US Veterans Affairs Medical Research Articles

Clinical exacerbations as a surrogate end point in heart failure research

We examined the utility of an index of clinical exacerbations of heart failure (HF) as a surrogate measure of outcome for use in modestly sized clinical trials and observational studies. Electronic records of 189 outpatients with HF in a US Veterans Affairs Medical Center were examined over a 2- to 3-year period. Data collected included patient characteristics, clinical exacerbations of HF, hospitalizations, and deaths. Subsets of patient were also assessed for HF-related level of functioning. Episodes of clinical exacerbation could be detected reliably (kappa = .83). An index of episodes (number of episodes divided by the time in years) was associated with lower quality of life, higher functional class, increased rate of HF hospitalization, poorer exercise tolerance, and up to 30% increased risk of mortality across 2 years. The index of HF exacerbations is potentially a useful surrogate end point for use in clinical HF research.

Review article: population screening for colorectal cancer

Colorectal cancer is a common cancer and common cause of death. The mortality rate from colorectal cancer can be reduced by identification and removal of cancer precursors, adenomas, or by detection of cancer at an earlier stage. Pilot screening programmes have demonstrated decreased colorectal cancer mortality; as a result many countries are developing colorectal cancer screening programmes. The most common modalities being evaluated are faecal occult blood testing, flexible sigmoidoscopy and colonoscopy. Implementation of screening tests has been hampered by cost, invasiveness, availability of resources and patient acceptance. New technologies such at computed tomographic colonography and stool screening for molecular markers of neoplasia are in development as potential minimally invasive tools. This review considers who should be screened, which test to use and how often to screen.

Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder

There are concerns regarding the validity of combat exposure reports of veterans seeking treatment for combat-related post-traumatic stress disorder (PTSD) within US Veterans Affairs Medical Centers. To verify combat exposure history for a relevant sample through objective historical data. Archival records were reviewed from the US National Military Personnel Records Center for 100 consecutive veterans reporting Vietnam combat in a Veterans Affairs PTSD clinic. Cross-sectional clinical assessment and 12-month service use data were also examined. Although 93% had documentation of Vietnam war-zone service, only 41% of the total sample had objective evidence of combat exposure documented in their military record. There was virtually no difference between the Vietnam 'combat' and 'no combat' groups on relevant clinical variables. A significant number of treatment-seeking Veterans Affairs patients may misrepresent their combat involvement in Vietnam. There are implications for the integrity of the PTSD database and the Veterans Affairs healthcare system.

Physician–patient communication following invasive procedures: an analysis of post-angiogram consultations

Although rarely studied, physician–patient interactions immediately following diagnostic tests are significant medical events because during these encounters the physician and patient often make decisions about major and sometimes invasive treatment. This investigation analyzed patterns of physician–patient communication following coronary angiography with particular attention to behaviors important to decision-making: physician information-giving, physician use of partnership-building, and active forms of patient participation (e.g., asking questions, being assertive, expressing concerns). We were particularly interested in effects related to the patient's race in light of documented evidence of racial disparities in cardiac care and outcomes. From audiotape recordings, 93 physician–patient interactions after coronary angiogram in a catheterization laboratory in a large US Veterans Affairs Medical Center were coded to measure the frequency of physicians’ information-giving and partnership-building and the frequency of active patient participation. We also stratified these behaviors according to whether the behavior was prompted (e.g., physician information in response to a patient's question; a patient's opinion solicited by the doctor) or self-initiated. Several findings were noteworthy. First, these interactions were very brief and dominated by the physician. Second, although physician information-giving increased with more active patient participation, which in turn was correlated with physicians’ use of partnership-building, proportionally little of the physicians’ information (8%) and active patient participation (9%) was directly prompted by the other interactant. Finally, there was a tendency for physicians to self-initiate less information giving to black patients and for black patients to self-initiate less active participation than white patients. Although these differences were attenuated when other variables (e.g., the physician's training, disease severity) were included in the analysis, the pattern suggests a potential cycle of passivity where certain patients tend to receive fewer informational resources and these patients in turn do less to prompt the doctor for more.

Regional variation in health care utilization and outcomes in ischemic stroke

Little information is available about regional variation in health care utilization and the effect of utilization on outcomes after ischemic stroke. The goal of this study was to investigate the effect of regional variation in outpatient health care use on mortality after ischemic stroke. We performed a retrospective cohort study of 55,094 veterans hospitalized for ischemic stroke at any US Veterans Affairs Medical Center between October 1, 1990, and September 30, 1997. We extracted administrative data on patient demographics, coexisting medical conditions, site of hospitalization, inpatient and outpatient health care utilization, and all-cause mortality during hospitalization and after stroke discharge. Predictors of long-term mortality in patients surviving at least 60 days post-stroke were modeled using Cox regression. Patients in the Northeast part of the country had higher comorbidity scores, a longer median length of stay, and higher in-hospital mortality than patients in other regions. However, Northeast and West patients had lower all-cause mortality after stroke than those in the Midwest or South. Patients in the Northeast (28%) and West (32%) were also more likely than those in the South (21%) or Midwest (22%) to have a neurology and/or general medicine visit within 60 days of discharge ( P < .001). Adjusted mortality (HR, 95% CI) was lower in the Northeast (0.84, 0.80–0.88) and West (0.93, 95% CI 0.89, 0.97), and in patients with neurology (0.72, 0.67–0.77) or general medicine (0.85, 0.81–0.89) follow-up within 60 days of stroke discharge. We concluded that regional variation exists in patient outcomes and patterns of care following stroke. Mortality is lower in regions where more patients have early outpatient care after stroke. Prospective studies evaluating the cause and impact of these variations are needed to identify optimal stroke care practices.

Co-prescribing of medications used to treat obstructive lung disease, congestive heart failure, and depression among users of topical beta blockers: estimates from three US Veterans Affairs Medical Centers. Valuck RJ, Perlman JI, Anderson CA, Wortman R. Pharmacoepidemiology 2001;10:511–516

Co-prescribing of medications used to treat obstructive lung disease, congestive heart failure, and depression among users of topical beta blockers: estimates from three US Veterans Affairs Medical Centers. Valuck RJ, Perlman JI, Anderson CA, Wortman R. Pharmacoepidemiology 2001;10:511–516

Co-prescribing of medications used to treat obstructive lung disease, congestive heart failure and depression among users of topical beta blockers: estimates from three US Veterans Affairs Medical Centers.

To estimate the frequency of co-prescribing of medications used to treat obstructive lung disease, congestive heart failure, and depression among US armed service veterans for whom topical beta blockers (TBB) have been prescribed. Prescription data from the computerized medical record systems of three US Veterans Affairs Medical Centers were obtained during Fall 1999 to identify patients for whom active prescriptions existed for TBB and/or drugs commonly used to treat obstructive lung disease, congestive heart failure, and depression. Among TBB users, the estimated co-prescribing rate of medications used to treat obstructive lung disease is in the range of 7.8-9.7%, of medications used to treat congestive heart failure is in the range of 4.3-25.1%, and of medications used to treat depression is in the range of 8.8-11.7%. The total number of TBB users with a concurrent prescription for one or more of the conditions studied was in the range of 30.2-45.7%. Since TBB may cause systemic side-effects and thus potentially cause exacerbations of selected chronic conditions, it is important for researchers and prescribers to be aware of the frequency with which their patients with glaucoma may have other concomitant conditions.

Postoperative complications in Parkinson's disease.

Although Parkinson's disease is relatively common in America, with an average annual incidence of 20 cases per 100,000 population, little information exists about postoperative morbidity and mortality in those Parkinson's patients who undergo elective surgery. We performed a retrospective cohort study using the Veterans Affairs (VA) Austin database system (a cumulative index of admissions and discharges from all US VA Medical Centers) to identify 41,213 patients who underwent elective bowel resection, cholecystectomy, or radical prostatectomy between January 1, 1990, and December 31, 1995. We examined the study population using univariate analysis, acute length of stay with multivariate analysis, and postoperative complications with logistic regression. The selected surgeries were performed on 234 patients with a diagnosis of Parkinson's disease and 40,979 with no such diagnosis. In univariate analysis, patients with Parkinson's disease had significantly longer acute hospital stays than non-Parkinson's patients (11.4 +/- 15.9 days vs 8.8 +/- 9.0 days, P < .001). In addition, Parkinson's patients had a higher in-hospital mortality than non-Parkinson's patients (7.3% vs 3.8%, P = .006). After we adjusted for coexisting morbidity, age, admitting location, and gender, patients with Parkinson's disease had an average acute hospital stay 2.34 days longer than that of non-Parkinson's patients (P < .001). However, the mortality difference did not reach statistical significance in multivariate analysis (P = .098). Finally, Parkinson's patients had significantly increased incidences of urinary-tract infection (odds ratio 2.045, P < .001), aspiration pneumonia (odds ratio 3.825, P < .001), and bacterial infections (odds ratio 1.682, P < .001). Patients with Parkinson's disease are at greater risk for specific complications and longer hospital stay after elective bowel resection, cholecystectomy, or radical prostatectomy. Awareness of these complications may help caregivers to reduce postoperative mortality and morbidity and to decrease the length of hospitalization.