (P = .035). The intent-to-treat analyses showed no difference in heavy drinking but did show a difference in average drinking days per week similar to that obtained from the explanatory analyses (P = .018). Neither explanatory nor intent-to-treat analyses showed any between-group differences in alcohol use as measured by intensity or the Alcohol Use Scale. The plasma concentrations of the active metabolite 9-hydroxyrisperidone were significantly lower in patients taking LAI (P < .05), despite their significantly (overall) better treatment adherence (P < .005).CONCLUSION:For the population considered here, schizophrenia patients with alcohol use disorder appear to continue drinking some alcohol while taking either form of risperidone. Nonetheless, our data suggest that injectable risperidone may be a better choice than the oral form for these dual diagnosis patients.TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT00130923.

BACKGROUND:Substance use disorders (SUDs) are a substantial problem in the United States (U.S.), affecting far more people than receive treatment. This is true broadly and within the U.S. military veteran population, which is our focus. To increase funding for treatment, the Veterans Health Administration (VA) has implemented several initiatives over the past decade to direct funds toward SUD treatment, supplementing the unrestricted funds VA medical centers receive. We study the 'flypaper effect' or the extent to which these directed funds have actually increased SUD treatment spending.METHODS:The study sample included all VA facilities and used observational data spanning years 2002 to 2010. Data were analyzed with a fixed effects, ordinary least squares specification with monetized workload as the dependent variable and funding dedicated to SUD specialty clinics the key dependent variable, controlling for unrestricted funding.RESULTS:We observed different effects of dedicated SUD specialty clinic funding over the period 2002 to 2008 versus 2009 to 2010. In the earlier period, there is no evidence of a significant portion of the dedicated funding sticking to its target. In the later period, a substantial proportion--38% in 2009 and 61% in 2010--of funding dedicated to SUD specialty clinics did translate into increased medical center spending for SUD treatment. In comparison, only five cents of every dollar of unrestricted funding is spent on SUD treatment.CONCLUSIONS:Relative to unrestricted funding, dedicated funding for SUD treatment was much more effective in increasing workload, but only in years 2009 and 2010. The differences in those years relative to prior ones may be due to the observed management focus on SUD and SUD-related treatment in the later years. If true, this suggests that in a centrally directed healthcare organization such as the VA, funding dedicated to a service is a necessary, but not sufficient condition for increasing resources expended for that service.

Context: Cross-sectional studies have identified rural-urban disparities in veterans' health-related quality-of-life (HRQOL) scores. Purpose: To determine whether longitudinal analyses confirmed that these disparities in veterans' HRQOL scores persisted. Methods: We obtained data from the SF-12 portion of the veterans health administration's (VA's) Survey of Healthcare Experiences of Patients (SHEP) collected between 2002 and 2006. During that time, the SHEP was randomly administered to approximately 250,000 veterans annually who had used VA outpatient services. We evaluated 163,709 responses from veterans who had completed 2 or more surveys during the years studied. Respondents were classified into rural-urban groups using ZIP Code-based rural-urban commuting area designations. We estimated linear regression models using generalized estimating equations to determine whether rural and urban veterans' HRQOL scores were changing at different rates over the time period examined. Findings: After adjustment for sociodemographic differences, we found that urban veterans had substantially better physical HRQOL scores than their rural counterparts and that these differences persisted over the study period. While urban veterans had worse mental HRQOL scores than rural veterans, those differences diminished over the time period studied. Conclusions: Rural-urban disparities in HRQOL scores persist when tracking veterans longitudinally. Reduced access among rural veterans to care may contribute to these disparities. Because rural soldiers are overrepresented in current conflicts, the VA should consider new models of care delivery to improve access to care for rural veterans.

Background: Gender-based, but not race-based, income disparities exist among general internists who practice medicine in the private sector.Objective: The aim of this study was to assess whether race- or gender-based income disparities existed among full-time white and Asian general internists who worked for the Veterans Health Administration of the US Department of Veterans Affairs (VA) between fiscal years 2004 and 2007, and whether any disparities changed after the VA enacted physician pay reform in early 2006.Methods: A retrospective study was conducted of all nonsupervisory, board-certified, full-time white or Asian VA general internists who did not change their location of practice between fiscal years 2004 and 2007. A longitudinal cohort design and linear regression modeling, adjusted for physician characteristics, were used to compare race- and gender-specific incomes in fiscal years 2004-2007.Results: A total of 176 physicians were included in the study: 82 white males, 33 Asian males, 30 white females, and 31 Asian females. In all fiscal years examined, white males had the highest mean annual incomes, though not statistically significantly so. Regression analyses for fiscal years 2004 through 2006 revealed that physician age and years of service were predictive of total income. After physician pay reform was enacted, Asian male VA primary care physicians had higher annual incomes than did physicians in all other race or gender categories, after adjustment for age and years of VA service, though these differences were not statistically significant.Conclusions: No significant gender-based income disparities were noted among these white and Asian VA physicians. Our findings for white and Asian general internists suggest that the VA's goal of maintaining a racially diverse workforce may have been effected, in part, through use of market pay among primary care general internists. (Gend Med. 2010;7:64-70) (C) 2010 Excerpta Medica Inc.

OBJECTIVES:More than 1 in 5 Veterans Affairs (VA) users lives in a rural setting. Rural veterans face different barriers to health care than their urban counterparts, but their risk of death relative to their urban counterparts is unknown. The objective of our study was to compare survival between rural and urban VA users.METHODS:We linked the Large Health Survey of Veteran Enrollees conducted in 1999 to the Veterans Administration vital status registry. We used time-to-event regression models controlling for patient race, education, ZIP-code median income, and marital and smoking status.FINDINGS:Of the 372,463 male veterans of age 65 or greater, 80,931 lived in rural settings. Age-adjusted mortality was 5.9% higher (95% CI, 4.5%-7.2%) in rural residents compared to urban residents. After adjusting for age, education, and ZIP-code median income, rural residents had 3.0% lower mortality (95% CI, 1.5%-4.4%). Compared to urban and suburban VA users, rural VA users' mortality at age 65 was 12% lower, but this advantage gradually diminished by age 75.CONCLUSION:Mortality after the age of 65 for male VA users is higher in rural dwellers than in urban dwellers. However, among veterans of the same socioeconomic characteristics, rural-dwelling veterans have up to 15% better mortality than urban-dwelling veterans until the age of 75.

Morbid obesity is associated with serious health and social consequences, high medical costs and is increasing in the USA, particularly among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long-term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, insurance categories, socioeconomic, and comorbidity levels.

We compared demographic profiles across two rural urban classification schemes to determine whether rural urban disparities in health status persisted among Veterans Administration (VA) users over time. Using demographic and SF-12 survey data collected from 2002 to 2006, we conducted serial cross-sectional analyses of demographic variables and health status for veterans residing in VA- and rural urban commuting area (RUCA)-defined rural urban groups. VA and RUCA definitions yielded similar results for the "urban" population; however. VA- and RUCA-defined "rural" categories represent dissimilar populations. Compared to earlier years, the VA user population in 2006 was younger, more educated, wealthier, and more likely to be employed and privately insured. For all years and using both VA and RUCA rural urban definitions, physical component summary (PCS) scores were lower but mental component summary (MCS) scores were slightly higher for more rural compared to urban veterans. Anticipating and meeting the needs of rural VA users will require accurate identification of those who lack access to services and therefore defining "rural" appropriately.

Context: Several classification systems exist for defining rural areas, which may lead to different interpretations of rural health services data. Purpose: To compare rural classification systems on their implications for estimating Veterans Administration (VA) utilization. Methods: Using 7 classification systems, we counted VA health care enrollees who lived in each category, and number admitted to VA hospitals or non-VA hospitals under Medicare. For dual VA-Medicare enrollees over age 65, we compared VA and private sector hospitalizations on numbers of admissions and bed-days of care. We compared VA enrollees' relative proportions across rural to urban categories for each classification system and evaluated discordance between systems at the veterans-integrated service networks (VISN) level. Findings: Enrollment and inpatient utilization counts for rural veterans vary considerably from one classification system to another, though the systems generally agree that admission rates, length of stay, and reliance on the VA for care are lower for rural veterans. Among older dual VA and Medicare enrollees, rural residents rely on non-VA facilities more, though this effect also varies widely depending on the classification scheme. VISNs vary greatly in the proportions of patients who are rural residents, and in the degree to which classification systems are discordant in designating patients as rural. Conclusions: Decisions about allocating VA health care resources to target "rural" patients may be affected greatly by the rural classification system chosen, and the impact of this choice will affect some hospital networks much more than others.

OBJECTIVE:To determine whether the Department of Veterans Affairs Health Care Personnel Enhancement Act (the Act), which was designed to achieve VA physician salary parity with American Academy of Medical Colleges (AAMC) Associate Professors and enacted in 2006, had achieved its goal.METHODS:Using VA human resources datasets and data from the AAMC, we calculated mean VA physician salaries, with 95 percent confidence intervals, for 15 different medical specialties. For each specialty, we compared VA salaries to the median, 25th, and 75th percentile of AAMC Associate Professors' incomes.RESULTS:The Act's passage resulted in a $20,000 annual increase in VA physicians' salaries. VA primary care physicians, medical subspecialists, and psychiatrists had salaries that were comparable to their AAMC counterparts prior to and after enactment of the Act. However, VA surgical specialists', anesthesiologists', and radiologists' salaries lagged their AAMC counterparts both before and after the Act's enactment. Income increases were negatively correlated with full-time workforce changes.CONCLUSIONS:VA does not appear to provide comparable salaries for physicians necessary for surgical care. In certain cases, VA should consider outsourcing surgical services.

We sought to determine whether the VA provides health care at a low cost.For fiscal years 2001-2007, we used data from the National Center for Health Statistics to calculate the VA's average per capita health care costs. We used data from the Medical Expenditure Panel Survey to calculate the average market value of health care received by patients who used the VA for health care. Finally, we examined several measures of health care quality provided by the VA and the private sector.Overall, VA health care costs 33 percent more than it would if purchased in the private sector (95 percent Confidence interval: 19 percent - 52 percent more); VA inpatient care costs were 56 percent higher (95 percent Confidence interval: 27 percent - 105 percent higher). The VA maintains a quality advantage in outpatient care, but its inpatient advantage has narrowed over recent years, and there is evidence that VA surgical care has worse outcomes than private sector surgical care.The VA's health care costs are considerably higher than could be purchased in the private sector. The VA should consider outsourcing inpatient services to high performance private sector hospitals.

OBJECTIVE Women working in traditionally male-dominated environments are at higher risk for alcohol use disorders (AUDs). The male-dominated U.S. military has additional risk factors associated with problem drinking, including isolation from family and exposure to life-threatening stressors. In the 1980s, the military conformed to all U.S. states' 21-year minimum legal drinking age (MLDA), and established prevention and intervention policies for abusive drinking. METHODS Using a serial cross-sectional design, we explored trends in annual alcohol treatment rates among female veterans versus civilians. From the Department of Health's Treatment Episode Data Set, we extracted AUD admissions from years 1992-2003 for female veterans and civilians in four age categories. Using age-specific population figures, we calculated annual AUD treatment rates and odds ratios for female veterans versus civilians. We used time-series analyses to examine trends in annual AUD treatment for female veterans and civilians across the years examined. RESULTS In 1992, odds ratios of alcohol treatment episodes for female veterans compared to civilians ranged from 1.9 for 25-29-year-olds to 4.2 for 40-44-year-olds (all p < 0.01). Female veterans' annual alcohol treatment rates dropped substantially from 1992 to 2003, while rates for female civilians ages 25-34 dropped marginally and those for civilians ages 35-44 increased. Time-series analysis showed a statistically significant drop in rates for veterans from 1992 to 2003 and a significant difference between veterans' and civilians' rates, but demonstrated that female civilian annual treatment rates remained static from 1992 to 2003. CONCLUSIONS Prior to the military's efforts to reduce underage and problem drinking, female veterans' alcohol treatment rates exceeded those of same-age civilians. However, with increasing exposure to an environment that discourages abusive drinking, female veterans' annual rates of alcohol treatment fell to below those for same-age civilians.

To develop guidelines for conducting statistically valid clinical n-of-1 (single-subject) trials, we compared actual clinical decisions with statistically based decisions about treatment efficacy. A series of n-of-1 trials involving methylphenidate (MPH) and placebo were conducted for clinical purposes on 11 hospitalized children and adolescents with attention-deficit hyperactivity disorder (ADHD). The original clinical data were retrospectively analyzed using standard statistical methods for n-of-1 trial data. Statistically based decisions were compared to decisions made by five child psychiatrists after inspection of the clinical data in two types of graphic display. In this study, clinicians' treatment decisions appeared to be based on the size of treatment effects rather than on statistical significance. Clinicians' decisions were frequently made in response to statistical artifacts before the collection of sufficient data to permit a sound decision. Data interpretation by graphic inspection resulted in a greater likelihood of falsely accepting a treatment as effective than would be generally acceptable by statistical standards. This may reflect clinician bias toward MPH treatment or to low intuitive weighting of the risks (versus benefits) of MPH in this population. Most raters appeared to intuitively accept making an erroneous judgment that a treatment was effective in about one out of five trials. It is unlikely that they were aware that this is what they were doing. Although the n-of-1 trial is useful for evaluating the effectiveness of MPH in patients with ADHD, several modifications to the standard clinical methodology are proposed to promote reliable, unbiased interpretation of the effects of medication treatments. Clinicians who apply n-of-1 trials to evaluate treatment efficacy in individual patients should be aware of their own level of acceptable risk of falsely accepting a treatment as effective when deciding upon a method of data interpretation and decision-making.

To explore the connection between primary care physicians' race and sex and their annual incomes, we used restricted versions of Community Tracking Study Physician Surveys administered in 1998-99, 2001-02, and 2004-05. Compared to white male primary care physicians, we inconsistently found lower yearly incomes for their black male peers but consistently found significantly lower incomes for their female peers of any race, after differences in work effort, physician characteristics, and practice characteristics were adjusted for. Sex-based differences persisted over time. Our findings suggest that addressing the underlying causes of sex-based income differences should be a priority for health professional organizations, particularly as more women enter the physician workforce.