Publications by authors named "Gayle E Reiber"

83 Publications

Using Video Telehealth to Facilitate Inhaler Training in Rural Patients with Obstructive Lung Disease.

Telemed J E Health 2019 03 17;25(3):230-236. Epub 2018 Jul 17.

1 Health Services Research and Development (HSR&D), Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.

Background: Proper inhaler technique is important for effective drug delivery and symptom control in chronic obstructive pulmonary disease (COPD) and asthma, yet not all patients receive inhaler instructions.

Introduction: Using a retrospective chart review of participants in a video telehealth inhaler training program, the study compared inhaler technique within and between monthly telehealth visits and reports associated with patient satisfaction.

Materials And Methods: Seventy-four (N = 74) rural patients prescribed ≥1 inhaler participated in three to four pharmacist telehealth inhaler training sessions using teach-to-goal (TTG) methodology. Within and between visit inhaler technique scores are compared, with descriptive statistics of pre- and postprogram survey results including program satisfaction and computer technical issues. Healthcare utilization is compared between pre- and post-training periods.

Results: Sixty-nine (93%) patients completed all three to four video telehealth inhaler training sessions. During the initial visit, patients demonstrated improvement in inhaler technique for metered dose inhalers (albuterol, budesonide/formoterol), dry powder inhalers (formoterol, mometasone, tiotropium), and soft mist inhalers (ipratropium/albuterol) (p < 0.01 for all). Improved inhaler technique was sustained at 2 months (p < 0.01). Ninety-four percent of participants were satisfied with the program. Although technical issues were common, occurring among 63% of attempted visits, most of these visits (87%) could be completed. There was no significant difference in emergency department visits and hospitalizations pre- and post-training.

Discussion: This study demonstrated high patient acceptance of video telehealth training and objective improvement in inhaler technique.

Conclusions: Video telehealth inhaler training using the TTG methodology is a promising program that improved inhaler technique and access to inhaler teaching for rural patients with COPD or asthma.
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http://dx.doi.org/10.1089/tmj.2017.0330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6916242PMC
March 2019

Multiple domains of social support are associated with diabetes self-management among Veterans.

Chronic Illn 2019 12 10;15(4):264-275. Epub 2018 Apr 10.

7 Department of Medicine, University of Washington, Seattle, WA, USA.

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http://dx.doi.org/10.1177/1742395318763489DOI Listing
December 2019

Vasomotor symptom characteristics: are they risk factors for incident diabetes?

Menopause 2018 05;25(5):520-530

Division of Epidemiology, Department of Family Medicine and Public Health, University of California San Diego School of Medicine, La Jolla, CA.

Objective: Vasomotor symptoms (VMS), encompassing hot flashes and night sweats, may be associated with diabetes, but evidence is limited. We sought to estimate these associations.

Methods: Among 150,007 postmenopausal Women's Health Initiative participants from 1993 to 2014, we prospectively examined associations of incident diabetes with VMS characteristics at enrollment: any VMS, severity (mild/ moderate/severe), type (hot flashes/night sweats), timing (early [premenopausal or perimenopausal]/late [postmenopausal]), and duration. Cox proportional-hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs).

Results: Mean duration of follow-up was 13.1 years. VMS prevalence was 33%. Reporting any VMS was associated with 18% increased diabetes risk (95% CI 1.14, 1.22), which increased with severity (mild: HR 1.13, 95% CI 1.08, 1.17; moderate: HR 1.29, 95% CI 1.22, 1.36; severe: HR 1.48, 95% CI 1.34, 1.62) and duration (4% per 5 years, 95% CI 1.03, 1.05), independent of obesity. Diabetes risk was more pronounced for women reporting any night sweats (night sweats only: HR 1.20, 95% CI 1.13, 1.26; night sweats and hot flashes: HR 1.22, 95% CI 1.17, 1.27) than only hot flashes (HR 1.08, 95% CI 1.02, 1.15) and was restricted to late VMS (late: HR 1.12, 95% CI 1.07, 1.18; early and late: HR 1.16, 95% CI 1.11, 1.22; early: HR 0.99, 95% CI 0.95, 1.04).

Conclusions: VMS are associated with elevated diabetes risk, particularly for women reporting night sweats and postmenopausal symptoms. The menopause transition may be an optimal window for clinicians to discuss long-term cardiovascular/metabolic risk with patients and leverage the bother of existing symptoms for behavior change to improve VMS and reduce diabetes risk.
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http://dx.doi.org/10.1097/GME.0000000000001033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898980PMC
May 2018

Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes.

Chronic Illn 2017 12 20;13(4):239-250. Epub 2017 Feb 20.

1 Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA.

Objective To determine whether the presence of an informal caregiver and the patient's level of social support are associated with better diabetes self-care among adults with poorly controlled diabetes. Methods Cross-sectional study using baseline data from 253 adults of age 30-70 with poorly controlled diabetes. Participants who reported receiving assistance with their diabetes from a friend or family member in the past month were classified as having a caregiver. We used multivariate linear and logistic regression models to evaluate the associations between having a caregiver and level of social support with five self-reported diabetes self-care behaviors: diet, foot checks, blood glucose monitoring, medications, and physical activity. Results Compared to participants with no informal caregiver, those with an informal caregiver were significantly more likely to report moderate or high medication adherence (OR = 1.93, 95% CI: 1.07-3.49, p = 0.028). When we included social support in the model, having a caregiver was no longer significantly associated with medication adherence (OR = 1.50, 95% CI: 0.80-2.82), but social support score was (OR = 1.22, 95% CI: 1.03-1.45, p = 0.023). Discussion Among low-income adults with poorly controlled diabetes, having both an informal caregiver and high social support for diabetes may have a beneficial effect on medication adherence, a key self-care target to improve diabetes control.
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http://dx.doi.org/10.1177/1742395317690032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993051PMC
December 2017

Inhaler Training Delivered by Internet-Based Home Videoconferencing Improves Technique and Quality of Life.

Respir Care 2017 Nov 18;62(11):1412-1422. Epub 2017 Jul 18.

Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care.

Background: COPD is common, and inhaled medications can reduce the risk of exacerbations. Incorrect inhaler use is also common and may lead to worse symptoms and increased exacerbations. We examined whether inhaler training could be delivered using Internet-based home videoconferencing and its effect on inhaler technique, self-efficacy, quality of life, and adherence.

Methods: In this pre-post pilot study, participants with COPD had 3 monthly Internet-based home videoconference visits with a pharmacist who provided inhaler training using teach-to-goal methodology. Participants completed mailed questionnaires to ascertain COPD severity, self-efficacy, health literacy, quality of life, adherence, and satisfaction with the intervention.

Results: A total of 41 participants completed at least one, and 38 completed all 3 home videoconference visits. During each visit, technique improved for all inhalers, with significant improvements for the albuterol metered-dose inhaler, budesonide/formoterol metered-dose inhaler, and tiotropium dry powder inhaler. Improved technique was sustained for nearly all inhalers at 1 and 2 months. Quality of life measured with the Chronic Respiratory Questionnaire improved following the training: dyspnea (+0.3 points, = .01), fatigue (+0.6 points, < .001), emotional function (+0.5 points, = .001), and mastery (+0.7 points, < .001). Coping skills measured with the Seattle Obstructive Lung Disease Questionnaire improved (+9.9 points, = .003). Participants reported increased confidence in inhaler use; for example, mean self-efficacy for using albuterol increased 3 points ( < .001). Inhaler adherence improved significantly after the intervention from 1.6 at the initial visit to 1.1 at month 2 ( = .045). The pharmacist reported technical issues in 64% of visits.

Conclusions: Inhaler training using teach-to-goal methodology delivered by home videoconference is a promising means to provide training to patients with COPD that can improve technique, quality of life, self-efficacy, and adherence.
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http://dx.doi.org/10.4187/respcare.05445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373850PMC
November 2017

Association Between Mental Health Staffing Level and Primary Care-Mental Health Integration Level on Provision of Depression Care in Veteran's Affairs Medical Facilities.

Adm Policy Ment Health 2018 01;45(1):131-141

Health Services Research & Development (HSR&D), Veteran Affairs (VA) Puget Sound Health Care System, 1660 Columbian Way, Seattle, WA, 98108, USA.

We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.
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http://dx.doi.org/10.1007/s10488-016-0775-9DOI Listing
January 2018

Diet quality is associated with mental health, social support, and neighborhood factors among Veterans.

Eat Behav 2016 12 19;23:168-173. Epub 2016 Oct 19.

VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, United States; Yale School of Medicine, 301 Cedar Street, New Haven, CT 06520, United States. Electronic address:

United States Veterans have a higher prevalence of overweight and related chronic conditions compared to the general population. Although diet is a primary and modifiable contributor to these conditions, little is known about factors influencing diet quality among Veterans. The goal of this study is to examine individual, social environment, and physical environment correlates of general diet quality among Veterans. Study participants (N=653) received care at an urban VA Medical Center in Seattle, WA and completed a mailed survey in 2012 and 2013. Diet quality was assessed with Starting the Conversation, an instrument that measures consumption of unhealthy snacks, fast food, desserts, sugar-sweetened beverages, and fats; fruits and vegetables; and healthy proteins. Variables significantly (p<0.05) associated with diet quality in bivariate analyses were included in a multivariate regression. In the multivariate model, higher level of depressive symptom severity (Diff=0.05; CI=0.01, 0.09; p=0.017); not having others eat healthy meals with the Veteran (Diff=-0.81; CI=-1.5, -0.1; p=0.022); and reduced availability of low-fat foods in neighborhood stores where the Veteran shops (Diff=-0.37; CI=-0.6, -0.2; p<0.001) were associated with poorer diet quality. Consistent with prior research in the general population, this study identified multiple domains associated with Veterans' diet quality, including psychological comorbidity, the social environment, and the physical environment. Findings from this study suggest that interventions aimed at mental health, social support, and neighborhood access to healthy foods are needed to improve Veteran diet quality.
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http://dx.doi.org/10.1016/j.eatbeh.2016.10.003DOI Listing
December 2016

Medicare-VHA dual use is associated with poorer chronic wound healing.

Wound Repair Regen 2016 Sep 19;24(5):913-922. Epub 2016 Jul 19.

VHA Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington.

Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non-VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare-enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow-up. We used a proportional hazards model to compare wound healing among VHA-exclusive and dual wound care users, using a time-varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow-up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use (HR = 0.63, 95%CI: 0.39-0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61-11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11-8.56, p = 0.031), were significantly higher for dual users compared to VHA-exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA-exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic wound care.
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http://dx.doi.org/10.1111/wrr.12454DOI Listing
September 2016

Association Between Chronic Conditions and Physical Function Among Veteran and Non-Veteran Women With Diabetes.

Gerontologist 2016 Feb;56 Suppl 1:S112-25

VA Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington. Department of Health Services, University of Washington School of Public Health, Seattle. Department of Epidemiology, University of Washington School of Public Health, Seattle.

Purpose Of The Study: To compare the number of chronic conditions among a list of 12 and their association with physical function among postmenopausal non-Veteran and Veteran women with diabetes.

Design And Methods: Among women with diabetes from the Women's Health Initiative, we compared the average number of chronic conditions between non-Veterans and Veterans and the association between total number of chronic conditions on subsequent RAND-36 physical function. To examine associations between each condition and subsequent physical function, we compared women with diabetes plus one chronic condition to women with diabetes alone using linear regression in separate models for each condition and for non-Veterans and Veterans.

Results: Both non-Veterans (N = 23,542) and Veterans (N = 618) with diabetes had a median of 3 chronic conditions. Decreases in physical function for each additional condition were larger among Veterans than non-Veterans (-6.3 vs. -4.1 points). Decreases in physical function among women with diabetes plus one chronic condition were greater than that reported for diabetes alone for all combinations and were more pronounced among Veterans (non-Veterans: -11.1 to -24.2, Veterans: -16.6 to -40.4 points). Hip fracture, peripheral artery disease, cerebrovascular disease, and coronary disease in combination with diabetes were associated with the greatest decreases in physical function.

Implications: Chronic conditions were common among postmenopausal women with diabetes and were associated with large declines in physical function, particularly among Veterans. Interventions to prevent and reduce the impact of these conditions and facilitate coordination of care among women with diabetes may help them maintain physical function.
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http://dx.doi.org/10.1093/geront/gnv675DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881620PMC
February 2016

Improving Our Understanding of Health Issues in Older Women Veterans.

Gerontologist 2016 Feb;56 Suppl 1:S10-3

VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California. Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health, Los Angeles.

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http://dx.doi.org/10.1093/geront/gnv672DOI Listing
February 2016

Older Women Veterans in the Women's Health Initiative.

Gerontologist 2016 Feb;56 Suppl 1:S1-5

Division of Epidemiology, Department of Family Medicine and Public Health, University of California San Diego, La Jolla.

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http://dx.doi.org/10.1093/geront/gnv673DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881618PMC
February 2016

Individual and contextual correlates of physical activity among a clinical sample of United States Veterans.

Soc Sci Med 2015 Oct 3;142:100-8. Epub 2015 Aug 3.

University of Washington, Department of Psychiatry and Behavioral Sciences, United States; Seattle Children's Research Institute, United States.

Rationale: Veterans, especially those using U.S. Department of Veterans Affairs (VA) healthcare, have poorer health than the general population. In addition, Veterans using VA services are more likely than non-VA users to be physically inactive. Little is known about physical activity correlates among Veterans. To identify targets for health promotion interventions, understanding barriers to and facilitators of physical activity in this population is critical.

Methods: This study examined individual-, social-, and perceived neighborhood-level associations of meeting weekly physical activity recommendations (150 min/week of combined leisure and transportation activity) based on the International Physical Activity Questionnaire (IPAQ) among N = 717 patients from VA Puget Sound, Seattle Division using a mailed survey sent 2012-2013 (response rate = 40%). Independent associations were identified with direct estimation of relative risks using generalized linear models (dichotomous outcome), and linear regression (continuous outcome), including variables associated in bivariate tests (p < .05).

Results: Most participants were male, Caucasian, and unemployed, and had an annual income ≤$40,000. Over two-thirds (69.9%) reported meeting physical activity recommendations. Fewer days of limitations due to physical or mental health (Relative Risk (RR) = 0.99 per day; 95% Confidence Interval (CI) = 0.98, 0.99; p = .01), others doing physical activity with the Veteran (RR = 1.18; 95% CI = 1.04, 1.33; p = .01), receiving ideas from others regarding physical activity (RR = 1.14; 95% CI = 1.01, 1.29; p = .03) and better perceived neighborhood aesthetics (RR = 1.14; 95% CI = 1.06, 1.24; p = .001) were associated with meeting physical activity recommendations. Findings were comparable for total weekly physical activity, but lower depression symptom severity was also associated with increased physical activity.

Conclusion: This study identified individual and contextual correlates of physical activity among VA-using Veterans. Targeting these factors will be important in promoting physical activity in order to address the disproportionate disease burden facing U.S. Veterans. Existing VA interventions targeting physical activity may need to be adapted to account for the influence of contextual factors.
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http://dx.doi.org/10.1016/j.socscimed.2015.07.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6918692PMC
October 2015

Evidence-based chronic ulcer care and lower limb outcomes among Pacific Northwest veterans.

Wound Repair Regen 2015 Sep 17;23(5):745-52. Epub 2015 Sep 17.

Department of Veterans Affairs, Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington.

Evidence-based ulcer care guidelines detail optimal components of care for treatment of ulcers of different etiologies. We investigated the impact of providing specific evidence-based ulcer treatment components on healing outcomes for lower limb ulcers (LLU) among veterans in the Pacific Northwest. Components of evidence-based ulcer care for venous, arterial, diabetic foot ulcers/neuropathic ulcers were abstracted from medical records. The outcome was ulcer healing. Our analysis assessed the relationship between evidence-based ulcer care by etiology, components of care provided, and healing, while accounting for veteran characteristics. A minority of veterans in all three ulcer-etiology groups received the recommended components of evidence-based care in at least 80% of visits. The likelihood of healing improved when assessment for edema and infection were performed on at least 80% of visits (hazard ratio [HR] = 3.20, p = 0.009 and HR = 3.54, p = 0.006, respectively) in patients with venous ulcers. There was no significant association between frequency of care components provided and healing among patients with arterial ulcers. Among patients with diabetic/neuropathic ulcers, the chance of healing increased 2.5-fold when debridement was performed at 80% of visits (p = 0.03), and doubled when ischemia was assessed at the first visit (p = 0.045). Veterans in the Pacific Northwest did not uniformly receive evidence-based ulcer care. Not all evidence-based ulcer care components were significantly associated with healing. At a minimum, clinicians need to address components of ulcer care associated with improved ulcer healing.
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http://dx.doi.org/10.1111/wrr.12341DOI Listing
September 2015

Reproductive Life Planning in Primary Care: A Qualitative Study of Women Veterans' Perceptions.

Womens Health Issues 2015 Sep-Oct;25(5):548-54. Epub 2015 Jun 27.

Department of Veterans Affairs (VA) Puget Sound Health Care System, Health Services Research and Development, Seattle, Washington; Department of Health Services, University of Washington School of Public Health, Seattle, Washington; VA Office of Patient Care Services, Women's Health Services, Washington, DC.

Background: Women veterans using Veterans Administration (VA) health care have high rates of medical and mental health comorbidities, placing them at increased risk of poor outcomes from unplanned pregnancy. Reproductive life planning is a strategy recommended by the U.S. Centers of Disease Control and Prevention that could promote healthy pregnancies and reduce unplanned pregnancy in the VA. However, no data exist on women veterans' perceptions of reproductive life planning discussions.

Methods: We trained six VA primary care physicians at two VA Women's Health Clinics to conduct reproductive life planning discussions with veterans aged 18 to 44 during primary care visits. After the visit, we performed semistructured telephone interviews with consenting veterans to explore perceptions of 1) reproductive life planning content and 2) provider-patient communication in reproductive life planning discussions. Interviews were audiorecorded, transcribed, and analyzed using content analysis.

Results: We interviewed 27 veterans with a mean age of 31 years (range, 22-42). Women veterans perceived generally reproductive life planning discussions as important opportunities to discuss reproductive goals with providers and to obtain new and relevant information about contraception, planning healthy pregnancies, and available VA reproductive health services. Perceptions of reproductive life planning content were influenced by women's pregnancy intentions. Perceptions related to provider-patient communication included preferences for provider-initiated discussions and nonjudgmental counseling that incorporates patients' values and preferences.

Conclusions: Women veterans perceived reproductive life planning as valuable and important to their health. Reproductive life planning has the potential to enhance patient-centered delivery of reproductive health services in VA primary care.
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http://dx.doi.org/10.1016/j.whi.2015.05.002DOI Listing
July 2016

Adverse Childhood Experiences, Military Service, and Adult Health.

Am J Prev Med 2015 Oct 16;49(4):573-82. Epub 2015 Jun 16.

Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, School of Public Health, University of Washington, Seattle, Washington; Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington.

Introduction: Prevalence of adverse childhood experiences (ACE) and associations with adult health may vary by gender and military service. This study compares the gender-specific prevalence of ACE by military service and determines the associations of ACE with adult health risk factors and health-related quality of life (HRQOL).

Methods: This 2014 analysis used data from the 2011 and 2012 CDC Behavioral Risk Factor Surveillance System. Total ACE was operationalized as the number of reported ACE. Associations of total ACE with adult health risk factors were estimated using general linear models; associations with HRQOL were estimated using negative binomial regression. All analyses adjusted for age and race/ethnicity.

Results: Those with military service had more total ACE than civilians. Higher ACE was associated with poorer HRQOL among women (physical health, military service, relative risk [RR]=1.20, 95% CI=1.09, 1.33; civilians, RR=1.18, 95% CI=1.17, 1.20; mental health, military service, RR=1.21, 95% CI=1.12, 1.32; civilians, RR=1.25, 95% CI=1.23, 1.26). Among men, these associations were somewhat attenuated in those with military service relative to civilians (physical health, military service, RR=1.13, 95% CI=1.09, 1.18; civilians, RR=1.20, 95% CI=1.17, 1.24; mental health, military service, RR=1.21, 95% CI=1.16, 1.27; civilians, RR=1.30, 95% CI=1.27, 1.34).

Conclusions: Relative to civilians, men and women with military service report more ACE, but associations of ACE with adult HRQOL are weaker among men with military service relative to civilians. There is a need to implement and disseminate evidence-based programs to prevent ACE and for research on the long-term health consequences of ACE in military populations.
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http://dx.doi.org/10.1016/j.amepre.2015.03.020DOI Listing
October 2015

Chronic Lower Limb Wound Outcomes Among Rural and Urban Veterans.

J Rural Health 2015 7;31(4):410-20. Epub 2015 May 7.

Health Services Research & Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington.

Purpose: Veterans in rural areas generally have lower health care utilization than veterans in urban areas, but the impact of this difference on health outcomes has received little study. Chronic wounds provide a model for studying access to complex chronic care since they often are related to underlying health conditions and require lengthy treatment. Our goals were to describe chronic wound care utilization among rural and urban veterans and to determine the association between rural residence and wound healing.

Methods: We conducted a retrospective cohort study of 160 rural and 160 urban veterans in the Pacific Northwest with an incident of chronic lower limb wound between October 1, 2006, and September 30, 2007. We followed individuals for up to 1 year, measuring wound care utilization within Veterans Health Administration and Medicare. We compared wound healing using a competing risks proportional hazards model accounting for amputation and death.

Findings: Rural veterans had fewer outpatient wound care visits (6.8 vs 9.9) than urban veterans and a similar number of inpatient wound care stays (0.9 and 0.8, respectively). During follow-up, 234 veterans' wounds healed (77% rural, 69% urban). The adjusted hazard ratio for wound healing was 1.11 (95% confidence intervals [CI]: 0.84-1.47, P = .45) for rural compared to urban veterans. The hazard of amputation was higher among rural veterans (hazard ratio [HR] = 2.65, 95% CI: 1.02-6.87, P = .045) and the hazard of death was lower (HR = 0.35, 95% CI: 0.12-0.97, P = .043).

Conclusions: Despite lower wound care utilization, rural veterans' wounds were as likely to heal as urban veterans' wounds.
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http://dx.doi.org/10.1111/jrh.12115DOI Listing
May 2016

Prenatal Care for Women Veterans Who Use Department of Veterans Affairs Health Care.

Womens Health Issues 2015 Jul-Aug;25(4):377-81. Epub 2015 Apr 29.

Women's Veterans Health Services, Office of Patient Services, VA Central Office, Washington, DC; Department of Obstetrics and Gynecology, New York University Langone School of Medicine, New York, New York.

Objective: The number of women Veterans of childbearing age enrolling in Department of Veterans Affairs (VA) health care is increasing. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits.

Study Design: We used data from the National Survey of Women Veterans, a population-based survey. VA-eligible women veterans with at least one live birth who had ever used VA and were younger than 45 years when VA prenatal benefits became available were categorized based on self-reported receipt of VA prenatal benefits. Characteristics of by use of VA prenatal benefits were compared using χ2 tests with Rao-Scott adjustment. All analyses used sampling weights.

Results: In our analytic sample, of those who potentially had the opportunity to use VA prenatal benefits, 25% used these benefits and 75% did not. Compared with women veterans not using VA prenatal benefits, those who did were more likely to be 18 to 24 years old (39.9% vs. 3.7%; p=.03), and more likely to have self-reported diagnosed depression (62.5% vs. 24.5%; p=.02) and current depression or posttraumatic stress disorder (PTSD) symptoms (depression, 46.1% vs. 8% [p=.02]; PTSD, 52.5% vs. 14.8% [p=.02]). Compared with women veterans not using VA prenatal benefits, those who did were more likely to resume VA use after delivery (p<.001).

Conclusion: Pregnant women veterans who use VA prenatal benefits are a high-risk group. Among those who opt not to use these benefits, pregnancy is an important point of attrition from VA health care, raising concerns regarding retention of women veterans within VA and continuity of care.
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http://dx.doi.org/10.1016/j.whi.2015.03.004DOI Listing
February 2016

Changes in classifications of chronic lower-limb wound codes in patients with diabetes: ICD-9-CM versus ICD-10-CM.

Adv Skin Wound Care 2015 Feb;28(2):84-92; quiz 93-4

Jeanne R. Lowe, PhD, RN • Affiliate Assistant Professor • University of Washington School of Nursing • Manager • Pay-for-Performance, Finance Department • UW Medical Health System • Seattle, Washington Greg Raugi, MD, PhD • Chief, Teledermatology • VA Puget Sound Medical, Center • Seattle, Washington Gayle E. Reiber, PhD, MPH • Senior VA Career Scientist • VA Puget Sound Health Care System • Seattle, Washington JoAnne D. Whitney, PhD, RN, CWCN, FAAN • Professor • Biobehavioral Nursing and Health Systems • University of Washington School of Nursing • Seattle, Washington.

Purpose: To enhance the learner's competence with knowledge of changes in classifications of chronic lower limb wound codes from ICD-9-CM to ICD-10-CM in patients with diabetes.

Target Audience: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

Objectives: After participating in this educational activity, the participant should be better able to:1. Identify the upcoming transition date and coding differences of ICD-9-CM and ICD-10-CM coding.2. Interpret the author's study population, methods, and design.3. Summarize the author's study findings comparing ICD-9-CM coding to ICD-10-CM coding.

Abstract:

Objective: To determine the sensitivity and specificity of International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) and ICD-10-CM codes for individuals with diabetes and foot ulcers.

Design And Methods: Wound care providers and researchers are concerned about the potential impacts when the United States transitions from ICD-9-CM to ICD-10-CM. To identify the impact on diabetic foot ulcers, health history and wound variables were prospectively assessed with criterion-standard data from a prospective study of 49 patients with 65 foot ulcer episodes representing 81 incident foot ulcers. The ICD-9-CM and ICD-10-CM code sets were mapped to correctly classify individuals with diabetes and foot ulcers.

Results: Frequencies for health history variables were similar in both systems. The ICD-9 code did not capture any data on laterality (left or right) or ulcer depth/severity. The ICD-9 captured 69 of 81 incident ulcers (85%) and 94% of heel and midfoot ulcers, whereas the ICD-10 code captured 78 of 81 incident ulcers (96%) and all incident heel or midfoot ulcers. Sensitivity and specificity for ulcer characteristics were consistently lower in ICD-9 than in ICD-10.

Conclusions: The ICD-9 and ICD-10 are similar for data capture on health history variables, but wound variables are captured more accurately using ICD-10. The increased specificity of ICD-10 for ulcer location and severity improves identification and tracking ulcers during an episode of care.
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http://dx.doi.org/10.1097/01.ASW.0000459576.85574.3fDOI Listing
February 2015

Response to Thomas E. Finucane, MD.

J Am Geriatr Soc 2015 Jan;63(1):203-4

Veteran Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington.

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http://dx.doi.org/10.1111/jgs.13209DOI Listing
January 2015

Improving outcomes for diabetic patients undergoing revascularization for critical limb ischemia: does the quality of outpatient diabetic care matter?

Ann Vasc Surg 2014 Oct 6;28(7):1719-28. Epub 2014 Jun 6.

Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH.

Background: Diabetic patients who undergo lower extremity surgical revascularization for critical limb ischemia (CLI) are at high risk for amputation or death, even when their inpatient procedures are successful. We hypothesized that postoperative outcomes might be improved in regions where diabetics with CLI receive more frequent high-quality outpatient care.

Methods: A retrospective cohort study was performed among 172,134 patients with CLI (52% male, 15% black, mean age 76 years) who underwent open and endovascular lower extremity revascularization procedures using Medicare claims (2004-2007), which included 84,653 (49%) beneficiaries who were diabetic. Regional utilization of annual serum cholesterol and hemoglobin A1c testing were used to assess the quality of outpatient diabetic care. We examined relationships between frequency of diabetic testing with amputation-free survival (AFS), major adverse limb events (MALE), and rates of readmission across all US hospital referral regions.

Results: There was significant regional variation in annual serum cholesterol and hemoglobin A1c testing across the United States (87% highest quartile vs. 59% lowest quartile, P < 0.01). Compared with the lowest quartile of diabetic testing, diabetic patients undergoing lower extremity revascularization in regions with the highest quartile of diabetic testing had significantly improved AFS (hazards ratio [HR]: 0.94, 95% confidence interval [CI]: 0.90-0.97; P < 0.01) and MALE (HR: 0.92, 95% CI: 0.89-0.96; P < 0.01) persisting up to 2 years after lower extremity revascularization, even after adjusting for procedure type, gender, age, race, and comorbidities. Moreover, the risk of 30-day readmission was significantly reduced in regions with the highest versus lowest quartile of diabetic testing (odds ratio: 0.91, 95% CI: 0.85-0.97; P < 0.01). Nondiabetic patients with CLI, in comparison, did not benefit to the same extent from undergoing revascularization in regions with high-quality outpatient diabetic care.

Conclusions: Diabetic patients undergoing lower extremity revascularization in regions with higher utilization of diabetic care quality measures have significantly better long-term limb salvage and readmission outcomes. Our study underscores the importance of providing optimal outpatient care to diabetics following vascular surgery and outlines a potential strategy for quality improvement in these high-risk patients.
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http://dx.doi.org/10.1016/j.avsg.2014.05.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4165745PMC
October 2014

Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression.

J Am Geriatr Soc 2014 Jul 2;62(7):1238-45. Epub 2014 Jun 2.

Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veteran Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington.

Objectives: To assess whether the relationship between antidepressant adherence and coronary artery disease (CAD) hospitalizations varied between older and younger adults with depression.

Design: Retrospective cohort study.

Setting: Department of Veterans Affairs outpatient clinics nationwide.

Participants: Chronically depressed individuals (n = 50,261; aged 20-97) who had been prescribed an antidepressant were identified from records indicating an outpatient clinic visit for depression (index depression visit) during fiscal years 2009 and 2010. Individuals were considered chronically depressed if they had had prior depression visits and treatment for depression within the previous 4 months. The sample was age-stratified into younger (<65) and older (≥ 65) groups.

Measurements: After the index depression visit, medication possession ratios were calculated from pharmacy refill data to determine whether participants had 80% or greater adherence to antidepressant refills during a 6-month treatment observation period. International Classification of Diseases, Ninth Revision, codes were used to derive CAD-related hospitalizations during the follow-up period. Mean follow-up was 24 months. Data were analyzed using Cox proportional hazard models.

Results: Older participants with 80% or greater antidepressant adherence had 26% lower risk of CAD hospitalizations (hazard ratio = 0.74, 95% confidence interval = 0.60-0.93). Antidepressant adherence was not significantly related to CAD hospitalizations in younger adults.

Conclusion: Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD hospitalizations at follow-up than those with less than 80% adherence. These preliminary results suggest that older adults with depression may derive cardiovascular benefits from clinical efforts to increase antidepressant adherence.
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http://dx.doi.org/10.1111/jgs.12849DOI Listing
July 2014

Bilateral transfemoral/transtibial amputations due to battle injuries: a comparison of Vietnam veterans with Iraq and Afghanistan servicemembers.

Clin Orthop Relat Res 2014 Oct;472(10):3010-6

Department of Orthopedic Surgery, Detroit Receiving Hospital, 4201 St Antoine Street, Detroit, MI, 48201, USA,

Background: Multiple limb loss from combat injuries has increased as a proportion of all combat-wounded amputees. Bilateral lower-extremity limb loss is the most common, with bilateral transfemoral amputations being the most common subgroup followed by bilateral amputations consisting of a single transfemoral amputation and a single transtibial amputation (TFTT). With improvements in rehabilitation and prostheses, we believe it is important to ascertain how TFTT amputees from the present conflicts compare to those from the Vietnam War.

Questions/purposes: We compared self-reported (1) health status, (2) quality of life (QoL), (3) prosthetic use, and (4) function level between TFTT amputees from the Vietnam War and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF).

Methods: As part of a larger survey, during 2007 to 2008, servicemembers with a diagnosis of amputation associated with battlefield injuries from the Vietnam War and OIF/OEF were identified from the Veterans Affairs and military databases. Participants were asked to respond to a questionnaire to determine their injuries, surgical history, presence of other medical problems, health status, QoL, function, and prosthetic use. We assessed QoL and health status using single-item questions and function using seven categories of physical activity. Thirteen of 298 (4.3%) participants in the Vietnam War group and 11 of 283 (3.8%) in the OIF/OEF group had sustained TFTT amputations. Mean age ± SD at followup was 61 ± 2 years and 28 ± 5 years for the Vietnam War and OIF/OEF groups, respectively.

Results: Excellent, very good, and good self-reported health (85% versus 82%; p = 0.85) and QoL (69% versus 72%; p = 0.85) were similar between the Vietnam War and OIF/OEF groups, respectively. Level of function was higher in the OIF/OEF group, with four of 11 reporting participation in high-impact activities compared to none in the Vietnam War group (p = 0.018).

Conclusions: Participants with TFTT limb loss from both conflicts reported similar scores for QoL and health status, although those from OIF/OEF reported better function and use of prosthetic devices. It is unclear whether the improved function is from age-related changes or improvements in rehabilitation and prosthetics. Some areas of future research might include longitudinal studies of those with limb loss and assessments of physical function of older individuals with limb loss as the demographics shift to where this group of individuals becomes more prominent.
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http://dx.doi.org/10.1007/s11999-014-3534-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4160512PMC
October 2014

Teledermatology in the diagnosis of melanoma.

J Telemed Telecare 2014 Jan 18;20(1):18-23. Epub 2013 Dec 18.

Health Services Research and Development, Department of Veterans Affairs, VA Puget Sound Health Care System, Seattle, USA.

We conducted a retrospective chart review of US Veterans in the Pacific Northwest area to compute melanoma incidence and Breslow depth at diagnosis. We compared Veterans with access to teledermatology (TD) and those without (non-TD). We identified pathology-confirmed primary melanomas in Veterans who had had at least one encounter at a VA facility during a 3-year study period. The age-adjusted melanoma incidence for all, TD and non-TD Veterans was 36, 15 and 57 per 100,000, respectively. The mean Breslow depth was significantly greater in the TD group (P = 0.03). Although a higher proportion of thin (Breslow depth ≤1 mm) TD melanomas were mitotically active, this difference was not significant. We also found that 180 (40%) of the non-TD (face-to-face) diagnosed melanomas were from Veterans living in areas where TD was available. This suggests that the higher melanoma incidence in the non-TD group was mainly due to under-utilization of TD services. The study demonstrated that the TD service was not fully utilized in the VISN20 region, although the reasons for this are not clear. Where TD was utilized it tended to diagnose more advanced melanomas with worse initial prognosis.
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http://dx.doi.org/10.1177/1357633X13517354DOI Listing
January 2014

Sexual behaviors and sexually transmitted infections in a nationally representative sample of women veterans and nonveterans.

J Womens Health (Larchmt) 2014 Mar 13;23(3):246-52. Epub 2013 Dec 13.

1 Mental Illness Research, Education, and Clinical Center (MIRECC) , VA Puget Sound Health Care System, Seattle, Washington.

Background: Women veterans are a growing population with unique characteristics and documented health disparities. Few studies have examined their sexual behaviors and rates of sexually transmitted infections (STIs), and none have compared women veterans to nonveterans to identify potential sexual health disparities.

Methods: We used data from the 1999-2010 National Health and Nutrition Examination Survey, a nationally representative U.S. survey. We compared lifetime sexual history (age at first intercourse, number of partners), sexual activity in the last year, and STIs between women veterans (n=151) and nonveterans (n=8738), adjusting for age, race/ethnicity, education, marital status, binge drinking, and survey year.

Results: Compared to nonveterans, women veterans reported a younger age at first intercourse and a greater number of female and male lifetime sexual partners, and they were more likely to have ever had sex with a woman. They were also more likely than nonveterans to have genital herpes and genital warts.

Conclusions: Women veterans reported higher rates of sexual activity and STIs than nonveterans. Future research is needed to assess high-risk behaviors and determine what factors may underlie these associations. Providers should ensure thorough screening and intervention services are provided for this growing population.
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http://dx.doi.org/10.1089/jwh.2013.4327DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3952661PMC
March 2014

Sex Differences in Associations of Depressive Symptoms with Cardiovascular Risk Factors and Metabolic Syndrome among African Americans.

Cardiovasc Psychiatry Neurol 2013 16;2013:979185. Epub 2013 Sep 16.

Northwest HSR&D Center of Excellence, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA ; Department of Health Services, University of Washington, Seattle, WA 98195, USA.

Young to middle-aged women usually have notably lower rates of cardiovascular disease (CVD) than their male counterparts, but African American women lack this advantage. Their elevated CVD may be influenced by sex differences in associations between depressed mood and CVD risk factors. This cross-sectional study examined whether relations between scores on the Center for Epidemiologic Studies-Depression (CES-D) scale and a spectrum of CVD risk factors varied by sex among African Americans (n = 1076; ages 30-64) from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. Sex-stratified multiple regressions and logistic regressions were conducted. Among women, CES-D scores correlated positively with systolic blood pressure and waist-to-hip ratio (P's < .05), but inversely with high-density lipoprotein cholesterol (HDL-C) (P < .01). Women had twice the odds for metabolic syndrome if CES-D scores ≥16 and had a ≥14% increase in odds of hypertension, abdominal obesity, and low HDL-C with each 5-unit increase in CES-D scores. Among men, CES-D scores correlated positively with high-sensitivity C-reactive protein (P < .05), and odds of hypertension increased by 21% with each 5-unit increase in CES-D scores. Depressive symptoms may promote premature CVD risk in African Americans, at least in part, via CVD risk factors and prevalent metabolic syndrome, particularly in African American women.
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http://dx.doi.org/10.1155/2013/979185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3787626PMC
October 2013

Primary care provider and imaging technician satisfaction with a teledermatology project in rural Veterans Health Administration clinics.

Telemed J E Health 2013 Nov 21;19(11):815-25. Epub 2013 Sep 21.

1 Health Services Research and Development , VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington.

Objective: Assessment of a multisite rural teledermatology project between 2009 and 2012 in four Pacific Northwest states that trained primary care providers and imaging technicians in state-of-the-art techniques of telemedicine.

Materials And Methods: In 2012, we assessed provider and imaging technician acceptability and satisfaction with a 32-item survey instrument based on the Patient Satisfaction Questionnaire developed by Ware et al. (Eval Program Plann 1983;6:247-63) and modified for telemedicine by Kraai et al. (J Card Fail 2011;17:684-690). Survey questions covered eight satisfaction domains: interpersonal manner, technical quality, accessibility, finances, efficacy, continuity, physical environment, and availability.

Results: Overall, 71% of the primary care providers and 94% of the imaging technicians reported being satisfied or extremely satisfied with the teledermatology project. Most (95%) providers found the continuing education classes on dermatology diagnosis and treatment topics useful, and 86% reported teledermatology was a good addition to regular patient services. Most (97%) of the imaging technicians were satisfied with the ability of teledermatology to improve the description of dermatology conditions using images of the lesions or rashes, and 91% were satisfied with the convenience of teledermatology. Challenges reported by both providers and imaging technicians include an increase in workload due to more patient visits related to dermatology care and limited information technology support.

Conclusions: Given the Veterans Health Administration's initiatives to promote accessible health care to underserved Veterans using telehealth, these findings can inform future program designs for teledermatology.
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http://dx.doi.org/10.1089/tmj.2012.0327DOI Listing
November 2013

Major traumatic limb loss among women veterans and servicemembers.

J Rehabil Res Dev 2013 ;50(2):173-82

VA Medical Center, 1660 S. Columbian Way S-152, Seattle, WA 98108, USA.

The number of women veterans is rapidly growing, and little is known regarding the health and healthcare needs of women veterans with traumatic limb loss. The objective of this study was to summarize physical and mental health conditions and rates of prosthetic prescriptions among women service members and veterans with major traumatic limb loss. Researchers and clinicians who administered the Survey for Prosthetic Use contacted and enrolled 283 servicemembers and veterans of Operation Iraqi Freedom/Operation Enduring Freedom with major traumatic limb loss. Participants provided information on health status; comorbidities; other combat injuries; and prosthetic device use, rejection, and replacement. Of the 283 veterans, 9 (3%) were women. Compared with men, women reported more than a threefold higher prevalence of migraine (67% vs 20%, p = 0.001). Compared with men, women received 0.42 more prostheses per year, rejected 0.11 more prostheses per year, but replaced 0.18 fewer prostheses per year. With the exception of migraine headaches, men and women servicemembers and veterans with major traumatic limb loss report similarly high prevalence of physical and mental health conditions. Women report higher rates of prosthesis receipt and rejection and lower rates of prosthesis replacement than men. These findings highlight some potential issues specific to women veterans that may require additional clinical attention.
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http://dx.doi.org/10.1682/jrrd.2012.01.0007DOI Listing
March 2014

Does incorporation of a clinical support template in the electronic medical record improve capture of wound care data in a cohort of veterans with diabetic foot ulcers?

J Wound Ostomy Continence Nurs 2013 Mar-Apr;40(2):157-62

Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Manager, UW Medicine Pay for Performance, Seattle, WA 98104, USA.

Purpose: The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention.

Methods: From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding.

Results: The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001).

Conclusions: An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.
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http://dx.doi.org/10.1097/WON.0b013e318283bcd8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3591837PMC
January 2014

Peripheral neuropathy defined by monofilament insensitivity and diabetes status: NHANES 1999-2004.

Diabetes Care 2013 Jun 28;36(6):1604-6. Epub 2012 Dec 28.

Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA.

Objective: To determine whether diabetes status, including prediabetes, is associated with increased risk of peripheral neuropathy as defined by monofilament insensitivity.

Research Design And Methods: This study used data from the 1999-2004 National Health and Nutrition Examination Survey (n = 7,818). Peripheral neuropathy was defined as one or more insensate sites detected by a Semmes-Weinstein 10-g monofilament. Generalized linear models were used to directly estimate relative risks (RRs) for the association of diabetes status and peripheral neuropathy.

Results: After adjustment compared with no diabetes, prediabetes [RR 1.11 (95% CI 0.92-1.34)] and undiagnosed diabetes [1.08 (0.73-1.61)] were associated with modest increases in risk of peripheral neuropathy, and diabetes was associated with a 74% higher risk of peripheral neuropathy [1.74 (1.50-2.01)].

Conclusions: Diabetes is associated with increased risk of peripheral neuropathy defined by monofilament insensitivity, but prediabetes and undiagnosed diabetes may be associated with only a modest increase in risk.
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http://dx.doi.org/10.2337/dc12-1102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3661813PMC
June 2013

A teledermatology care management protocol for tracking completion of teledermatology recommendations.

J Telemed Telecare 2012 Oct 19;18(7):374-8. Epub 2012 Oct 19.

University of Washington School of Medicine, Seattle, Washington, USA.

In July 2009 we implemented a 3-year store-and-forward teledermatology project to provide dermatology care to veterans living in rural and underserved areas of the US Pacific Northwest. We also developed a follow-up protocol and tracking system. Information about all completed teledermatology consultations was entered into a database, and major procedures and select medications were tracked. In the first 21 months, 8202 dermatology conditions in 5232 veterans were treated and 3370 major procedures carried out. Ninety-five percent of conditions were associated with no more than two teledermatology consultations, and no condition required more than ten consultations. In total, 1454 conditions were reviewed for clinical pathological correlation, and in 310 (21%) there was a subsequent clinical pathological correlation conference, resulting in a change in final diagnosis for 93 conditions. The follow-up was important in ensuring high quality patient care.
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http://dx.doi.org/10.1258/jtt.2012.120417DOI Listing
October 2012
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