Importance Many patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. Palliative care approaches may benefit this population prior to end of life. Objective Determine the effect of a nurse and social worker palliative telecare team on quality of life in outpatients with COPD, HF, or ILD compared with usual care. Design, Setting, and Participants Single-blind, 2-group, multisite randomized clinical trial with accrual between October 27, 2016, and April 2, 2020, in 2 Veterans Administration health care systems (Colorado and Washington), and including community-based outpatient clinics. Outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life participated. Intervention The intervention involved 6 phone calls with a nurse to help with symptom management and 6 phone calls with a social worker to provide psychosocial care. The nurse and social worker met weekly with a study primary care and palliative care physician and as needed, a pulmonologist, and cardiologist. Usual care included an educational handout developed for the study that outlined self-care for COPD, ILD, or HF. Patients in both groups received care at the discretion of their clinicians, which could include care from nurses and social workers, and specialists in cardiology, pulmonology, palliative care, and mental health. Main Outcomes and Measures The primary outcome was difference in change in quality of life from baseline to 6 months between the intervention and usual care groups (FACT-G score range, 0-100, with higher scores indicating better quality of life, clinically meaningful change >= 4 points). Secondary quality-of-life outcomes at 6 months included disease-specific health status (Clinical COPD Questionnaire; Kansas City Cardiomyopathy Questionnaire-12), depression (Patient Health Questionnaire-8) and anxiety (Generalized Anxiety Disorder-7) symptoms. Results Among 306 randomized patients (mean [SD] age, 68.9 [7.7] years; 276 male [90.2%], 30 female [9.8%]; 245 White [80.1%]), 177 (57.8%) had COPD, 67 (21.9%) HF, 49 (16%) both COPD and HF, and 13 (4.2%) ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% (intervention, 117 of 154; usual care, 116 of 152) at 6 months for both groups. Mean (SD) length of intervention was 115.1 (33.4) days and included a mean of 10.4 (3.3) intervention calls per patient. In the intervention group, 112 of 154 (73%) patients received the intervention as randomized. At 6 months, mean FACT-G score improved 6.0 points in the intervention group and 1.4 points in the usual care group (difference, 4.6 points [95% CI, 1.8-7.4]; P = .001; standardized mean difference, 0.41). The intervention also improved COPD health status (standardized mean difference, 0.44; P = .04), HF health status (standardized mean difference, 0.41; P = .01), depression (standardized mean difference, -0.50; P < .001), and anxiety (standardized mean difference, -0.51; P < .001) at 6 months. Conclusions and Relevance For adults with COPD, HF, or ILD who were at high risk of death and had poor quality of life, a nurse and social worker palliative telecare team produced clinically meaningful improvements in quality of life at 6 months compared with usual care.

PDF file - 97K, shRNA target sequences (S1); Primers used for quantitative RT-PCR (S2).

Supplementary Table S2 from Baseline Gene Expression Predicts Sensitivity to Gefitinib in Non–Small Cell Lung Cancer Cell Lines

PDF file - 1864K, NRP2 is stably up-regulated by TGFβ in lung cancer cells without increasing the halflife of mRNA or protein (S1); NRP2 up-regulation is blocked by inhibition of TβRI, AKT, ERK and ZEB1, but not by expression of inhibitory SMAD7 (S2); NRP2 knockdown blunts TGFβ-mediated transcriptional responses, ERK and AKT phosphorylation but does not influence SMAD activation (S3); NRP2 knockdown blocks cell scattering induced by TGFβ (S4); Immunohistochemical detection of NRP2 and cytokeratin in TGFβ exposed xenograft tumors with NRP2 or control knockdowns (S5); E-cadherin and NRP2 immunostaining of samples from a tumor microarray (S6); Predicted miRNA target sites in the 3' UTR of NRP2 and up-regulated NRP2 protein levels in hnRNP E1 knockdown cells (S7).

Supplementary Table S1 from Baseline Gene Expression Predicts Sensitivity to Gefitinib in Non–Small Cell Lung Cancer Cell Lines

Background The renin-angiotensin-aldosterone system (RAAS) contributes to pulmonary hypertension (PH) pathogenesis. Although animal data suggest that RAAS inhibition attenuates PH, it is unknown if RAAS inhibition is beneficial in PH patients. Research Question Is RAAS inhibitor use associated with lower mortality in a large cohort of patients with hemodynamically confirmed PH? Study Design and Methods We used the Department of Veterans Affairs Clinical Assessment Reporting and Tracking Database to study retrospectively relationships between RAAS inhibitors (angiotensin converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs], and aldosterone antagonists [AAs]) and mortality in 24,221 patients with hemodynamically confirmed PH. We evaluated relationships in the full and in propensity-matched cohorts. Analyses were adjusted for demographics, socioeconomic status, comorbidities, disease severity, and comedication use in staged models. Results ACEI and ARB use was associated with improved survival in unadjusted Kaplan-Meier survival analyses in the full cohort and the propensity-matched cohort. This relationship was insensitive to adjustment, independent of pulmonary artery wedge pressure, and also was observed in a cohort restricted to individuals with precapillary PH. AA use was associated with worse survival in unadjusted Kaplan-Meier survival analyses in the full cohort; however, AA use was associated less robustly with mortality in the propensity-matched cohort and was not associated with worse survival after adjustment for disease severity, indicating that AAs in real-world practice are used preferentially in sicker patients and that the unadjusted association with increased mortality may be an artifice of confounding by indication of severity. Interpretation ACEI and ARB use is associated with lower mortality in veterans with PH. AA use is a marker of disease severity in PH. ACEIs and ARBs may represent a novel treatment strategy for diverse PH phenotypes. The renin-angiotensin-aldosterone system (RAAS) contributes to pulmonary hypertension (PH) pathogenesis. Although animal data suggest that RAAS inhibition attenuates PH, it is unknown if RAAS inhibition is beneficial in PH patients. Is RAAS inhibitor use associated with lower mortality in a large cohort of patients with hemodynamically confirmed PH? We used the Department of Veterans Affairs Clinical Assessment Reporting and Tracking Database to study retrospectively relationships between RAAS inhibitors (angiotensin converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs], and aldosterone antagonists [AAs]) and mortality in 24,221 patients with hemodynamically confirmed PH. We evaluated relationships in the full and in propensity-matched cohorts. Analyses were adjusted for demographics, socioeconomic status, comorbidities, disease severity, and comedication use in staged models. ACEI and ARB use was associated with improved survival in unadjusted Kaplan-Meier survival analyses in the full cohort and the propensity-matched cohort. This relationship was insensitive to adjustment, independent of pulmonary artery wedge pressure, and also was observed in a cohort restricted to individuals with precapillary PH. AA use was associated with worse survival in unadjusted Kaplan-Meier survival analyses in the full cohort; however, AA use was associated less robustly with mortality in the propensity-matched cohort and was not associated with worse survival after adjustment for disease severity, indicating that AAs in real-world practice are used preferentially in sicker patients and that the unadjusted association with increased mortality may be an artifice of confounding by indication of severity. ACEI and ARB use is associated with lower mortality in veterans with PH. AA use is a marker of disease severity in PH. ACEIs and ARBs may represent a novel treatment strategy for diverse PH phenotypes. Identifying New Targets for Treatment of Pulmonary HypertensionCHESTVol. 159Issue 4PreviewPulmonary hypertension (PH), defined by elevated pulmonary artery pressure, is commonly encountered in clinical practice of cardiovascular and pulmonary medicine. The World Symposium on PH divides PH into groups based on common underlying conditions, pathophysiology, or treatment response.1 Accurate group assignment in PH informs appropriate medical management and our understanding of prognosis. For example, early recognition and prompt treatment of pulmonary arterial hypertension (group 1 PAH) with evidence-based pulmonary vasodilator therapy has been a central thesis of World Symposium guidelines. Full-Text PDF

•Recall at least 3 psychosocial issues commonly associated with post-traumatic stress disorder.•Describe at least 3 medical conditions commonly associated with post-traumatic stress disorder and describe how this population level study may or may not support an association with those medical conditions. Post-traumatic stress disorder (PTSD) has been linked to specific medical conditions, such as cardiovascular disease and dementia. However, little is known about the intersection of PTSD and serious medical illness. To examine differences in demographics and in medical and psychiatric comorbidities between veterans with and without PTSD, among a cohort of veterans dying with serious medical illness. Descriptive data of 564,262 users of Veterans Affairs, dying between 2012 and 2015 with serious medical illnesses, based on ICD-9 codes and stratified by PTSD, were compared using Student's t-test (continuous data) and chi-square (categorical data). Relative risks were calculated for psychiatric and medical diagnoses, comparing veterans with PTSD to those without PTSD, stratified by age (<60, 60-69, 70-79, ≥80). Of the cohort, 55,804 (9.9%) had a PTSD diagnosis. Veterans with PTSD were more likely to be younger at death (age 71.9 vs 78.7, p<0.001), non-white (17.6% vs 11.7%, p<0.001), of lower socioeconomic status (4.0 vs 4.4, p<0.001) and have a history of homelessness (13.7% vs 5.4%, p<0.001). The relative risks (RRs) for alcohol and drug use disorders in veterans with PTSD were 3.07 (95% CI 3.00-3.15) and 2.35 (95% CI 2.30-2.40), respectively. For medical conditions, the highest RR for veterans with PTSD was for chronic liver disease (2.04, 95% CI 1.99-2.10). The RR for dementia in veterans with PTSD was 0.85 (95% CI 0.84-0.86). However, when stratified by age, dementia RR was highest for those < age 60 (1.42, 95% CI 1.26-1.61) and was >1 across all age subgroups (range 1.22-1.42). Only chronic pulmonary disease had RRs > 1 overall (1.14, 95% CI 1.13-1.15) and across all age subgroups. Cardiac disease risk was more modest, even with age stratification. A combination of social, psychological, and medical challenges may contribute to the experiences of veterans with PTSD and serious medical illness.

Accurate assessment of hypoglycemia risk is critical for treatment selection in individuals with diabetes and cardiovascular disease (CVD) - patients for whom hypoglycemia is particularly harmful. We developed and validated a hypoglycemia prediction model in diabetes patients with and without CVD using data routinely available in electronic health records (EHR) and compared performance to a published prediction model. We studied 128,893 US Veterans with diabetes and angiographic assessment of CVD from 2005 to 2018. We used a random 2/3 of the sample for model development and the remaining 1/3 for validation. The primary outcome was severe hypoglycemia based on a previously validated algorithm that uses diagnosis codes and glucose measurements. We evaluated 33 potential predictors, including demographics, diabetes-related variables, comorbidities, and CVD risk factors. We sequentially used two machine learning algorithms for model development. First, we used multivariable adaptive regression splines, which can accommodate interactions and non-linearities for continuous variables, to select predictors. Second, we used adaptive elastic net, which can accommodate time-to-event outcomes, to fit a model with the selected variables. We tested model discrimination using the area under the ROC curve (AUC) and calibration by plotting predicted versus observed event rates in the independent validation cohort. The best-fitting prediction model included 18 predictors; a history of hypoglycemia was the strongest predictor (Table). In external validation, AUC was 0.729 for 2-year events, and the slope of the calibration curve was 1.05, exceeding performance of the published model in this patient population for both discrimination and calibration (Table). Conclusions: Applying supervised machine learning to EHR data may provide an efficient approach to tailoring prediction of preventable clinical outcomes, e.g., hypoglycemia, for high risk patients receiving care in an integrated healthcare system.

SESSION TITLE: Advancing the Decision-Making Process in Lung Cancer SESSION TYPE: Original Investigations PRESENTED ON: 10/22/2019 10:45 AM - 11:45 AM PURPOSE: The Center for Medicare and Medicaid Services requires documentation of shared decision-making (SDM) for lung cancer screening (LCS) reimbursement. The purpose of this pilot study was to determine what patients recall about LCS eligibility, benefits, and risks 6-12 months after an SDM encounter. METHODS: We developed a knowledge survey containing 34 questions about LCS eligibility, risks, and benefit. Surveys were reviewed by experts for accuracy and were then pre-tested in LCS patients to assess survey content and flow. Surveys were sent by postal service or email to patients who had a baseline screening CT 6-12 months prior. Analysis focused on seven key questions: 1. Should all current and former smokers be screened for lung cancer? 2. How old do people have to be before they can be screened for lung cancer? 3. What is the minimum number of pack years required to be eligible for lung cancer screening? 4. Is a CT scan better at detecting a possible lung cancer than a chest x-ray? 5. Without screening, is lung cancer often found at a later stage when cure is less likely? 6. Can a CT scan suggest you have lung cancer when you do not? 7. Is radiation exposure one of the harms of lung cancer screening? RESULTS: Surveys were sent to 162 patients; 39 complete responses were obtained, yielding a 24% response rate. Respondents were 100% non-Hispanic white, 63% were male, and had a mean 51 pack year smoking history (range 28 – 147 pack years). Respondents answered questions about LCS benefit (questions 4 & 5) correctly 88% of the time, however questions about LCS risk (questions 6 & 7) were correctly answered 35% of the time and questions about LCS eligibility (questions 1, 2, & 3) were answered correctly only 9% of the time. The p-value for differences across response rates was <0.0001. Interestingly, females answered questions related to risks (questions 6 & 7) more accurately by 45% (p = 0.05). CONCLUSIONS: LCS patients recall information about potential LCS benefit much better then they recall information about LCS risks or eligibility. CLINICAL IMPLICATIONS: Clinicians must maintain an active role in identifying and counseling patients for LCS as patients tend to dramatically overestimate benefit while minimizing risk. DISCLOSURES: No relevant relationships by Anna Baron, source=Web Response No relevant relationships by Erin Hirsch, source=Web Response No relevant relationships by Stephen Malkoski, source=Web Response No relevant relationships by Melissa New, source=Web Response

Abstract More than 200,000 Veterans transition between hospital and skilled nursing facility (SNF) annually. Capturing outcomes of these transitions has been challenging because older adult Veterans receive care at VA and non-VA hospitals, and four different kinds of SNFs: VA-owned and -operated Community Living Centers (CLCs), VA-contracted community nursing homes (CNHs), State Veterans Homes (SVHs), and non-VA community SNFs. We used a novel data source which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans, to calculate the rate of adverse outcomes associated with the transition from hospital to SNF in all enrolled Veterans age 65 and older undergoing this transition 2012-2014. The composite primary outcome included Emergency Department (ED) visits, rehospitalizations, and mortality (not in the context of hospice) within 7 days of hospital discharge to SNF. We used multivariable logistic regression to adjust for Veteran and hospital characteristics and hospital random effects. In the 388,339 Veterans discharged from 1502 hospitals in our sample, we found more than 4 in 5 Veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7%. After adjustment, VA hospitals had lower adverse outcome rates than non-VA hospitals (OR 0.80, 95% CI 0.74-0.86). VA hospital-CLC transitions had the lowest adverse outcome rates; in comparison, non-VA hospital-CNH (OR 2.51, 95% CI 2.09-3.02) and non-VA hospital-CLC (OR 2.25, 95% CI 1.81-2.79) had the highest rates. These findings raise important questions about the VA’s role as a major provider and payer of post-acute care in SNF.

Objective: The aim of this study was to examine whether falls are associated with the subsequent ability to work among workers aged 65 years and older. Methods: This longitudinal cohort study followed older workers enrolled in the Health and Retirement Study. Outcomes included time to health-related work limitation and to labor force exit. Results: After adjustment, multiple falls with or without a medically treated injury were associated with time to limitation [hazard ratio (HR) = 1.77, 95% confidence interval (95% CI): 1.30 to 2.40; HR = 1.48, 95% CI: 1.26 to 1.73, respectively]. Adjustment mitigated a crude relationship between falls and time to exit. Significant interactions suggest that the relationship between falls and labor force exit depends on age, race, and job demands. Conclusion: Falls, both noninjurious and injurious, are associated with subsequent health-related work limitation among workers aged 65 years and older. Fall prevention activities would benefit workers who want or need to keep working past age 65.

ABSTRACT Novel measures of hospital quality are needed. Because quality improvement efforts seek to reduce variability in processes and outcomes, hospitals with higher variability in adverse events may be delivering poorer quality care. We sought to evaluate whether within-hospital variability in adverse events after a procedure might function as a quality metric that is correlated with facility-level mortality rates. We analyzed all percutaneous coronary interventions (PCIs) performed in the Veterans Health Administration (VHA) system from 2007 to 2013 to evaluate the correlation between within-hospital variability in 30-day postdischarge adverse events (readmission, emergency department visit, and repeat revascularization), and facility-level mortality rates, after adjustment for patient demographics, comorbidities, PCI indication, and PCI urgency. The study cohort included 47,567 patients at 48 VHA hospitals. The overall 30-day adverse event rate was 22.0% and 1-year mortality rate was 4.9%. The most variable sites had relative changes of 20% in 30-day rates of adverse events period-to-period. However, within-hospital variability in 30-day events was not correlated with 1-year mortality rates (correlation coefficient = .06; p = .66). Thus, measuring within-hospital variability in postdischarge adverse events may not improve identification of low-performing hospitals. Evaluation in other conditions, populations, and in relationship with other quality metrics may reveal stronger correlations with care quality.

BACKGROUND As the workforce ages, occupational injuries from falls on the same level will increase. Some industries may be more affected than others. METHODS We conducted a cross-sectional study using data from the Bureau of Labor Statistics to estimate same-level fall injury incidence rates by age group, gender, and industry for four sectors: 1) healthcare and social assistance; 2) manufacturing; 3) retail; and 4) transportation and warehousing. We calculated rate ratios and rate differences by age group and gender. RESULTS Same-level fall injury incidence rates increase with age in all four sectors. However, patterns of rate ratios and rate differences vary by age group, gender, and industry. Younger workers, men, and manufacturing workers generally have lower rates. CONCLUSIONS Variation in incidence rates suggests there are unrealized opportunities to prevent same-level fall injuries. Interventions should be evaluated for their effectiveness at reducing injuries, avoiding gender- or age-discrimination and improving work ability.

Introduction: Cocaine use has been associated with adverse cardiovascular outcomes. Methods: The Department of Veterans Affairs Clinical Assessment Reporting and Tracking Program database was used ...

Introduction: Patients with critical limb ischemia (CLI) are at high risk for amputation and death. However, there is sparse data on predictors of amputation and death among CLI patients who have u...