Publications by authors named "Bridget M Smith"

64 Publications

Comparing recruitment strategies for a digital smoking cessation intervention: Technology-assisted peer recruitment, social media, ResearchMatch, and

Contemp Clin Trials 2021 Feb 8;103:106314. Epub 2021 Feb 8.

Division of Health Informatics and Implementation Science, Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.

Background: Choosing the right recruitment strategy has implications for the successful conduct of a trial. Our objective was to compare a novel peer recruitment strategy to four other recruitment strategies for a large randomized trial testing a digital tobacco intervention.

Methods: We compared enrollment rates, demographic and baseline smoking characteristics, and odds of completing the 6-month study by recruitment strategy. Cost of recruitment strategies per retained participant was calculated using staff personnel time and advertisement costs.

Findings: We enrolled 1487 participants between August 2017 and March 2019 from: Peer recruitment n = 273 (18.4%), Facebook Ads n = 505 (34%), Google Ads = 200 (13.4%), ResearchMatch n = 356 (23.9%) and Smokefree.govn = 153 (10.3%). Mean enrollment rate per active recruitment month: 1) Peer recruitment, n = 13.9, 2) Facebook ads, n = 25.3, 3) Google ads, n = 10.51, 4) Research Match, n = 59.3, and 5), n = 13.9. Peer recruitment recruited the greatest number of males (n = 110, 40.3%), young adults (n = 41, 14.7%), participants with a high school degree or less (n = 24, 12.5%) and smokers within one's social network. Compared to peer recruitment (retention rate = 57%), participants from Facebook were less likely (OR 0.46, p < 0.01, retention rate = 40%), and those from ResearchMatch were more likely to complete the study (OR 1.90, p < 0.01, retention rate = 70%). Peer recruitment was moderate in cost per retained participant ($47.18) and substantially less costly than Facebook ($173.60).

Conclusions: Though peer recruitment had lower enrollment than other strategies, it may provide greater access to harder to reach populations and possibly others who smoke within one's social network while being moderately cost-effective. NCT03224520.
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February 2021

Characterization of Telehealth Use in Veterans With Spinal Cord Injuries and Disorders.

PM R 2020 Oct 24. Epub 2020 Oct 24.

Edward Hines Jr. Department of VA Hospital, Center of Innovation for Complex Chronic Healthcare, Chicago, IL, USA.

Background: Individuals with spinal cord injuries and disorders (SCI/D) require frequent interdisciplinary health care to address impairments in mobility, autonomic function, and secondary complications. Telehealth has the capacity to substantially transform health care delivery and improve care by increasing access and communication. However, relatively little is known about telehealth use in this specific population. Here we attempt to fill part of this gap.

Objective: To investigate the frequency and characteristics associated with telehealth use in Veterans with SCI/D.

Design: Cross-sectional, descriptive project.

Setting: Veterans Health Administration (VHA) facilities.

Participants: A total of 15 028 Veterans living with SCI/D who received services from the VHA SCI/D System of Care.

Intervention: Not applicable.

Outcome Measures: Frequency and characteristics associated with VHA telehealth utilization.

Results: Of the 15 028 Veterans with SCI/D included in the evaluation, 17% used some form of telehealth in VHA Fiscal Year (FY)2017. Veterans older than 65 years of age had lower odds (odds ratio [OR] = 0.88, P < .05, confidence interval [CI] 0.80-0.98) of using telehealth. Being Caucasian (OR = 1.29, P < .01, CI 1.09-1.52), living in rural areas (OR = 1.16, P < .01, CI 1.05-1.28), living greater distances away from the VHA (P < .01 for all distances), and being in priority group 8, meaning that Veterans have higher copayment requirements (OR = 1.46, P < .001, CI 1.19-1.81), were all significantly associated with greater odds of telehealth use. The most frequent types of telehealth used were real-time clinical video and store-and-forward between a provider and patient within the same hub network.

Conclusion: There are opportunities to increase telehealth adoption in the SCI/D arena. The findings from this project highlight which Veterans are currently using telehealth services, as well as gaps regarding telehealth adoption in this population.
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October 2020

Effect of the Affordable Care Act on healthcare utilization for Veterans with spinal cord injuries and disorders.

J Spinal Cord Med 2020 Oct 21:1-10. Epub 2020 Oct 21.

Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Department of Veterans Affairs, Hines, Illinois, USA.

Provisions of the Affordable Care Act (ACA) potentially increase insurance options for Veterans with disabilities. We examined Veterans with spinal cord injuries and disorders (SCI/D) to assess whether the ACA was associated with changes in healthcare utilization from Department of Veterans Affairs (VA) healthcare facilities. Using national VA data, we investigated impacts on VA healthcare utilization pre- (2012/13) and post-ACA (2014/15) implementation with negative binomial regression models. VA healthcare facilities. 8,591 VA users with SCI/D. Veterans with acute myelitis, Guillain-Barré syndrome, multiple sclerosis, or amyotrophic lateral sclerosis were excluded as were patients who died during the study period. We assessed VA healthcare utilization before and after ACA implementation. Total numbers of VA visits for SCI/D care, diagnostic care, primary care, specialty care, and mental health care, and VA admissions. The number of VA admissions was 7% higher in the post than pre-ACA implementation period (P < 0.01). The number of VA visits post-implementation increased for SCI/D care (8%; P < 0.01) and specialty care (12%; P < 0.001). Conversely, the number of mental health visits was 17% lower in the post-ACA period (P < 0.001). Veterans with SCI/D who live <5 miles from their nearest VA facility received VA care more frequently than those ≥40 miles from VA (P < 0.001). Counter to expectations, results suggest that Veterans with SCI/D sought more frequent VA care after ACA implementation, indicating Veterans with SCI/D continue to utilize the lifelong, comprehensive care provided at VA.
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October 2020

Supporting the Implementation of Connected Care Technologies in the Veterans Health Administration: Cross-Sectional Survey Findings from the Veterans Engagement with Technology Collaborative (VET-C) Cohort.

J Particip Med 2020 Sep 30;12(3):e21214. Epub 2020 Sep 30.

eHealth Partnered Evaluation Initiative, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States.

Background: Widespread adoption, use, and integration of patient-facing technologies into the workflow of health care systems has been slow, thus limiting the realization of their potential. A growing body of work has focused on how best to promote adoption and use of these technologies and measure their impacts on processes of care and outcomes. This body of work currently suffers from limitations (eg, cross-sectional analyses, limited patient-generated data linked with clinical records) and would benefit from institutional infrastructure to enhance available data and integrate the voice of the patient into implementation and evaluation efforts.

Objective: The Veterans Health Administration (VHA) has launched an initiative called the Veterans Engagement with Technology Collaborative cohort to directly address these challenges. This paper reports the process by which the cohort was developed and describes the baseline data being collected from cohort members. The overarching goal of the Veterans Engagement with Technology Collaborative cohort is to directly engage veterans in the evaluation of new VHA patient-facing technologies and in so doing, to create new infrastructure to support related quality improvement and evaluation activities.

Methods: Inclusion criteria for veterans to be eligible for membership in the cohort included being an active user of VHA health care services, having a mobile phone, and being an established user of existing VHA patient-facing technologies as represented by use of the secure messaging feature of VHA's patient portal. Between 2017 and 2018, we recruited veterans who met these criteria and administered a survey to them over the telephone.

Results: The majority of participants (N=2727) were male (2268/2727, 83.2%), White (2226/2727, 81.6%), living in their own apartment or house (2519/2696, 93.4%), and had completed some college (1176/2701, 43.5%) or an advanced degree (1178/2701, 43.6%). Cohort members were 59.9 years old, on average. The majority self-reported their health status as being good (1055/2725, 38.7%) or very good (524/2725, 19.2%). Most cohort members owned a personal computer (2609/2725, 95.7%), tablet computer (1616/2716, 59.5%), and/or smartphone (2438/2722, 89.6%).

Conclusions: The Veterans Engagement with Technology Collaborative cohort is an example of a VHA learning health care system initiative designed to support the data-driven implementation of patient-facing technologies into practice and measurement of their impacts. With this initiative, VHA is building capacity for future, rapid, rigorous evaluation and quality improvement efforts to enhance understanding of the adoption, use, and impact of patient-facing technologies.
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September 2020

Developing an animal-assisted support program for healthcare employees.

BMC Health Serv Res 2020 Aug 3;20(1):714. Epub 2020 Aug 3.

Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, 5000 South 5th Avenue (151H), Hines, IL, 60141, USA.

Background: Employee burnout and its associated consequences is a significant problem in the healthcare workforce. Workplace animal therapy programs offer a potential strategy for improving employee well-being; however, research on animal therapy programs for healthcare workers is lacking. This study aimed to evaluate the feasibility, acceptability and preliminary impact of an animal-assisted support program to improve healthcare employee well-being.

Methods: In this mixed-methods pilot intervention study, we implemented an animal-assisted support program in a multidisciplinary healthcare clinic at a large VA hospital. The program included 20 sessions over 3 months, each approximately 1-h long. Real-time mood data were collected from participants immediately before and after each session. Participation rates were tracked in real time and self-reported at follow-up. Data on burnout and employee perceptions of the program were collected upon completion via a survey and semi-structured interviews. Differences in mood and burnout pre/post program participation were assessed with t-tests.

Results: Participation was high; about 51% of clinic employees (n = 39) participated in any given session, averaging participation in 9/20 sessions. Mood (on a scale of 1 = worst to 5 = best mood) significantly improved from immediately before employees interacted with therapy dogs (M = 2.9) to immediately after (M = 4.5) (p = 0.000). Employees reported significantly lower levels of patient-related burnout (e.g., how much exhaustion at work relates to interaction with patients) after (M = 18.0 vs. before, M = 40.0) participating (p = 0.002). Qualitative findings suggested that employees were highly satisfied with the program, noticed an improved clinic atmosphere, and experienced a reduction in stress and boost in mood.

Conclusions: Establishing an animal-assisted support program for employees in a busy healthcare clinic is feasible and acceptable. Our pilot data suggest that animal-assisted programs could be a means to boost mood and decrease facets of burnout among healthcare employees.
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August 2020

Patient portal use among veterans with depression: Associations with symptom severity and demographic characteristics.

J Affect Disord 2020 10 15;275:255-259. Epub 2020 Jul 15.

Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, United States; Center for Healthcare Studies, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.

Background: Patient portals can support self-management behaviors and increase continuity of care. It is therefore important to understand how individuals with depression are interacting with patient portals, to ensure that they have access to tools that can improve outcomes. The purpose of the current retrospective analysis was to examine associations between symptom severity, demographic characteristics and patient portal adoption and use among Veterans with depression diagnoses.

Methods: Data were collected within a larger retrospective analysis of use of the Veterans Health Administration patient portal, My HealtheVet (MHV). The final sample included 3053 Veterans with diagnoses of depression and at least two measures of depressive symptoms. Regressions tested whether depressive symptoms and demographic variables were associated with MHV registration and feature use.

Results: Veterans with more severe depression were more likely to have registered for MHV and downloaded medical record content compared to those with milder symptoms. Maleand older Veterans had lower rates of portal registration, and African American Veterans had lower rates of portal feature use.

Limitations: Limitations include restriction to a Veteran population who first used MHV in FY2013 as opposed to prior or subsequent years.

Conclusions: Patients with more severe depression may have increased interest in and use of patient portals. Demographic differences in portal use continue to be observed; barriers to uptake must be identified so disparities can be addressed.
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October 2020

TeleWound Practice Within the Veterans Health Administration: Protocol for a Mixed Methods Program Evaluation.

JMIR Res Protoc 2020 Jul 20;9(7):e20139. Epub 2020 Jul 20.

Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Hines, IL, United States.

Background: Chronic wounds, such as pressure injuries and diabetic foot ulcers, are a significant predictor of mortality. Veterans who reside in rural areas often have difficulty accessing care for their wounds. TeleWound Practice (TWP), a coordinated effort to incorporate telehealth into the provision of specialty care for patients with skin wounds, has the potential to increase access to wound care by allowing veterans to receive this care at nearby outpatient clinics or in their homes. The Veterans Health Administration (VA) is championing the rollout of the TWP, starting with regional implementation.

Objective: This paper aims to describe the protocol for a mixed-methods program evaluation to assess the implementation and outcomes of TWP in VA.

Methods: We are conducting a mixed-methods evaluation of 4 VA medical centers and their community-based outpatient clinics that are participating in the initial implementation of the TWP. Data will be collected from veterans, VA health care team members, and other key stakeholders (eg, clinical leadership). We will use qualitative methods (ie, semistructured interviews), site visits, and quantitative methods (ie, surveys, national VA administrative databases) to assess the process and reach of TWP implementation and its impact on veterans' clinical outcomes and travel burdens and costs.

Results: This program evaluation was funded in October 2019 as a Partnered Evaluation Initiative by the US Department of Veterans Affairs, Diffusion of Excellence Office, and Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative Program (PEC 19-310).

Conclusions: Evaluation of the TWP will identify barriers and solutions to TeleWound implementation in a small number of sites that can be used to inform successful rollout of the TWP nationally. Our evaluation work will inform future efforts to scale up the TWP across VA and optimize reach of the program to veterans across the nation.

International Registered Report Identifier (irrid): DERR1-10.2196/20139.
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July 2020

Did the Affordable Care Act Decrease Veteran Enrollment in the Veterans Health Administration?

Med Care 2020 08;58(8):703-709

Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines.

Background: Provisions of the Affordable Care Act (ACA) provided nonelderly individuals, including Veterans, with additional health care coverage options. This may impact enrollment for health care through the Veterans Health Administration (VHA). National enrollment data was used to: (1) compare characteristics of enrollees at 3 time points in relation to the implementation of ACA insurance provisions (2012); and (2) examine enrollment trends.

Methods: The study population included a 10% sample of Veterans under age 65 who were VHA enrollees between January 2012 and September 2015. Demographic and baseline characteristics were compared between 3 enrollment groups: pre-2012, pre-ACA (2012-2013), and post-ACA (2014-2015). Using an interrupted time series approach, we employed pooled logistic regression to assess trends in new VHA enrollment, overall, and by select enrollee characteristics.

Results: A total of 429,833 enrollees were identified. Compared with pre-ACA enrollees, post-ACA enrollees were more likely to be older, have a service-connected disability, live further away from a VHA medical center, but less likely to use primary care within 6 months. The post-ACA quarterly trend in the odds of being a new enrollee was 3% lower (95% confidence interval: 0.96, 0.98) as compared with the pre-ACA trend. This decline was consistent across sex, geography, (all but 1) priority group, and state Medicaid-expansion subgroups.

Conclusions: The ACA appears to have contributed to a decline in new VHA enrollment. In addition, the profile of newer enrollees differs from that of pre-ACA enrollees. The VHA must continue to monitor trends in demand in order to continue delivering high-quality, efficient care.
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August 2020

Teamwork for smoking cessation: which smoker was willing to engage their partner? Results from a cross-sectional study.

BMC Res Notes 2020 Jul 20;13(1):344. Epub 2020 Jul 20.

Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.

Objective: Smokers are greatly influenced by those living with them, but strategies that increase partner support for smoking cessation are lacking. Using a cross-sectional study design, we explored factors associated with willingness to engage a partner in smoking cessation in smokers registered on a web-assisted tobacco intervention trial.

Results: Study participants (n = 983) were recruited between July 2018 and March 2019. About 28% of smokers were willing to engage their partner in cessation efforts. The odds of willingness to engage a partner were more than two-fold for smokers reporting presence of other smokers in the immediate family (adjusted odds ratio (aOR): 2.18; 95% confidence interval (CI) 1.51-3.15 for 1-3 smokers; aOR, 3.12; 95% CI 1.95-4.98 for ≥ 4 smokers) compared to those with no smokers in the immediate family. Women had lower odds of willingness to engage (aOR; 0.82; 95% CI 0.58-1.16) than men, but this was not statistically significant. Use of e-cigarettes and visitation to a smoking cessation website prior to the intervention were both positively associated with willingness to engage partners in cessation. Future research should assess whether interventions tailored to smokers willing to engage partners or spouses could increase effectiveness of partner support during cessation.
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July 2020

Experiences with the Veterans' Choice Program.

J Gen Intern Med 2019 10 6;34(10):2141-2149. Epub 2019 Aug 6.

Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA.

Background: To address concerns about Veterans' access to care at US Department of Veterans Affairs (VA) healthcare facilities, the Veterans Access, Choice, and Accountability Act was enacted to facilitate Veterans' access to care in non-VA settings, resulting in the "Veterans Choice Program" (VCP).

Objectives: To assess the characteristics of Veterans who used or planned to use the VCP, reasons for using or planning to use the VCP, and experiences with the VCP.

Design: Mixed-methods.

Subjects: After sampling Veterans in the Midwest census region receiving care at VA healthcare facilities, we included 4521 Veterans in the analyses. Of these, 60 Veterans participated in semi-structured qualitative interviews.

Approach: Quantitative data were derived from VA's administrative and clinical data and a survey of Veterans including Veteran characteristics and self-reported use of VCP. Associations between Veterans' characteristics and use or planned use of the VCP were assessed using logistic regression analysis. Interview data were analyzed using thematic analysis.

Key Results: Veterans with a higher odds of reporting use or intended use of the VCP were women, lived further distances from VA facilities, or had worse health status than other Veterans (P ≤ 0.01). Key themes included positive experiences with the VCP (timeliness of care, location of care, access to services, scheduling improvements, and coverage of services), and negative experiences with the VCP (complicated scheduling processes, inconveniently located appointments, delays securing appointments, billing confusion, and communication breakdowns).

Discussion: Our findings suggest that Veterans value access to care close to their home and care that addresses the needs of women and Veterans with poor health status. The Mission Act was passed in June 2018 to restructure the VCP and consolidate community care into a single program, continuing VA's commitment to support access to community care into the future.
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October 2019

Dissemination and Effectiveness of the Peer Marketing and Messaging of a Web-Assisted Tobacco Intervention: Protocol for a Hybrid Effectiveness Trial.

JMIR Res Protoc 2019 Jul 23;8(7):e14814. Epub 2019 Jul 23.

Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.

Background: Smoking continues to be the leading preventable cause of death. Digital Interventions for Smoking Cessation (DISCs) are health communication programs accessible via the internet and smartphones and allow for greater reach and effectiveness of tobacco cessation programs. DISCs have led to increased 6-month cessation rates while also reaching vulnerable populations. Despite this, the impact of DISCs has been limited and new ways to increase access and effectiveness are needed.

Objective: We are conducting a hybrid effectiveness-dissemination study. We aim to evaluate the effectiveness of a machine learning-based approach (recommender system) for computer-tailored health communication (CTHC) over a standard CTHC system based on quit rates and risk reduction. In addition, this study will assess the dissemination of providing access to a peer recruitment toolset on recruitment rate and variability of the sample.

Methods: The Smoker-to-Smoker (S2S) study is a 6-month hybrid effectiveness dissemination trial conducted nationally among English-speaking, current smokers aged ≥18 years. All eligible participants will register for the DISC (Decide2quit) and be randomized to the recommender system CTHC or the standard CTHC, followed by allocation to a peer recruitment toolset group or control group. Primary outcomes will be 7-day point prevalence and risk reduction at the 6-month follow-up. Secondary outcomes include recruitment rate, website engagement, and patient-reported outcomes collected via the 6-month follow-up questionnaire. All primary analyses will be conducted on an intent-to-treat basis.

Results: The project is funded from 2017 to 2020 by the Patient Centered Outcomes Research Institute. Enrollment was completed in early 2019, and 6-month follow-ups will be completed by late 2019. Preliminary data analysis is currently underway.

Conclusions: Conducting a hybrid study with both effectiveness and dissemination hypotheses raises some unique challenges in the study design and analysis. Our study addresses these challenges to test new innovations and increase the effectiveness and reach of DISCs.

International Registered Report Identifier (irrid): DERR1-10.2196/14814.
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July 2019

Health Care Utilization and Costs of Veterans Evaluated for Traumatic Brain Injury Through Telehealth.

Telemed J E Health 2019 12 15;25(12):1144-1153. Epub 2019 Mar 15.

Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois.

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December 2019

Prevalence and Severity of Food Allergies Among US Adults.

JAMA Netw Open 2019 01 4;2(1):e185630. Epub 2019 Jan 4.

Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, California.

Importance: Food allergy is a costly, potentially life-threatening condition. Although studies have examined the prevalence of childhood food allergy, little is known about prevalence, severity, or health care utilization related to food allergies among US adults.

Objective: To provide nationally representative estimates of the distribution, severity, and factors associated with adult food allergies.

Design, Setting, And Participants: In this cross-sectional survey study of US adults, surveys were administered via the internet and telephone from October 9, 2015, to September 18, 2016. Participants were first recruited from NORC at the University of Chicago's probability-based AmeriSpeak panel, and additional participants were recruited from the non-probability-based Survey Sampling International (SSI) panel.

Exposures: Demographic and allergic participant characteristics.

Main Outcomes And Measures: Self-reported food allergies were the main outcome and were considered convincing if reported symptoms to specific allergens were consistent with IgE-mediated reactions. Diagnosis history to specific allergens and food allergy-related health care use were also primary outcomes. Estimates were based on this nationally representative sample using small-area estimation and iterative proportional fitting methods. To increase precision, AmeriSpeak data were augmented by calibration-weighted, non-probability-based responses from SSI.

Results: Surveys were completed by 40 443 adults (mean [SD] age, 46.6 [20.2] years), with a survey completion rate of 51.2% observed among AmeriSpeak panelists (n = 7210) and 5.5% among SSI panelists (n = 33 233). Estimated convincing food allergy prevalence among US adults was 10.8% (95% CI, 10.4%-11.1%), although 19.0% (95% CI, 18.5%-19.5%) of adults self-reported a food allergy. The most common allergies were shellfish (2.9%; 95% CI, 2.7%-3.1%), milk (1.9%; 95% CI, 1.8%-2.1%), peanut (1.8%; 95% CI, 1.7%-1.9%), tree nut (1.2%; 95% CI, 1.1%-1.3%), and fin fish (0.9%; 95% CI, 0.8%-1.0%). Among food-allergic adults, 51.1% (95% CI, 49.3%-52.9%) experienced a severe food allergy reaction, 45.3% (95% CI, 43.6%-47.1%) were allergic to multiple foods, and 48.0% (95% CI, 46.2%-49.7%) developed food allergies as an adult. Regarding health care utilization, 24.0% (95% CI, 22.6%-25.4%) reported a current epinephrine prescription, and 38.3% (95% CI, 36.7%-40.0%) reported at least 1 food allergy-related lifetime emergency department visit.

Conclusions And Relevance: These data suggest that at least 10.8% (>26 million) of US adults are food allergic, whereas nearly 19% of adults believe that they have a food allergy. Consequently, these findings suggest that it is crucial that adults with suspected food allergy receive appropriate confirmatory testing and counseling to ensure food is not unnecessarily avoided and quality of life is not unduly impaired.
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January 2019

The Public Health Impact of Parent-Reported Childhood Food Allergies in the United States.

Pediatrics 2018 12 19;142(6). Epub 2018 Nov 19.

Sean N. Parker Center for Allergy and Asthma Research at Stanford University School of Medicine, Stanford, California.

: media-1vid110.1542/5840360268001PEDS-VA_2018-1235 BACKGROUND: Childhood food allergy (FA) is a life-threatening chronic condition that substantially impairs quality of life. This large, population-based survey estimates childhood FA prevalence and severity of all major allergenic foods. Detailed allergen-specific information was also collected regarding FA management and health care use.

Methods: A survey was administered to US households between 2015 and 2016, obtaining parent-proxy responses for 38 408 children. Prevalence estimates were based on responses from NORC at the University of Chicago's nationally representative, probability-based AmeriSpeak Panel (51% completion rate), which were augmented by nonprobability-based responses via calibration weighting to increase precision. Prevalence was estimated via weighted proportions. Multiple logistic regression models were used to evaluate FA predictors.

Results: Overall, estimated current FA prevalence was 7.6% (95% confidence interval: 7.1%-8.1%) after excluding 4% of children whose parent-reported FA reaction history was inconsistent with immunoglobulin E-mediated FA. The most prevalent allergens were peanut (2.2%), milk (1.9%), shellfish (1.3%), and tree nut (1.2%). Among food-allergic children, 42.3% reported ≥1 severe FA and 39.9% reported multiple FA. Furthermore, 19.0% reported ≥1 FA-related emergency department visit in the previous year and 42.0% reported ≥1 lifetime FA-related emergency department visit, whereas 40.7% had a current epinephrine autoinjector prescription. Prevalence rates were higher among African American children and children with atopic comorbidities.

Conclusions: FA is a major public health concern, affecting ∼8% of US children. However, >11% of children were perceived as food-allergic, suggesting that the perceived disease burden may be greater than previously acknowledged.
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December 2018

Allergic Diseases and Immune-Mediated Food Disorders in Pediatric Acute-Onset Neuropsychiatric Syndrome.

Pediatr Allergy Immunol Pulmonol 2018 Sep 17;31(3):158-165. Epub 2018 Sep 17.

Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.

The prevalence and impact of allergic and immune-mediated food disorders in pediatric acute-onset neuropsychiatric syndrome (PANS) are mostly unknown. We sought to explore the prevalence of atopic dermatitis (AD), asthma, allergic rhinitis (AR), IgE-mediated food allergies (FAs), and other immune-mediated food disorders requiring food avoidance in patients with PANS. In addition, to further understand the extent of food restriction in this population, we investigated the empiric use of dietary measures to improve PANS symptoms. Pediatric patients in a PANS Clinic and Research Program were given surveys regarding their caregiver burdens, allergic and food-related medical history, and whether food elimination resulted in perception of improvement of PANS symptoms. A review of health records was conducted to confirm that all responses in the survey were concordant with documentation of each patient's medical chart. Sixty-nine (ages 4-20 years) of 80 subjects who fulfilled PANS criteria completed the surveys. Thirteen (18.8%) had AD, 11 (15.9%) asthma, 33 (47.8%) AR, 11 (15.9%) FA, 1 (1.4%) eosinophilic gastrointestinal disorders, 1 (1.4%) food protein-induced enterocolitis syndrome, 3 (4.3%) milk protein-induced proctocolitis syndrome, and 3 (4.3%) celiac disease. Thirty subjects (43.5%) avoided foods due to PANS; elimination of gluten and dairy was most common and was associated with perceived improvement of PANS symptoms (by parents). This perceived improvement was not confirmed with objective data. The prevalence of allergic and immune-mediated food disorders in PANS is similar to the general population as reported in the literature, with the exception of AR that appears to be more prevalent in our PANS cohort. More research will be required to establish whether diet or allergies influence PANS symptoms.
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September 2018

Characteristics and medication use of veterans in Medicare Advantage plans.

Am J Manag Care 2018 05;24(5):247-255

Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago, 2160 S First Ave, CTRE 554, Maywood, IL 60153. Email:

Objectives: To compare characteristics, health conditions, and medication acquisition patterns by fee-for-service (FFS) or Medicare Advantage (MA) plan enrollment status for Medicare-eligible veterans.

Study Design: Retrospective analysis of all female and a random 10% sample of male veterans.

Methods: Data were derived from the US Department of Veterans Affairs (VA) and Medicare administrative databases. Demographic, geographic, and RxRisk-V risk classes were ascertained in 2008. Medicare Part D enrollment, medication acquisition, and use of high-risk medications (HRMs) were examined in 2009. A veteran was classified as an MA enrollee if he or she was enrolled in an MA plan for at least 1 month in 2008-2009. Descriptive and regression analyses were conducted to compare veterans' characteristics and medication acquisition patterns by plan enrollment type controlling for veterans' characteristics.

Results: Veterans who resided in urban settings and in the West or Northeast and who had co-payments for their VA medications had greater odds of enrolling in MA programs compared with their counterparts. MA-enrolled veterans were more likely to be dual (32.3% vs 7.0%) or Medicare-reimbursed (31.1% vs 14.5%) pharmacy users and less likely to be VA-only pharmacy users (29.4% vs 48.7%) than FFS enrollees. Higher proportions of MA-enrolled veterans received HRMs compared with those in the FFS sector (17.0% vs 14.3%).

Conclusions: Providers both inside and outside of the VA should consider that substantial information about the medication use of veterans may be unavailable in their healthcare systems' electronic records.
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May 2018

Parent perspectives on school food allergy policy.

BMC Pediatr 2018 05 12;18(1):164. Epub 2018 May 12.

Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Background: Food allergy affects up to 8% of children in the U.S. There is minimal research to date on food allergy policies that are currently in place in schools and the opinions of parents of children with food allergy on the effectiveness of or need for these policies.

Methods: An electronic survey was disseminated to parents of children with food allergy. Frequencies were calculated to describe respondent characteristics and responses. Chi-square tests were performed to examine associations between school and child characteristics and outcomes.

Results: Of the 289 parent respondents, 27.4% were unsure or felt school was unsafe for their child with food allergy. While the majority felt that the polices in their child's school were helpful, most also believed that implementation of additional polices was necessary, including availability of stock epinephrine (94.2%), lunch menus with allergen information (86%), ingredient labels on food items (81%), and direct food allergy education for students (86%). There were significant differences in school food allergy policy depending on the age of the student body, private versus public school, and geographic location.

Conclusions: While most schools reportedly have one or more food allergy policies in place, many parents have concerns over the safety of their child at school and feel that additional policies are necessary to improve the safety of the school environment for children with food allergy. The availability of stock epinephrine, improved allergen labeling of food and menus and increased food allergy education may be key policy areas on which to focus.
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May 2018

Barriers and strategies for coordinating care among veterans with traumatic brain injury: a mixed methods study of VA polytrauma care team members.

Brain Inj 2018 14;32(6):755-762. Epub 2018 Mar 14.

g Center for Healthcare Organization and Implementation Research (CHOIR) , Edith Nourse Rogers Memorial Veterans Hospital , Bedford , MA , USA.

Background: Veterans who experience traumatic brain injury (TBI) may have long-term needs placing a premium on well-coordinated care. This study aimed to (1) identify barriers to care coordination for Veterans with TBI; and (2) describe strategies used by VA polytrauma care team members to coordinate care for Veterans with TBI.

Methods: We utilised a mixed method design, including an online survey of VA polytrauma care team members (N = 236) and subsequent semi-structured interviews (N = 25). Analysis of the survey data was descriptive; interview data was analysed using constant comparative techniques.

Results: The most common system-related barriers 25 for access to military records (64%) and insufficient time (58%). The most common patient-related barriers were missed appointments/no shows (87%) and the mental health issues (74%). Strategies reported on the survey to promote coordination reflected the centrality of teamwork and communication, and included promoting multidisciplinary team collaboration (32%) and holding 30 regular meetings (23%). Interview findings were consistent, emphasising the effective functioning of multidisciplinary clinics.

Conclusion: Polytrauma care team members encounter barriers to care coordination for Veterans with TBI, and have developed strategies in response. Information sharing, provider workload, communication, and patient engagement will be critical to address in future efforts to enhance care coordination in this context.
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May 2019

Parental and parent-perceived child interest in clinical trials for food allergen immunotherapy.

Ann Allergy Asthma Immunol 2018 03;120(3):331-333.e1

Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. Electronic address:

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March 2018

Evaluating the Use of Medicare Part D in the Veteran Population With Spinal Cord Injury/Disorder.

Arch Phys Med Rehabil 2018 06 6;99(6):1099-1107. Epub 2018 Feb 6.

Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Chicago, IL; Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL. Electronic address:

Objective: To examine the different sources of medications, the most common drug classes filled, and the characteristics associated with Medicare Part D pharmacy use in veterans with spinal cord injury/disorder (SCI/D).

Design: Retrospective, cross-sectional, observational study.

Setting: Outpatient clinics and pharmacies.

Participants: Veterans (N=13,442) with SCI/D using Medicare or Veteran Affairs pharmacy benefits.

Interventions: Not applicable.

Main Outcome Measures: Characteristics and top 10 most common drug classes were examined in veterans who (1) used VA pharmacies only; (2) used both VA and Medicare Part D pharmacies; or (3) used Part D pharmacies only. Chi-square tests and multinomial logistic regression analyses were used to determine associations between various patient variables and source of medications. Patient level frequencies were used to determine the most common drug classes.

Results: A total of 13,442 veterans with SCI/D were analyzed in this study: 11,788 (87.7%) used VA pharmacies only, 1281 (9.5%) used both VA and Part D pharmacies, and 373 (2.8%) used Part D pharmacies only. Veterans older than 50 years were more likely to use Part D pharmacies, whereas those with traumatic injury, or secondary conditions, were less associated with the use of Part D pharmacies. Opioids were the most frequently filled drug class across all groups. Other frequently used drug classes included skeletal muscle relaxants, gastric medications, antidepressants (other category), anticonvulsants, and antilipemics.

Conclusions: Approximately 12% of veterans with SCI/D are receiving medication outside the VA system. Polypharmacy in this population of veterans is relatively high, emphasizing the importance of health information exchange between systems for improved care for this medically complex population.
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June 2018

A Mixed-Methods Study of Veterans Affairs Providers' Experiences Communicating With Patients About the Affordable Care Act.

Mil Med 2017 05;182(5):e1715-e1723

Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Department of Veterans Affairs, 5000 South 5th Avenue (151H), Hines, IL 60141.

Objective: The provisions under the Affordable Care Act (ACA) can potentially increase insurance options for Veterans. Veterans must be informed about their options, and potential benefits and challenges associated with use of multiple health care systems. This study aimed to assess VA providers' perceptions of how they contributed to Veterans' health care decision-making within the health care context established by the ACA.

Materials And Methods: A mixed-methods approach including an online survey and semi-structured interviews was used to assess the experiences of health care providers (e.g., physicians, nurses, and social workers) communicating with Veterans about the ACA. Closed-ended survey questions were analyzed using descriptive statistics. Qualitative analysis of open-ended responses to the survey and semi-structured interview entailed thematic analysis, which involved identifying themes and patterns within and across participants until reaching saturation.

Results: A total of 251 providers completed the survey (20% response rate), and 26 providers completed a semi-structured interview (23% participation rate). Most providers (75.3%) reported being only "a little" or "somewhat" knowledgeable about the overall provisions of the ACA, and 90.8% of providers reported needing more information about the ACA. Key themes that emerged from the qualitative analyses included a variety of issues related to the ACA. According to providers, Veterans raised concerns about: signing up for the ACA, retaining VA benefits, knowledge about VA benefits and the ACA, understanding implications of insurance coverage through the ACA, and affordability of the ACA. Providers expressed the need for provider and patient educational resources.

Conclusion: Our findings suggest that Veterans and their providers encounter challenges comprehending recent policy changes and navigating ongoing dual health care use. According to providers, Veterans' knowledge about the ACA can affect their ability to make informed health care decisions. Equipping patients and providers with more information about the ACA, and promoting communication between patients and providers may foster shared decision-making processes with regard to health care and treatment options. Strategies to improve knowledge transfer and patient-provider communication about policy changes warrant further investigation.
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May 2017

Economic Factors Impacting Food Allergen Management: Perspectives from the Food Industry.

J Food Prot 2017 10;80(10):1719-1725

2 Northwestern University Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611.

Food allergies affect up to 8% of children in the United States and may occasionally lead to severe life-threatening reactions. Because there is currently no cure for food allergies, strict avoidance of the allergen-containing foods is the only means of preventing an allergic reaction. Consumers rely on food manufacturers to reliably track and declare the presence of food allergens in products. Over the past 10 to 20 years, the food industry has increasingly adopted allergen control approaches in its processing facilities. However, the major industry costs related to food allergen management have not been fully described. The objective of this study was to characterize the factors that contribute to the economic impact of food allergen control practices on the food industry. A focus group (n = 100) was conducted with food industry professionals to identify key areas of cost for food allergen management. A survey based on the domains identified was then developed and disseminated to a convenience sample (n = 50) of quality control food industry specialists with knowledge of their company's food allergen management practices. Nearly all companies (92%) produced food products containing one or more of the top eight allergenic foods recognized by the U.S. Food and Drug Administration or sesame seeds. Cleaning procedures, employee training, and the potential for a recall due to allergen cross-contact were most frequently rated as the important factors in food allergen management. Recalls due to food allergen cross-contact, cleaning procedures, equipment and premises design, and employee training were ranked as the greatest allergen management expenses. Although 96% of companies had a food allergen control plan in place, nearly half (42%) had at least one food allergen-related recall within the past 5 years. The industry appears to endorse a willingness to unify precautionary allergen labeling to communicate a clear message more effectively to consumers.
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October 2017

Opioid dispensing and overlap in veterans with non-cancer pain eligible for Medicare Part D.

J Am Pharm Assoc (2003) 2017 May - Jun;57(3):333-340.e3. Epub 2017 Apr 10.

Objectives: Pain is the most prevalent problem among veterans, who receive pain diagnoses 5 times more frequently than the general population. Opioids are commonly prescribed for pain, but they have potential for misuse and serious adverse events. The study objective was to evaluate opioid dispensing patterns and predictors for overlap in veterans who are eligible for Medicare Part D benefits.

Methods: A sample of male and all female veterans aged 66 years and older without cancer in 2005-2009 was included. Overlapping days' supply of opioids were evaluated within the U.S. Department of Veterans Affairs (VA), within Part D, and in cross-system users of VA and Part D-reimbursed pharmacies during 2007-2009. Dispensing patterns were analyzed with t tests and chi-square tests. Predictors of overlap were identified with general estimating equations.

Results: At least 1 opioid was dispensed to 88.5% of the sample. In 2006 after Part D implementation, 55.2% of opioids were dispensed by VA, decreasing to 44.3% in 2009 (P <0.0001). Opioids dispensed from Part D-reimbursed pharmacies had a higher frequency of overlap compared to those filled at a VA facility (P <0.0001). While overlapping days' supply for opioids filled at VA decreased, overlap increased for prescriptions filled at Part D-reimbursed pharmacies (P <0.0001). There was minimal overlap in opioids between systems, but cross-system use increased over the study period. Predictors for overlap include females, Part D enrollment, no VA medication copay, sleep disorders, psychiatric diagnoses, and substance or alcohol abuse (all P <0.01). Veterans who were Hispanic, older, and had higher incomes had lower overlap odds (all P <0.0001).

Conclusions: Opioids dispensed from Part D-reimbursed pharmacies had a higher frequency of overlapping days' supply as compared to those filled by the VA, but there was minimal overlap between systems. While overlapping opioid prescriptions filled by the VA decreased from 2007 to 2009, overlap increased for prescriptions filled at Part D-reimbursed pharmacies. Tools, such as drug monitoring programs, should be used by VA and non-VA providers to decrease opioid-related harms and misuse.
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February 2018

Potential of personal health record portals in the care of individuals with spinal cord injuries and disorders: Provider perspectives.

J Spinal Cord Med 2018 05 21;41(3):298-308. Epub 2017 Mar 21.

g Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Health Administration , Bedford , Massachusetts , USA.

Context/objective: Although personal health record (PHR) portals are designed for patients, healthcare providers are a key influence in how patients use their features and realize benefits from them. A few studies have examined provider attitudes toward PHR portals, but none have focused on those who care for individuals with spinal cord injuries and disorders (SCI/D). We characterize SCI/D provider perspectives of PHR portals, including perceived advantages and disadvantages of PHR portal use in SCI/D care.

Design: Cross-sectional; semi-structured interviews.

Setting: Spinal Cord Injury (SCI) Centers in the Veterans Health Administration.

Participants: Twenty-six SCI/D healthcare providers.

Interventions: None.

Outcome Measures: Perceived advantages and disadvantages of PHR portals.

Results: The complex situations of individuals with SCI/D shaped provider perspectives of PHR portals and their potential role in practice. Perceived advantages of PHR portal use in SCI/D care included the ability to coordinate information and care, monitor and respond to outpatient requests, support patient self-management activities, and provide reliable health information to patients. Perceived disadvantages of PHR portal use in SCI/D care included concerns about the quality of patient-generated health data, other potential liabilities for providers and workload burden, and the ability of individuals with SCI/D to understand clinical information accessed through a portal.

Conclusion: Our study highlights advantages and disadvantages that should be considered when promoting engagement of SCI/D healthcare providers in use of PHR portals, and portal features that may have the most utility in SCI/D care.
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May 2018

Use of the PARIHS Framework for Retrospective and Prospective Implementation Evaluations.

Worldviews Evid Based Nurs 2017 Apr 8;14(2):99-107. Epub 2017 Mar 8.

Research Health Scientist, Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA.

Background: The Promoting Action on Research Implementation in Health Services (PARIHS) framework has been used by implementation researchers to assess factors impacting implementation and to use that information to identify optimal interventions and implementation strategies. In this paper, two studies are presented demonstrating the utility of PARIHS as a tool for retrospective and prospective evaluation of implementation in the health care setting.

Study Design: Descriptive case study.

Methods: A qualitative consensus process was used to evaluate provider perceptions of PARIHS constructs of evidence, context, and facilitation and their subelements which were scored on a continuum of low to high.

Results: The first example demonstrates retrospective use of PARIHS which provided insight into the factors contributing to variations in implementation across sites in an ongoing program. Evidence was strong (high), whereas context noted some challenges in culture and measurement (mixed), and the presence of dedicated program facilitators was positive but dual roles limited their ability to fully support implementation (mixed). The second example demonstrates prospective use of PARIHS for evaluation which gathered information about intervention sites for the purposes of selecting implementation strategies responsive to site needs. Evidence supporting the intervention was limited (low), context noted that limited awareness of the intervention was a challenge (low), and that a strong internal facilitator supported implementation (high).

Linking Evidence To Action: The descriptive case study presented here underscores the value of a theory-guided approach to implementation and highlights that PARIHS can help implementers understand factors impacting implementation, identify areas for future intervention, and inform selection of strategies to support or enhance implementation efforts.
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April 2017

Food Allergy-Related Risk-Taking and Management Behaviors Among Adolescents and Young Adults.

J Allergy Clin Immunol Pract 2017 Mar - Apr;5(2):381-390.e13. Epub 2017 Jan 27.

Northwestern University Feinberg School of Medicine, Chicago, Ill; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill. Electronic address:

Background: Food allergy (FA) affects 8% of children and adolescents in the United States. Nearly 40% of those affected have experienced severe reactions. Fatal food-induced anaphylaxis is most common among adolescents and young adults (AYA); however, FA-related risk behaviors persist in this population and factors associated with these behaviors remain unclear.

Objective: To characterize FA-related risk-taking and self-management behaviors of AYA with FA.

Methods: A cross-sectional survey was administered to 200 AYA with FA. Latent class analysis was used to identify distinct behavioral risk classes and predictors of risk class membership.

Results: Two distinct FA behavioral risk classes were identified, representing less (N = 120) and more (N = 80) risky subpopulations. After adjusting for age, sex, and anaphylaxis history, odds of more risky class membership were significantly reduced for AYA with peanut allergy (odds ratio [OR], 0.27; 95% CI, 0.11-0.65), supportive female friends (OR, 0.27; 95% CI, 0.07-0.99), overprotective mothers (OR, 0.42; 95% CI, 0.18-0.97), teachers who are aware of their FA (OR, 0.39; 95% CI, 0.17-0.91), a history of being bullied (OR, 0.22; 95% CI, 0.09-0.51), and an established 504 education plan (OR, 0.35; 95% CI, 0.15-0.81). AYA also reported numerous positive outcomes of their FA, such as greater responsibility, empathy, and improved diet, which was significantly associated with reduced odds of risky class membership (OR, 0.38; 95% CI, 0.18-0.80).

Conclusions: Among AYA, increased FA-related risk-taking was associated with clinical, demographic, and social factors, including peanut allergy, greater age, as well as absence of social support and specific school FA policies. These associations may be used to inform future interventions designed to address FA-related risk and management behaviors.
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November 2017

Medication acquisition by veterans dually eligible for Veterans Affairs and Medicare Part D pharmacy benefits.

Am J Health Syst Pharm 2017 02;74(3):140-150

Veterans Administration Pharmacy Benefit Management Services, Edward Hines Jr. Veterans Administration Hospital, Hines, IL.

Purpose: The patterns of medication acquisition for veterans dually eligible for pharmacy benefits from the Department of Veterans Affairs (VA) and Medicare Part D-reimbursed pharmacies were examined.

Methods: The characteristics of veterans who used pharmacies reimbursed by (1) VA only, (2) both VA and Part D-reimbursed, and (3) Part D-reimbursed only pharmacies in 2009 were compared and their medication types and sources examined. Pharmacy usage was measured as the number of 30-day medication supplies and the number of different drug classes that veterans received from VA and Part D-reimbursed pharmacies. Chi-square testing and analysis of variance were used to compare unadjusted patient characteristics and healthcare utilization.

Results: A total of 145,899 veterans with any VA or Part D-reimbursed pharmacy use were included in the study: 69.6% used VA pharmacies only, 9.9% used VA and Part D-reimbursed pharmacies, and 20.5% used Part D-reimbursed pharmacies only. Veterans who lived in rural areas, were non-Black, had VA medication copayments, or were dual or Medicare-only outpatient users were more likely to be dual or Part D-reimbursed only pharmacy users (p < 0.001). Dual pharmacy users received more 30-day supplies than did the other two pharmacy-use groups (p < 0.001).

Conclusion: Nearly one third of VA users received medications from Part D-reimbursed pharmacies, either alone or together with VA pharmacies. Among dual pharmacy users, over half received medications from the same drug class from both VA and Part D-reimbursed pharmacies for which the days' supplies overlapped by more than seven days.
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February 2017

Sociotechnical Perspective on Implementing Clinical Video Telehealth for Veterans with Spinal Cord Injuries and Disorders.

Telemed J E Health 2017 07 9;23(7):567-576. Epub 2017 Jan 9.

1 Center of Innovation for Complex Chronic Healthcare , Edward Hines Jr. Veterans Affairs Hospital, U.S. Department of Veterans Affairs, Hines, Illinois.

Background: Real-time videoconferencing technology such as clinical video telehealth (CVT) offers a means to reach patient populations who face limited access to healthcare. The Veterans Health Administration has invested in CVT to improve care access for U.S. military veterans with spinal cord injuries and disorders (SCI/D); however, no studies have assessed the factors that influence implementation of this technology in clinical practice for individuals with SCI/D.

Introduction: Guided by a sociotechnical perspective, the purpose of this study was to identify factors that influence implementation of CVT for veterans with SCI/D.

Materials And Methods: We conducted semistructured telephone interviews with 40 healthcare providers who use CVT to deliver services to veterans with SCI/D.

Results: Factors related to workflow and communication were widely reported as implementation barriers. Coordinating logistics for CVT appointments was challenging, and effective communication between CVT team members across facilities was considered crucial. Providers also cited factors related to technical infrastructure, people, and organizational features, including the need for appropriate equipment, space, personnel, and support for using CVT equipment.

Discussion: The implementation of CVT in the care of veterans with SCI/D was influenced by an interrelated set of social and technical factors. Key among them were social factors related to people, workflow, and communication, given that CVT supports healthcare teams interacting remotely in real time.

Conclusions: CVT implementation requires teams working together to negotiate a complex, distributed process across multiple sites. Such complexity places a premium on teamwork and communication among healthcare teams before, during, and after a CVT encounter.
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July 2017

Hygiene factors associated with childhood food allergy and asthma.

Allergy Asthma Proc 2016 11;37(6):e140-e146

Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.

Background: Childhood food allergy and asthma rates are increasing. The hygiene hypothesis has been proposed as an explanation for the increased incidence of allergic disease.

Objective: To describe the association of childhood food allergy and asthma with hygiene factors, such as the number of siblings, antibiotic use, infection history, pet exposure, child care exposure, and maternalchild factors.

Methods: Children ages 021 years old (N = 1359) were recruited for a cross-sectional family-based study, including children with food allergy and children without food allergy, and their siblings. We assessed the associations between childhood food allergy and asthma with hygiene factors.

Results: Of the 1359 children, 832 (61.2%) had food allergy, and 406 (30%) had asthma. In the adjusted analysis, the prevalence of food allergy was increased if there was a history of skin infection (prevalence ratio [RRR] 1.12 [95% confidence interval {CI}, 1.011.24]) or eczema (RRR 1.89 [95% CI, 1.702.10]). The prevalence of asthma was increased with a history of respiratory syncytial virus infection (RRR 1.60 [95% CI, 1.341.90]) or eczema (RRR 1.54 [95% CI, 1.271.86]). A greater number of siblings were associated with a decreased prevalence of food allergy (RRR 0.79 [95% CI, 0.750.84]) and asthma (RRR 0.82 [95% CI, 0.740.91]).

Conclusion: Our findings supported the accumulating evidence of an association between skin infections and eczema with food allergy. Because these results could be subject to recall bias, additional prospective studies are needed to substantiate these findings.
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November 2016

Patient prioritization of comorbid chronic conditions in the Veteran population: Implications for patient-centered care.

SAGE Open Med 2016 29;4:2050312116680945. Epub 2016 Nov 29.

Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Veterans Health Administration, Bedford, MA, USA; Division of Health Informatics and Implementation Science, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.

Objective: Patients with comorbid chronic conditions may prioritize some conditions over others; however, our understanding of factors influencing those prioritizations is limited. In this study, we sought to identify and elaborate a range of factors that influence how and why patients with comorbid chronic conditions prioritize their conditions.

Methods: We conducted semi-structured, one-on-one interviews with 33 patients with comorbidities recruited from a single Veterans Health Administration Medical Center.

Findings: The diverse factors influencing condition prioritization reflected three overarching themes: (1) the perceived role of a condition in the body, (2) self-management tasks, and (3) pain. In addition to these themes, participants described the rankings that they believed their healthcare providers would assign to their conditions as an influencing factor, although few reported having shared their priorities or explicitly talking with providers about the importance of their conditions.

Conclusion: Studies that advance understanding of how and why patients prioritize their various conditions are essential to providing care that is patient-centered, reflecting what matters most to the individual while improving their health. This analysis informs guideline development efforts for the care of patients with comorbid chronic conditions as well as the creation of tools to promote patient-provider communication regarding the importance placed on different conditions.
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November 2016