AIMS:To evaluate the association between Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) alcohol screening scores, collected as part of routine clinical care, and three outcomes in the following year (Aim 1), and the association between changes in AUDIT-C risk group at 1-year follow-up and the same outcomes in the subsequent year (Aim 2).DESIGN:Cohort study.SETTING:Twenty-four US Veterans Affairs (VA) healthcare systems (2004-07), before systematic implementation of brief intervention.PARTICIPANTS:A total of 486 115 out-patients with AUDIT-Cs documented in their electronic health records (EHRs) on two occasions ≥ 12 months apart ('baseline' and 'follow-up').MEASUREMENTS:Independent measures were baseline AUDIT-C scores and change in standard AUDIT-C risk groups (no use, low-risk use and mild, moderate, severe misuse) from baseline to follow-up. Outcome measures were (1) high-density lipoprotein cholesterol (HDL), (2) alcohol-related gastrointestinal hospitalizations ('GI hospitalizations') and (3) physical trauma, each in the years after baseline and follow-up.FINDINGS:Baseline AUDIT-C scores had a positive association with outcomes in the following year. Across AUDIT-C scores 0-12, mean HDL ranged from 41.4 [95% confidence interval (CI) = 41.3-41.5] to 53.5 (95% CI = 51.4-55.6) mg/l, and probabilities of GI hospitalizations from 0.49% (95% CI = 0.48-0.51%) to 1.8% (95% CI = 1.3-2.3%) and trauma from 3.0% (95% CI = 2.95-3.06%) to 6.0% (95% CI = 5.2-6.8%). At follow-up, patients who increased to moderate or severe alcohol misuse had consistently higher mean HDL and probabilities of subsequent GI hospitalizations or trauma compared with those who did not (P-values all < 0.05). For example, among those with baseline low-risk use, in those with persistent low-risk use versus severe misuse at follow-up, the probabilities of subsequent trauma were 2.65% (95% CI = 2.54-2.75%) versus 5.15% (95% CI = 3.86-6.45%), respectively. However, for patients who decreased to lower AUDIT-C risk groups at follow-up, findings were inconsistent across outcomes, with only mean HDL decreasing in most groups that decreased use (P-values all < 0.05).CONCLUSIONS:When AUDIT-C screening is conducted in clinical settings, baseline AUDIT-C scores and score increases to moderate-severe alcohol misuse at follow-up screening appear to have predictive validity for HDL cholesterol, alcohol-related gastrointestinal hospitalizations and physical trauma. Decreasing AUDIT-C scores collected in clinical settings appear to have predictive validity for only HDL.

Background Many HIV antiretroviral medications have been associated with chronic liver injury. HIV-infected patients frequently develop HIV and highly active antiretroviral treatment-associated lipodystrophy syndrome (HALS), characterized by accumulation of intra-abdominal fat, insulin resistance, and hepatic steatosis. We sought to determine whether long-term exposure to specific antiretroviral medications or the presence of HALS predispose HIV-infected patients to the development of cirrhosis.Methods HIV-infected patients with cirrhosis who received care in the Veterans Affairs Healthcare System nationally in 2009 were matched by hepatitis C virus (HCV) coinfection status and year of first visit for HIV to the Veterans Affairs Healthcare System with HIV-infected patients without cirrhosis in a 1 : 3 ratio.Results Among HIV/HCV coinfected patients (593 with cirrhosis and 1591 matched controls), HALS was associated with a significantly increased risk for cirrhosis (adjusted odds ratio 1.6, 95% confidence interval 1.1-2.3), especially among Black patients (adjusted odds ratio 2.9, 95% confidence interval 1.6-5.2). In addition, among HIV/HCV coinfected patients, longer cumulative exposures to all antiretroviral medications, all nucleoside reverse transcriptase inhibitors, all protease inhibitors, and selected individual medications (didanosine, stavudine, and nelfinavir) were found to be significantly associated with cirrhosis. In contrast, among HIV-infected patients not coinfected with HCV (245 with cirrhosis and 658 matched controls), HALS or exposure to antiretroviral medications was found not to be significantly associated with cirrhosis, with the exception of didanosine.Conclusion HALS and cumulative exposure to nucleoside reverse transcriptase inhibitors and protease inhibitors, especially stavudine, didanosine, and nelfinavir, were found to be associated with the development of cirrhosis in HIV/HCV coinfected patients, but not in HIV-monoinfected patients. Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights reserved.

OBJECTIVES:To compare healthcare costs, utilization, and medication adherence between diabetic responders and nonresponders to a patient satisfaction survey.STUDY DESIGN:We performed a retrospective cohort study of 40,766 patients with diabetes who had been randomly selected to receive the 2006 Veterans Affairs' Survey of Healthcare Experiences of Patients. Outcomes were measured during the following year.METHODS:We used multivariable models to compare healthcare costs (generalized linear models), utilization (negative binomial regression), and adherence to oral hypoglycemic medications (logistic regression) between survey responders and nonresponders.RESULTS:There were 26,051 patients (64%) who responded to the survey. Survey nonresponders incurred significantly higher healthcare costs (incremental effect, $792; 95% CI, $599-$986; P < .01). Nonresponders had a modest increase in primary care (incidence rate ratio [IRR], 1.06; 95% CI, 1.05-1.08; P < .01) and specialty care visits (IRR, 1.17; 95% CI, 1.12-1.22; P < .01), but more substantial increases in mental health visits (IRR, 1.74; 95% CI, 1.62-1.87; P < .01) and hospitalizations (IRR, 1.60; 95% CI, 1.46-1.75; P < .01). Medication adherence was significantly lower among survey nonresponders (odds ratio, 0.68; 95% CI, 0.65-0.74; P < .01).CONCLUSIONS:Nonresponders to a patient satisfaction survey incurred higher healthcare costs and utilization, but had lower medication adherence. Understanding these characteristics helps to assess the impact of nonresponse bias on patient satisfaction surveys and identifies clinical practices to improve care delivery.

BACKGROUND:Thiazolidinediones (TZDs) are oral antihyperglycemic medications that are selective agonists to peroxisome proliferator-activated receptor gamma and have been shown to have potent anti-inflammatory effects in the lung.OBJECTIVE:The purpose of this study was to assess whether exposure to TZDs is associated with a decreased risk of chronic obstructive pulmonary disease (COPD) exacerbation.METHODS:A cohort study was performed by collecting data on all US veterans with diabetes and COPD who were prescribed oral antihyperglycemic medications during from period of October 1, 2005 to September 30, 2007. Patients who had two or more prescriptions for TZDs were compared with patients who had two or more prescriptions for an alternative oral anti-hyperglycemic medication. Multivariable negative binomial regression was performed with adjustment for potential confounding factors. The primary outcome was COPD exacerbations, including both inpatient and outpatient exacerbations.RESULTS:We identified 7,887 veterans who were exposed to TZD and 42,347 veterans who were exposed to non-TZD oral diabetes medications. COPD exacerbations occurred in 1,258 (16%) of the TZD group and 7,789 (18%) of the non-TZD group. In multivariable negative binomial regression, there was a significant reduction in the expected number of COPD exacerbations among patients who were exposed to TZDs with an incidence rate ratio of 0.86 (95% CI 0.81-0.92).CONCLUSION:Exposure to TZDs was associated with a small but significant reduction in risk for COPD exacerbation among diabetic patients with COPD.

OBJECTIVES:Veterans Health Administration (VA) operates the largest integrated health system in the nation. The Affordable Care Act (ACA) does not require any changes to VA, but the individual mandate and expanded health insurance options may change veterans' preferences for coverage. We examined the impact of healthcare reform in Massachusetts, which also included these policy changes, on veterans' enrollment in VA, private insurance, and Medicaid.STUDY DESIGN:Massachusetts' healthcare reform in June 2006 served as a natural experiment. Using data from the 2004-2013 Current Population Surveys, we examined enrollment in VA, private insurance, and Medicaid, comparing veterans residing in Massachusetts with veterans residing in neighboring New England states that did not undergo health reform.METHODS:We estimated the probability of being enrolled in VA, private insurance, and Medicaid before and after healthcare reform, using multivariate probit models while adjusting for individual characteristics. Using a difference-in-difference approach, we compared pre-post changes in enrollment probability among Massachusetts and non-Massachusetts veterans, respectively.RESULTS:Compared with other New England veterans, Massachusetts veterans decreased their enrollment in VA and private insurance by 0.2 (P = .857) and 0.9 (P = .666) percentage points, respectively, following health reform. In contrast, Medicaid enrollment increased by 2.5 percentage points (P = .038).CONCLUSIONS:Healthcare reform in Massachusetts was associated with greater Medicaid enrollment, but was not significantly associated with VA and private insurance enrollment. Our results are significant for informing VA fiscal planning in the post ACA era.

Although extensive investigation has been made on miR-29a in relation to malignancies, only a little information has been provided about the angiogenic property of this miRNA so far. Herein, we sought to investigate the role of miR-29a in regulating cell cycle and angiogenic phenotype of endothelial cells. The results showed that miR-29a is highly expressed and upregulated by hypoxia-mimicking reagents in human umbilical vein endothelial cells (HUVEC). Consistent with this preliminary finding, introduction of exogenous agomiR-29a, or Antagomir-29a altered cell cycle progression and promoted, or repressed the proliferation and tube formation of HUVEC, respectively. Furthermore, by using luciferase reporter assay, the expression of HBP1, a suppressor transcription factor was directly regulated by miR-29a through 3′-UTR. Increased or decreased HBP1 protein level was associated with the inhibition or overexpression of miR-29a, respectively. We conclude that miR-29a has a significant role in regulating cell cycle, proliferation and angiogenic properties of HUVEC, and this function is likely mediated through HBP1 protein at the post-transcriptional level. As a novel molecular target, miR-29a may have a potential value for the treatment of angiogenesis-associated diseases such as cardiovascular diseases and cancers.

BACKGROUND:In the United States, more than 25 million people have diabetes. Medication adherence is known to be important for disease control. However, factors that consistently predict medication adherence are unclear and the literature lacks patient perspectives on how health care systems affect adherence to oral hypoglycemic agents (OHAs). This study explored facilitators and barriers to OHA adherence by obtaining the perspectives of Veterans Affairs (VA) patients with OHA prescriptions.METHODS:A total of 45 patients participated in 12 focus groups that explored a wide range of issues that might affect medication adherence. Participants were patients at clinics in Seattle, Washington; San Antonio, Texas; Portland, Oregon; Salem, Oregon, and Warrenton, Oregon.RESULTS:Key system-level facilitators of OHA adherence included good overall pharmacy service and several specific mechanisms for ordering and delivering medications (automated phone refill service, Web-based prescription ordering), as well as providing pillboxes and printed lists of current medications to patients. Barriers mirrored many of the facilitators. Poor pharmacy service quality and difficulty coordinating multiple prescriptions emerged as key barriers.CONCLUSIONS:VA patient focus groups provided insights on how care delivery systems can encourage diabetes medication adherence by minimizing the barriers and enhancing the facilitators at both the patient and system levels. Major system-level factors that facilitated adherence were overall pharmacy service quality, availability of multiple systems for reordering medications, having a person to call when questions arose, counseling about the importance of adherence and providing tools such as pillboxes and updated medication lists.

Background/Objective: Though the safety of transradial percutaneous coronary intervention (TRI) has been demonstrated in clinical trial and registry studies, adoption of TRI in the United States has been slow. We fielded a national survey with VA interventional cardiologists to understand factors influencing TRI use. Methods: The structured survey was developed from telephone interviews with interventional cardiologists, catheterization laboratory nurses and radiology technicians at 3 VA hospital cath labs. The survey assessed extent of interventional cardiologists’ experience with TRI, perceptions of the advantages or disadvantages of TRI relative to transfemoral PCI (TFI), and barriers to adopting and implementing TRI. We used the the Cardiovascular Assessment Reporting and Tracking (CART) registry to define our sampling frame, all VA interventional cardiologists, and to obtain cath lab TRI rates. We tested whether respondents’ opinions of the relative advantages of and barriers to TRI were associated with site-level TRI rates in a 13-month period following to the survey (January 2012 to January 2013). Results: We received responses from 78 of 235 interventional cardiologists representing 48 of 65 VA cath labs (33% response rate; 73% of cath labs). The most prevalent barriers to TRI adoption cited by cardiologists were increased radiation exposure to the cardiologist (63% cited as a major or minor barrier) or staff (51% of respondents), and the steep learning curve (44%). Other barriers such as difficulty obtaining necessary equipment (25%), lack of support from cath lab staff (23%), and lack of training opportunities (18%), were less prevalent. The majority of cardiologists rated TRI as superior for ease of post-procedure monitoring (52%), patient comfort (60%), early discharge (65%), fewer vascular access complications (69%), and less bleeding (72%). However, a majority rated TFI superior for shorter procedure duration (69%) and technical results (47% rated superior, 49% as no difference). One-year cath lab TRI rates ranged from 1.1% (3 of 270) to 90.2% (286 of 317), with a median of 7.3%. Only nine cath labs had a 1-year TRI rate greater than 50%. No barriers were correlated with TRI rates; however, all of the relative advantage measures were significantly, positively correlated. The strongest correlations were for faster procedure time (r=.59, p<.0001) and ease of post-procedure monitoring (r=.52, p<.0001). Conclusions: This study demonstrates that while interventional cardiologists are familiar with the advantages of TRI over TFI, there is still limited adoption of TRI on a broad scale. There were no reported barriers associated with site-level radial rates suggesting that obstacles to TRI adoption are likely multifactorial. Effective TRI training programs should focus on methods to reduce radiation exposure and manage expectations about the radial learning curve.

Thiazolidinediones are oral diabetes medications that selectively activate peroxisome proliferator-activated receptor gamma and have potent anti-inflammatory properties. While a few studies have found improvements in pulmonary function with exposure to thiazolidinediones, there are no studies of their impact on asthma exacerbations. Our objective was to assess whether exposure to thiazolidinediones was associated with a decreased risk of asthma exacerbation.

Care continuity, access, and coordination are important features of the patient-centered medical home model and have been emphasized in the Veterans Health Administration patient-centered medical home implementation, called the Patient Aligned Care Team. Data from more than 4.3 million Veterans were used to assess the relationship between these attributes of Patient Aligned Care Team and Veterans Health Administration hospitalization and mortality. Controlling for demographics and comorbidity, we found that continuity with a primary care provider was associated with a lower likelihood of hospitalization and mortality among a large population of Veterans receiving VA primary care.

Care continuity, access, and coordination are important features of the patient-centered medical home model and have been emphasized in the Veterans Health Administration patient-centered medical home implementation, called the Patient Aligned Care Team. Data from more than 4.3 million Veterans were used to assess the relationship between these attributes of Patient Aligned Care Team and Veterans Health Administration hospitalization and mortality. Controlling for demographics and comorbidity, we found that continuity with a primary care provider was associated with a lower likelihood of hospitalization and mortality among a large population of Veterans receiving VA primary care.

UNLABELLED:Cirrhosis is a leading cause of death among patients infected with human immunodeficiency virus (HIV). We sought to determine risk factors for and time trends in the prevalence of cirrhosis, decompensated cirrhosis, and hepatocellular carcinoma (HCC) among patients diagnosed with HIV who received care in the Veterans Affairs (VA) health care system nationally between 1996 and 2009 (n = 24,040 in 2009). Among patients coinfected with HIV and hepatitis C virus (HCV), there was a dramatic increase in the prevalence of cirrhosis (3.5%-13.2%), decompensated cirrhosis (1.9%-5.8%), and HCC (0.07%-1.6%). Little increase was observed among patients without HCV coinfection in the prevalence of cirrhosis (1.7%-2.2%), decompensated cirrhosis (1.1%-1.2%), and HCC (0.03%-0.13%). In 2009, HCV infection was present in the majority of patients with HIV who had cirrhosis (66%), decompensated cirrhosis (62%), and HCC (80%). Independent risk factors for cirrhosis included HCV infection (adjusted odds ratio [AOR], 5.82; 95% confidence interval [CI], 5.0-6.7), hepatitis B virus (HBV) infection (AOR, 2.40; 95% CI, 2.0-2.9), age (AOR, 1.03; 95% CI, 1.02-1.04), Hispanic ethnicity (AOR, 1.76; 95% CI, 1.4-2.2), diabetes (AOR, 1.79; 95% CI, 1.6-2.1), and alcohol abuse (AOR, 1.78; 95% CI, 1.5-2.1), whereas black race (AOR, 0.56; 95% CI, 0.48-0.64) and successful eradication of HCV (AOR, 0.61; 95% CI, 0.4-0.9) were protective. Independent risk factors for HCC included HCV infection (AOR, 10.0; 95% CI, 6.1-16.4), HBV infection (AOR, 2.82; 95% CI, 1.7-4.7), age (AOR, 1.05; 95% CI, 1.03-1.08), and low CD4+ cell count (AOR, 2.36; 95% CI, 1.3-4.2). Among 5999 HIV/HCV-coinfected patients, 994 (18%) had ever received HCV antiviral treatment, of whom 165 (17%) achieved sustained virologic response. CONCLUSION:The prevalence of cirrhosis and HCC has increased dramatically among HIV-infected patients driven primarily by the HCV epidemic. Potentially modifiable risk factors include HCV infection, HBV infection, diabetes, alcohol abuse, and low CD4+ cell count.

School of Psychology, National University of Ireland, Galway Galway, Ireland The author declares no conflict of interest.

Background-Studies examining the association between radial approach and post-percutaneous coronary intervention (PCI) bleeding and mortality have reached conflicting conclusions. There are no current data about the use and outcomes of transradial PCI (r-PCI) in the Veterans Affairs system.Methods and Results-Consecutive veterans (n=24143 patients) undergoing PCI in the Veterans Affairs between 2007 and 2010 were examined. On the basis of propensity to undergo r-PCI, 3 cohorts matched with veterans undergoing transfemoral access were constructed among sites performing >= 1 r-PCI, >= 50 r-PCI (high volume), and <50 r-PCI (low volume). Cox proportional hazard models were used to determine the association between PCI access site, blood transfusion, and mortality. The prevalence of r-PCI increased over time (2007=2.1%; 2010=8.8%). Overall, there was no difference in procedure success between matched groups (r-PCI 97.3% versus transfemoral PCI 96.6%; P=0.182), or in the risk of postprocedure transfusion or mortality. Among matched patients treated at high r-PCI volume sites, radial access was associated with a decreased risk of post-PCI blood transfusion (hazard ratio, 0.4; 95% confidence interval, 0.3-0.7; P<0.001), and no significant difference in the risk of mortality (hazard ratio, 0.7; 95% confidence interval, 0.4-1.3; P=0.279).Conclusions-Within the Veterans Affairs, the use of r-PCI increased over time. r-PCI may be associated with a significant decreased risk of post-PCI blood transfusion among higher volume r-PCI sites. These data demonstrate that potential benefits of r-PCI in terms of reduced post-PCI blood transfusions may be more pronounced at sites that routinely use radial access.

BACKGROUND:The Veterans Health Administration (VHA) is the largest integrated US health system to implement the patient-centered medical home. The Patient Aligned Care Team (PACT) initiative (implemented 2010-2014) aims to achieve team based care, improved access, and care management for more than 5 million primary care patients nationwide.OBJECTIVES:To describe PACT and evaluate interim changes in PACT-related care processes.STUDY DESIGN:Data from the VHA Corporate Data Warehouse were obtained from April 2009 (pre- PACT) to September 2012. All patients assigned to a primary care provider (PCP) at all VHA facilities were included.METHODS:Nonparametric tests of trend across time points.RESULTS:VHA increased primary care staff levels from April 2010 to December 2011 (2.3 to 3.0 staff per PCP full-time equivalent). In-person PCP visit rates slightly decreased from April 2009 to April 2012 (53 to 43 per 100 patients per calendar quarter; P < .01), while in-person nurse encounter rates remained steady. Large increases were seen in phone encounters (2.7 to 28.8 per 100 patients per quarter; P < .01), enhanced personal health record use (3% to 13% of patients enrolled), and electronic messaging to providers (0.01% to 2.3% of patients per quarter). Post hospitalization follow-up improved (6.6% to 61% of VA hospital discharges), but home telemonitoring (0.8% to 1.4% of patients) and group visits (0.2 to 0.65 per 100 patients per quarter; P < .01) grew slowly.CONCLUSIONS:Thirty months into PACT, primary care staff levels and phone and electronic encounters have greatly increased; other changes have been positive but slower.