Texas Veterans Health Care System Research Articles

Implementation of a CIWA-Ar alcohol withdrawal protocol in a veterans hospital.

The South Texas Veterans Health Care System (STVHCS) implemented a Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)-based alcohol-withdrawal protocol in June 2013. The aim of this study was to determine the efficacy and safety of the new protocol. The primary objective was the evaluation of whether implementation of the CIWA-Ar alcohol-withdrawal protocol decreased the average length of hospital stay for patients admitted with alcohol withdrawal syndrome (AWS) as compared with treatment before the introduction of the protocol. Secondary endpoints evaluated benzodiazepine (BZD)-prescribing practices, use of adjunctive medications for AWS, and safety outcomes. We reviewed 748 admissions with documented AWS or alcohol-related diagnoses during the study periods of July 2012 to December 2012 (preprotocol) and July 2013 to December 2013 (postprotocol). Patients in the preprotocol group needed to have a scheduled dose of a BZD in the electronic medical record, and those assigned to the postprotocol group needed to have at least one documented CIWA-Ar note in their electronic medical record. Exclusion criteria included prior conditions that interfered with accurate treatment of alcohol withdrawal. There were no statistical differences in baseline characteristics between groups. No difference was found in the primary endpoint of length of stay when comparing hospitalizations pre- and postprotocol implementation (3.84 ± 2.31 days vs 3.82 ± 2.7 days; P = 0.667). There was no statistical significance in total cumulative dose of BZD, daily dose of BZD, or duration of BZD use when compared pre- and postprotocol. No safety events requiring further intervention occurred. Implementation of a CIWA-Ar protocol at our institution did not result in a decreased duration of hospital stay; however, a decline in prescribing fixed-schedule BZDs was documented.

Improving outcomes of hospitalized patients: the Physician Relationships, Improvising, and Sensemaking intervention protocol.

BackgroundOur goal is to improve the safety and effectiveness of inpatient care. Rather than focus on improving process of care, we focus on the social structure within physician teams. We have developed the Physician Relationships, Improvising, and Sensemaking (PRISm) intervention to improve the way physician teams round, enabling them to better relate, make sense of their patients’ conditions, and improvise in uncertain clinical situations. We are currently studying the impact of PRISm on adverse events and complications in hospitalized patients. This manuscript describes the PRISm intervention.Methods/designPRISm is a structured communication tool consisting of three components: daily briefings before rounds; use of the Situation, Task, Intent, Concern, and Calibrate (STICC) framework during rounds as part of the discussion of individual patients; and debriefings after rounds. We are implementing the PRISm intervention on eight inpatient medical and surgical physician teams in the South Texas Veterans Health Care System. We are assessing PRISm impact on the way team members relate to each other, round, and discuss patients through pre- and post-implementation observations and surveys. We are also assessing PRISm impact on complications and adverse events. Finally, we are interviewing physicians regarding their experience using the intervention.DiscussionOur results will allow us to begin to understand the potential impact of interventions designed to improve how providers relate to each other, improvise, and make sense of what is happening as a strategy for improving inpatient care. Our in-depth data collection will enable us to assess how relationships, improvising, and sensemaking influence patient outcomes, potentially through creating shared mental models or enhancing distributed cognition during clinical reasoning. Finally, our results will lay the groundwork for larger implementation studies to improve clinical outcomes through improving how providers, and providers, patients, and caregivers, relate.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-014-0171-3) contains supplementary material, which is available to authorized users.

Post-traumatic stress disorder in veterans of Operation Enduring Freedom/Operation Iraqi Freedom: Retrospective review of treatment received compared to evidence-based practice guidelines

Background: Post-Traumatic Stress Disorder (PTSD) is a syndrome that can emerge after exposure to a traumatic event. In the veteran population, the strongest predictor of developing PTSD is frequency and intensity of direct combat exposure. The 2010 Veterans Affairs (VA)/Department of Defense (DoD) guidelines for the treatment of PTSD published in 2010 recommend psychotherapy techniques and/or pharmacotherapy (selective serotonin reuptake inhibitor or venlafaxine) as initial management.Objective: This study aimed to determine whether Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans received treatment for PTSD in concordance with VA/DoD guidelines.Methods: A retrospective chart review was conducted for 400 patients at the South Texas Veterans Health Care System (STVHCS) with OEF/OIF service who had a PTSD-related encounter between September 1, 2011 and August 31, 2012. The primary outcome was the percentage of OEF/OIF veterans with PTSD who received treatment in concordance with VA/DoD guidelines. Secondary outcomes included length of time veterans waited to see mental health (MH) providers, and comparison of outcomes between patients who received evidence-based treatment to those that did not.Results: Two-hundred and seventy-nine patients met the inclusion criteria and the majority of patients (n = 183, 65.5%) received treatment consistent with the VA/DoD Guidelines. The overall median wait time to see a MH provider was 10 +/−26.64 days, and did not differ significantly between groups. Patients whose treatment did not follow guideline recommendations had statistically more psychiatric emergency department (ED) visits (10 vs. 17, p=0.0026).Conclusions: The majority of patients at the STVHCS received treatment for PTSD in concordance with the VA/DoD guidelines, and 67.7% of patients saw MH providers within 14 days. Patients who did not receive guideline-supported treatment had more frequent ED visits, but the reason for this is unknown and may be due to a number of factors not accounted for in this review. The number of ED visits may be reduced by fully utilizing the processes in place that work to improve veteran access to MH care and the provision of guideline-based treatment. Prospective studies are needed to clearly elucidate the factors that may impact whether or not patients receive recommended treatment.

The Double Parallel Curriculum in Palliative Care(DP-PC): Using a Double Parallel Education Strategy with Multimedia to Enhance Learners Knowledge and Skills in End of Life Palliative Care (EOL-PC) (TH325-C)

The Double Parallel Curriculum in Palliative Care(DP-PC): Using a Double Parallel Education Strategy with Multimedia to Enhance Learners Knowledge and Skills in End of Life Palliative Care (EOL-PC) (TH325-C) Jennifer Healy, DO, University of Texas Health Science Center, San Antonio, TX. Shuko Lee, MS, South Texas Veterans Health Care System, San Antonio, TX. Jeanette Ross, MD, University of Texas Health Science Center at San Antonio and South Texas Veterans Healthcare System, San Antonio, TX. Sandra Sanchez-Reilly, MD FAAHPM, University of Texas Health Science Center and South Texas Veterans Healthcare System, San Antonio, TX. Phylliss Chappell, MD, University of Texas Health Science Center at San Antonio, San Antonio, TX. Deborah Villarreal, MD, University of Texas Health Science Center at San Antonio, San Antonio, TX. (All authors listed above had no relevant financial relationships to disclose.)

Datapoints: Prevalence of QT Prolongation Among Veterans With Severe Mental Illness

Back to table of contents Previous article Next article ColumnsFull AccessDatapoints: Prevalence of QT Prolongation Among Veterans With Severe Mental IllnessEileen M. Stock, Ph.D., Laurel A. Copeland, Ph.D., M.P.H., Ruth L. Bush, M.D., M.P.H., and John E. Zeber, Ph.D., M.H.A.Eileen M. StockSearch for more papers by this author, Ph.D., Laurel A. CopelandSearch for more papers by this author, Ph.D., M.P.H., Ruth L. BushSearch for more papers by this author, M.D., M.P.H., and John E. ZeberSearch for more papers by this author, Ph.D., M.H.A.Published Online:1 Oct 2013https://doi.org/10.1176/appi.ps.201300212AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The QT interval refers to the time required for the heart to repolarize after ventricular depolarization. The U.S. Food and Drug Administration (FDA) has issued Drug Safety Communications on drugs associated with QT prolongation and fatal ventricular arrhythmias. Antidepressants received attention after the 2011 FDA communication on citalopram, often prescribed off-label for posttraumatic stress disorder (PTSD).Aggregated data (diagnosis codes and outpatient prescriptions) were examined for all Veterans Health Administration (VHA) patients treated between October 2005 and September 2009. Among 7.1 million patients, 1,224 had a diagnosis of QT prolongation (ICD−9 code 426.82). Chi square tests assessed the association of prior-year severe mental illness with QT prolongation.Among patients with QT prolongation, the mean age was similar to that for all VHA patients (about 61 years). However, rates of severe mental illness were higher (28% versus 12% for all VHA patients). Risk factors for QT prolongation included gender (35 females versus 16 males per 100,000) and African-American race (31 per 100,000 versus 20 for all patients). QT prolongation among patients with severe mental illness was nearly triple that among patients without severe mental illness (40 per 100,000 versus 14), and it was elevated for specific illnesses (Figure 1). Citalopram was prescribed to 8% of the study sample, more commonly for patients with PTSD (16%) or major depression (21%). Receipt of any drug associated with QT prolongation varied by illness: without severe mental illness, 14%; schizophrenia, 20%; PTSD, 24%; and major depression, 28%.Figure 1 Prevalence of QT prolongation among Veterans Health Administration patients, October 2005 to September 2009aa95% confidence intervals reported in parentheses. PTSD, posttraumatic stress disorderFindings highlight the need to reevaluate types and combinations of medications that may potentiate heart disease or death among patients with severe mental illness. A study limitation is that the data precede the 2011–2012 FDA Drug Safety Communications, and citalopram use may change in the wake of the warnings.Except for Dr. Bush, the authors are affiliated with the Center for Applied Health Research, which is jointly sponsored by the Central Texas Veterans Health Care System and Scott & White Healthcare, 2102 Birdcreek Dr., Temple, TX 76502 (e-mail: eileen.[email protected]gov). All authors are affiliated with Texas A&M Health Science Center, Bryan, Texas. Amy M. Kilbourne, Ph.D., M.P.H., and Tami L. Mark, Ph.D., are editors of this column.Acknowledgments and disclosuresThe study was supported by grant IIR-09-335 from VA Health Services Research and Development. The views do not necessarily represent those of the Department of Veterans Affairs.The authors report no competing interests. FiguresReferencesCited byDetailsCited byPsychotropic Pharmacotherapy Associated With QT Prolongation Among Veterans With Posttraumatic Stress Disorder11 April 2018 | Annals of Pharmacotherapy, Vol. 52, No. 9Evaluating the risk of QTc prolongation associated with antidepressant use in older adults: a review of the evidence4 May 2018 | Therapeutic Advances in Drug Safety, Vol. 9, No. 6 Volume 64Issue 10 October 2013Pages 942-942 Metrics Acknowledgments and disclosuresThe study was supported by grant IIR-09-335 from VA Health Services Research and Development. The views do not necessarily represent those of the Department of Veterans Affairs.The authors report no competing interests.PDF download History Published online 1 October 2013 Published in print 1 October 2013

A Retrospective Review of the Clinical Impact of Hydrogen Breath Testing for Small Bowel Bacterial Overgrowth in South Texas Veterans Health Care System

Purpose: The aim of our study is to assess the clinical impact of positive hydrogen breath testing for small bowel bacterial overgrowth in VA population. Methods: The charts of 80 patients that were referred for hydrogen breath testing for suspect diagnosis of small bowel bacterial overgrowth were reviewed from July 2010-February 2013. Patients with positive hydrogen breath testing were identified and their charts were reviewed regarding the treatment modality and clinical response. Results: Patients were referred for hydrogen breath tests due to primary symptoms of diarrhea, bloating, vitamin B12 deficiency, diabetes mellitus and abdominal pain. 18/80 (22.5%) patient referred had a positive test. All patients tested positive were treated with antibiotics. There were a total of 18 women and 62 men in the study. 72% of the patients with small bowel bacterial overgrowth who were treated with antibiotics had an improvement of their symptoms, however, this was not statistically significant (p-value 0.07). In our study there were more positive tests among females that underwent testing when compared to males (p-value 0.0113). Conclusion: There was a gender difference for positive testing in our population. Despite small number of females in our study they had more positive tests. Overall symptoms improved with therapy in both groups however this was not statistically significant. In addition, we found that objective testing for response to therapy by repeat breath testing did not occur in any of the patients.

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Effects of an antipsychotic restriction policy in a veteran population

Introduction: Recent trials have failed to demonstrate differences in efficacy between first generation antipsychotics (FGAs) and second generation antipsychotics (SGAs). To reduce costs, many health care systems have restricted the availability of SGAs through use of prior authorizations. Restrictions for the off-label use of SGAs and the use of dual-antipsychotic therapy have also been implemented in many health care systems. At the South Texas Veterans Health Care System (STVHCS), a restricted drug request (RDR) method has been implemented to manage costs and improve patient safety. Risperidone, due to its lower cost and equal efficacy, is the first-line option of SGAs. If one wishes to prescribe an SGA other than risperidone, an RDR is submitted and reviewed by Veterans Integrated Service Network (VISN) pharmacists. Since the introduction of these policies at the STVHCS, the impact of the RDR has not been assessed. Rationale: The primary aim of this study was to determine the effects of the RDR policy on the care of STVHCS veterans as evidenced by changes in hospitalization rates of veterans with a denied request for an SGA due to initial criterion failure. Secondary outcomes included: impact of antipsychotic RDR denial on mental health as evidenced by changes in no-shows and cancellations for follow-up psychiatric appointments, psychiatric emergency department visits, presence of suicidal ideation, change in weight, hemoglobin A1c, number of psychotropic medications prescribed, and extrapyramidal symptoms. Methods: A retrospective chart review of veterans denied an initial SGA request was conducted from 3 months prior to denial to 3 months post request denial (index date). Data collected included: patient demographics, indication for SGA request, reason for SGA denial, length of time for request evaluation, number of psychiatric hospitalizations, number of no-shows and cancellations for mental health appointments, number of psychiatric emergency department visits, number of reports of suicidal ideation or attempts, weight, hemoglobin A1c lab results, presence of extrapyramidal symptoms, and number of prescribed psychotropic medications. The health care utilization data collected pre- and post-index date, were compared. Results were analyzed using Fisher's Exact, 2-tailed standardized t-tests, and descriptive statistics appropriately matched to data type. Results: Results for both primary and secondary outcomes were not statistically significant. No differences were found in the number of veterans hospitalized pre- versus post-index date [0/33 (0%) versus 2/33 (6%), p=0.492.] The most requested indication for an SGA was PTSD [22/33 (66.7%)] and the most frequently denied SGA was quetiapine [16/33 (48.5%)]. Conclusions: Although outcomes were not statistically significant, several valuable conclusions were drawn from this research. Positive outcomes from a RDR policy were seen by the limitations placed on inappropriate medication prescribing. Also, it was observed that the number of approvals for SGAs was almost three times higher than denials. A subsequent finding from this research is the apparent lack of metabolic monitoring for veterans prescribed SGAs. Further research on these observations, as well as conducting a pharmacoeconomic analysis on the RDR policy, would also be beneficial information for health care providers.

Potential Changes to the Wireless Medical Telemetry Service

Arif Subhan, MS, CCE, FACCE, is chief biomedical engineer of South Texas Veterans Health Care System in San Antonio, Texas, and an adjunct assistant professor in Biomedical Engineering at the University of Connecticut, Storrs, Connecticut. Corresponding author: Arif Subhan, MS, CCE, FACCE, is chief biomedical engineer of South Texas Veterans Health Care System in San Antonio, Texas, and an adjunct assistant professor in Biomedical Engineering at the University of Connecticut, Storrs, Connecticut. The author declares no conflict of interest.

The Aging Phenomenon, Related with DNA Damage, MMR Deficiency and Oxidative Stress, Has Different Outcomes in Two Species of the Order Chiroptera

Divergent Roles for 12/15-Lipoxygenase and 5Lipoxygenase Lipid Metabolic Pathways in Neurogenic Muscle Atrophy Arunabh Bhattacharya, Ryan Hamilton, Carmen Rios, Amanda L Jernigan, Yiqiang Zhang, Marian Sabia, Md M Rahman, Yan Li, Wenbo Qi, and Holly Van Remmen University of Texas Health Science Center at San Antonio, GRECC, South Texas Veterans Health Care System, San Antonio Aging is associated with progressive decline in muscle mass and function which significantly impacts the quality of life in the elderly population. Studies by our group and others have shown that decline in neuromuscular junction integrity (i.e. loss of innervation) during aging plays a causative role in age-related loss of muscle mass and function. However, little is known about the pathways and/or mediators that induce muscle atrophy during age-related loss of skeletal muscle during denervation. We previously showed that muscle atrophy during aging and surgical denervation is associated with increase in the expression of cytosolic phospholipase A2, the rate limiting step for release of arachidonic acid from membranes which then acts as a substrate for lipid metabolic pathways catalyzed by 12/15-lipoxygenase (12/15-LO), 5-lipoxygenase (5-LO) and cyclooxygenase and leads to the generation of bioactive lipid metabolites that are important mediators of inflammation and/or oxidative stress. In this study, we report that the expression and activity of 5and 12/15-LO pathways are significantly elevated in atrophied muscles from denervated mice. While genetic ablation/pharmacological inhibition of 12/15-LO confers protection against denervationinduced muscle atrophy, genetic ablation/pharmacological inhibition of 5-LO tends to increase muscle atrophy. We find that the activation of 12/15-LO pathway during denervation-atrophy increases NADPH oxidase mediated oxidative stress which leads to oxidative damage to lipids and proteins and increased proteolytic degradation by the ubiquitin-proteasome pathway. These findings reveal for the first time divergent roles for 5-LO and 12/15-LO lipid signaling pathways in muscle atrophy during loss of innervation.

Reverse Mentorships: Younger Workers Can Help Veterans Stay on Right Track

We know that mentoring is a process where a person with more experience shares it with someone, usually younger, who has less. Now enter reverse mentoring, almost the same as traditional mentoring, but typically a junior employee shows a senior employee the way— highly unusual, you might initially think. Alan Webber, co-founder of the business magazine Fast Company, once offered this gritty observation about the process: “It’s a situation where the old fogies in an organization realize that by the time you’re in your forties and fifties, you’re not in touch with the future the same way the young twenty-something’s (are). They come with fresh eyes, open minds, and instant links to the technology of our future.” In fact, this upside-down mentoring concept was introduced more than a decade ago by former General Electric CEO Jack Welch. Not everyone is jumping on the bandwagon, but reverse mentoring is “trending.” Interested in pursuing a reverse mentorship? Have a formal plan before you dive in, recommends Diane Piktialis, a consultant and research working group leader at The Conference Board, a business membership and research association. She focuses on issues related to the aging and multigenerational workforce and cross-generational knowledge transfer. In a 2009 article for the website Encore Careers, she cautions both parties to be aware of age stereotypes and address them head on. ‘Learn Every Day’ Formal reverse mentoring may not be practiced in your office, but it is quietly occurring daily and informally in companies worldwide, as it wears different hats such as “interning.” “Most of our interns have very strong computer skills both from engineering, architectural level and programming software levels,” says Paul Canaris, director of clinical engineering for Central Texas Veterans Health Care System in Temple, TX. Canaris’ last college-related computer course was in the early 80s. “Now, I learn every day from the interns,” he says. In his highly administrative job, Canaris finds he needs more in-depth knowledge of computers. He’s grateful for interns “fresh out of college who live and breathe PCs, networks and social media. They’ve really opened my eyes.” AAMI President Mary Logan thinks reverse mentoring is really lifelong learning, no matter one’s profession. A disproportionately large segment of the healthcare technology management sector is between 45 and 70, “middle-aged,” she suggests. “We may think we hold all the cards of wisdom, but we don’t.” Once while she mentored, reverse mentoring just happened. “I told her I’d be her mentor if she’d be mine,” remembers Logan, describing the time while, in another job, she mentored a professional in her late 20s. Logan’s younger charge ultimately helped the executive enhance her own communications technology skills. While looking for a job, Logan’s own daughter, then 25, asked her mom questions about starting About the Author

Methicillin-resistant Staphylococcus aureus bacteraemia and endocarditis treated with ceftaroline salvage therapy

One of the newest methicillin-resistant Staphylococcus aureus (MRSA) antibiotics to receive FDA approval is ceftaroline fosamil, a member of a new subclass of cephalosporins with unique activity against MRSA. However, ceftaroline is currently only FDA approved for complicated skin/soft tissue infections and community-acquired pneumonia; there are currently no clinical data regarding its use in MRSA bacteraemia and endocarditis. We report a series of six patients in which ceftaroline was utilized as salvage monotherapy in persistent MRSA bacteraemia or endocarditis. Using pharmacy records, 11 ceftaroline-treated patients were identified between January 2011 and November 2011 at University Health System and the South Texas Veterans Health Care System in San Antonio, TX, USA. All cases were reviewed and six patients received ceftaroline therapy for MRSA bacteraemia or endocarditis due to persistent or recurrent bacteraemia while on standard antibiotics (vancomycin or daptomycin). All six patients experienced rapid clearance of their bacteraemia after starting ceftaroline. In the case of endocarditis for which the patient subsequently developed heart failure and required valve replacement, there was no evidence of growth from cultures taken from the excised valve, suggesting sterilization within 13 days of starting ceftaroline. Ceftaroline exhibits potent anti-MRSA activity in both in vitro and animal studies, including rabbit endocarditis models; however, the lack of clinical data has limited its use in bacteraemia and endovascular infections in humans. We hope that this series serves as an initial stepping stone for further evaluation of this compound for more invasive infections due to MRSA.

Clinical evaluation of the role of ceftaroline in the management of community acquired bacterial pneumonia

Ceftaroline fosamil (ceftaroline) was recently approved for the treatment of community- acquired pneumonia (CAP) and complicated skin infections. This newly developed cephalosporin possesses a broad spectrum of activity against gram-positive and gram-negative bacteria. Most importantly, ceftaroline demonstrates potent in vitro antimicrobial activity against multi-drug resistant Streptococcus pneumoniae and methicillin-resistant strains of Staphylococcus aureus. In two Phase III, double-blinded, randomized, prospective trials (FOCUS 1 and FOCUS 2), ceftaroline was shown to be non-inferior to ceftriaxone for the treatment of CAP in hospitalized patients. Ceftaroline exhibits low resistance rates and a safety profile similar to that of other cephalosporins. In this review, we will evaluate the pharmacological characteristics, safety, antimicrobial properties, and efficacy of ceftaroline and its applications in the treatment of CAP.

Bereaved Family Members as Teachers: Educating Medical Students in What Matters Most (752)

Bereaved Family Members as Teachers: Educating Medical Students in What Matters Most (752) Jennifer Healy, DO, UTHSCSA/HPM fellowship, San Antonio, TX. Samih El Ahdab, MD, UTHSCSA, San Antonio, TX. Shuko Lee, MS, South Texas Veterans Health Care System, San Antonio, TX. Jeanette Ross, MD, UTHSCSA, San Antonio, TX. Sandra Sanchez-Reilly, MD, University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX.

A Model for Increasing Palliative Care in the Intensive Care Unit: Enhancing Interprofessional Consultation Rates and Communication

Background Only a minority of patients who die in the medical intensive care unit (MICU) receive palliative care services. At the South Texas Veterans Health Care System Audie L. Murphy Hospital, only 5% of patients who died in the MICU from May to August 2010 received a palliative care consultation. Measures We measured the percentage of MICU patients for which there was a palliative care consultation during the intervention period. Intervention Starting October 1, 2010 and ending April 30, 2011, the palliative care and MICU teams participated in daily “pre-rounds” to identify patients at risk for poor outcomes, who may benefit from a palliative care consultation. Outcomes Palliative care consultation increased significantly from 5% to 59% for patients who died in the MICU during the intervention period. Additionally, palliative care consultation increased from 5% to 21% for all patients admitted to the MICU during the intervention period. Conclusions/Lessons Learned Daily pre-rounds between the palliative care and MICU teams increased palliative care services for MICU patients at risk for poor outcomes, who may benefit from a palliative care consultation.

Evaluation of the incidence and risk factors for development of fenofibrate-associated nephrotoxicity

Fenofibrate-associated nephrotoxicity has been described in two randomized controlled trials and several observational studies. However, little is known regarding its incidence and the population(s) at risk. This study aims to quantify the incidence and identify potential risk factors for development of nephrotoxicity in patients receiving fenofibrate. A retrospective, observational study was conducted in the South Texas Veterans Health Care System. Data were collected regarding baseline demographics, concurrent medical conditions, medications, laboratory results, and fenofibrate use. Within 6 months after initiation of fenofibrate in 428 patients, 115 (27%) experienced an increase in serum creatinine of ≥ 0.3 mg/dL. Any renal disease (P = .001), chronic kidney disease (P = .01), and diabetes (P = .02) were significantly more prevalent in patients with fenofibrate-associated nephrotoxicity. Patients with nephrotoxicity had significantly greater serum creatinine (1.2 [SD 0.3] vs. 1.1 mg/dL [SD 0.3], P = .0002) and lower estimated glomerular filtration rate (72 [SD 20] vs 81 mL/min/1.73 m² [SD 20], P < .0001) at baseline. These patients also had greater use of calcium channel blockers (P = .0003), furosemide (P = .02), and angiotensin-converting enzyme inhibitors (P = .02). The incidence of nephrotoxicity was significantly greater in patients initiated on high-dose versus those on low-dose fenofibrate (P = .002). In a multivariable regression model, renal disease (P = .02), high-dose fenofibrate (P = .001), and dihydropyridine calcium channel blocker use (P = .02) were determined to be independent predictors of development of increased serum creatinine on fenofibrate. This observational study suggests fenofibrate-associated nephrotoxicity occurs more frequently than previously reported, particularly in patients with renal disease and in those receiving high-dose fenofibrate or concomitant calcium channel blockers.

Parenteral Diuretic Rescue for Hospice Patients with CHF Refractory to Oral Diuretics (759)

Health System & Temple University, Pittsburgh, PA. Shuko Lee, MS, South Texas Veterans Health Care System, San Antonio, TX. Jeanette Ross, MD, University of Texas Health Science Center San Antonio, San Antonio, TX. Sandra Sanchez-Reilly, MD, University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX. (All speakers have disclosed no relevant financial relationships.)

Optimizing management of chronic obstructive pulmonary disease in the upcoming decade.

Chronic obstructive pulmonary disease (COPD) is a leading cause of disability and mortality. Caring for patients with COPD, particularly those with advanced disease who experience frequent exacerbations, places a significant burden on health care budgets, and there is a global need to reduce the financial and personal burden of COPD. Evolving scientific evidence on the natural history and clinical course of COPD has fuelled a fundamental shift in our approach to the disease. The emergence of data highlighting the heterogeneity in rate of lung function decline has altered our perception of disease progression in COPD and our understanding of appropriate strategies for the management of stable disease. These data have demonstrated that early, effective, and prolonged bronchodilation has the potential to slow the rate of decline in lung function and to reduce the frequency of exacerbations that contribute to functional decline. The goals of therapy for COPD are no longer confined to controlling symptoms, reducing exacerbations, and maintaining quality of life, and slowing disease progression is now becoming an achievable aim. A challenge for the future will be to capitalize on these observations by improving the identification and diagnosis of patients with COPD early in the course of their disease, so that effective interventions can be introduced before the more advanced, disabling, and costly stages of the disease. Here we critically review emerging data that underpin the advances in our understanding of the clinical course and management of COPD, and evaluate both current and emerging pharmacologic options for effective maintenance treatment.

Access-Related Measures and Out-of-System Utilization Among Veterans With Bipolar Disorder

This study examined associations between access-related measures and out-of-system health services utilization (general medicine and mental health services) among patients with bipolar disorder at a U.S. Department of Veterans Affairs (VA) medical center. VA patients (N=391) with bipolar disorder answered questions about health services access (non-VA insurance coverage, travel distance to their VA facility, service-connected disability status, and difficulty receiving needed mental health care) and out-of-system services utilization. Multivariable Tobit regression was used to evaluate associations between access measures and propensity to receive out-of-system services. More than half the veterans (56%) reported some non-VA utilization. Out-of-system utilization was more likely among patients who were married, younger, homeless, with private insurance, without service-connected disabilities, and who reported access difficulties. Out-of-system utilization was associated with multiple measures of access and indicators specific to VA and non-VA providers. Enhancing health system access for patients with bipolar disorder may reduce out-of-system utilization, potentially enhancing continuity of care.

Providers' behavioral beliefs regarding the delivery of genomic medicine at the Veterans Health Administration.

To examine providers' behavioral intention toward the utilization of genomic services at the Veterans Health Administration (VHA; Washington, DC, USA) through the lens of the 'Theory of Planned Behavior'. The theory of planned behavior posits that individuals' behaviors (using genomic services) are driven by their behavioral intentions. Behavioral intentions is a function of: first, behavioral beliefs; second, normative beliefs, and third; control beliefs. Semi-structured interviews were conducted with 20 providers working in different units at the South Texas Veterans Health Care System (STVHCS; TX USA). The interviews focused on assessing providers' behavioral beliefs, normative beliefs and control beliefs regarding the delivery of genomic medicine at the STVHCS. Interview materials were tape recorded, transcribed and the content was analyzed using qualitative methods. All participating providers perceived genomic medicine to be an important area in medicine (behavioral beliefs). They agreed that the VHA has the necessary infrastructure to foster the delivery of genomic services. The majority of participants (n = 18; 90%) agreed that primary care providers will play a major role in delivering genomic services. Providers indicated that referents' (other providers) opinions about genomic services may affect their decisions about whether to utilize genomic services (normative beliefs). However, most providers (n = 17; 85%) raised concerns about the impact of using genomic services on the process of care (control beliefs). Participants indicated that additional training for providers and patients, and decision support will facilitate the delivery of genomic services (control beliefs). Providers also identified three external barriers: first, uncertainty about genomic findings; second, coordination of care between primary care, specialists and genetic services (system level barriers); and third ethical issues associated with genomic information and services. Our findings highlight several opportunities and challenges related to the delivery of genomic medicine at the VHA. The results suggest that strategies to address providers' concerns in the control beliefs domain may be necessary to enhance providers' utilization of genomic services in clinical practice.