Publications by authors named "Laura Petersen"

246 Publications

Acute and chronic effects of adjuvant therapy on inflammatory markers in breast cancer patients.

JNCI Cancer Spectr 2022 Jul 28. Epub 2022 Jul 28.

Jonsson Comprehensive Cancer Center, University of California, Los Angeles; Los Angeles, California, United States.

Background: Inflammation contributes to poor behavioral, functional, and clinical outcomes in cancer survivors. We examined whether standard cancer treatments-radiation and chemotherapy-led to acute and persistent changes in circulating markers of inflammation in breast cancer patients.

Methods: One-hundred and ninety-two women diagnosed with early-stage breast cancer provided blood samples before and after completion of radiation and/or chemotherapy and at 6, 12, and 18-month post-treatment follow-ups. Samples were assayed for circulating inflammatory markers, including TNF-α and IL-6, downstream markers of their activity [soluble TNF receptor type II (sTNF-RII), C reactive protein (CRP)], and other inflammatory mediators (IL-8, IFN-γ). Analyses evaluated within-group changes in inflammatory markers in four treatment groups: no radiation or chemotherapy (n = 39), radiation only (n = 77), chemotherapy only (n = 18), and chemotherapy with radiation (n = 58).

Results: Patients treated with chemotherapy showed statistically significant increases in circulating concentrations of TNF-α, sTNF-RII, IL-6, and IFN-γ from pre- to post-treatment, with parameter estimates in standard deviation units ranging from 0.55 to 1.20. Those who received chemotherapy with radiation also showed statistically significant increases in IL-8 over this period. Statistically significant increases in TNF-α, sTNF-RII, IL-6, IFN-γ, and IL-8 persisted at 6, 12, and 18 months post-treatment among patients treated with chemotherapy and radiation (all ps < .05). Patients treated with radiation only showed a statistically significant increase in IL-8 at 18-months post-treatment; no increases in any markers were observed in patients treated with surgery only.

Conclusions: Chemotherapy is associated with acute increases in systemic inflammation that persist for months after treatment completion in patients who also receive radiation therapy. These increases may contribute to common behavioral symptoms and other comorbidities in cancer survivors.
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http://dx.doi.org/10.1093/jncics/pkac052DOI Listing
July 2022

State-Level Social Vulnerability Index and Healthcare Access in Patients With Atherosclerotic Cardiovascular Disease (from the BRFSS Survey).

Am J Cardiol 2022 Sep 2;178:149-153. Epub 2022 Jul 2.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas. Electronic address:

We analyzed the association between social vulnerability index (SVI) and healthcare access among patients with atherosclerotic cardiovascular disease (ASCVD). Using cross-sectional data from the Behavioral Risk Factor Surveillance System 2016 to 2019, we identified measures related to healthcare access in individuals with ASCVD, which included healthcare coverage, presence of primary care clinician, duration since last routine checkup, delay in access to healthcare, inability to see doctor because of cost, and cost-related medication nonadherence. We analyzed the association of state-level SVI (higher SVI denotes higher social vulnerability) and healthcare access using multivariable-adjusted logistic regression models. The study population comprised 203,347 individuals aged 18 years or older who reported a history of ASCVD. In a multivariable-adjusted analysis, prevalence odds ratios (95% confidence interval) for participants residing in states in the third tertile of SVI compared with those in the first tertile (used as reference) were as follows: absence of healthcare coverage = 1.03 (0.85 to 1.24), absence of primary care clinician = 1.33 (1.12 to 1.58), >1 year since last routine checkup = 1.09 (0.96 to 1.23), delay in access to healthcare = 1.39 (1.18, 1.63), inability to see a doctor because of cost = 1.21 (1.06 to 1.40), and cost-related medication nonadherence = 1.10 (0.83 to 1.47). In conclusion, SVI is associated with healthcare access in those with pre-existing ASCVD. Due to the ability of SVI to simultaneously and holistically capture many of the factors of social determinants of health, SVI can be a useful measure for identifying high-risk populations.
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http://dx.doi.org/10.1016/j.amjcard.2022.05.025DOI Listing
September 2022

Guideline-Concordant Statin Therapy Use in Secondary Prevention: Should the Medical Community Wait for Divine Intervention?

J Am Coll Cardiol 2022 05;79(18):1814-1817

Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.

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http://dx.doi.org/10.1016/j.jacc.2022.02.042DOI Listing
May 2022

State-Level Social Vulnerability Index and Healthcare Access: The Behavioral Risk Factor Surveillance System Survey.

Am J Prev Med 2022 Apr 30. Epub 2022 Apr 30.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Health Policy, Quality & Informatics Program, Michael E.DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Department of Veterans Affairs Medical Center, Houston, Texas. Electronic address:

Introduction: Access to health care is affected by social determinants of health. The social vulnerability index encompasses multiple social determinants of health simultaneously and may therefore be associated with healthcare access.

Methods: Cross-sectional data were used from the 2016‒2019 Behavioral Risk Factor Surveillance System, a nationally representative U.S. telephone-based survey of adults aged ≥18 years. State-level social vulnerability index was derived using county-level social vulnerability index estimates from the Centers for Disease Control and Prevention Agency for Toxic Substances and Disease Registry. Analyses were performed in October 2021. Social vulnerability index was ranked according to percentiles, which were divided into tertiles: Tertile 1 (0.10-0.32), Tertile 2 (0.33-0.53), and Tertile 3 (0.54-0.90).

Results: In multivariable-adjusted models comparing U.S. states in Tertile 3 with those in Tertile 1 of social vulnerability index, there was a higher prevalence of absence of healthcare coverage (OR=1.39 [95% CI=1.22, 1.58]), absence of primary care provider (OR=1.34 [95% CI=1.22, 1.48]), >1-year duration since last routine checkup (OR=1.18 [95% CI=1.10, 1.27]), inability to see a doctor because of cost (OR=1.38 [95% CI=1.23, 1.54]), and the composite variable of any difficulty in accessing healthcare (OR=1.15 [95% CI=1.08, 1.22]).

Conclusions: State-level social vulnerability is associated with several measures related to healthcare access. These results can help to identify targeted interventions to improve access to health care in U.S. states with high social vulnerability index burden.
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http://dx.doi.org/10.1016/j.amepre.2022.03.008DOI Listing
April 2022

Preparing railway stakeholders against CBRNe threats through better cooperation with security practitioners.

Appl Ergon 2022 Jul 5;102:103752. Epub 2022 Apr 5.

Deutsche Hochschule der Polizei (DHPol), Germany.

This paper presents partial results from the Horizon2020 PROACTIVE project, following a set of literature reviews and surveys conducted with first responder organisations and rail security experts. Qualitative and quantitative data from two surveys are being presented. The results provide an overview of the CBRNe (Chemical, Biological, Radiological, Nuclear and explosive) preparedness and response capabilities of railway stakeholders and how these relate to a wider context represented by CBRNe first responders. The results highlight a set of challenges as well as five core skills that railway staff need to develop or improve: 1) understand the specific characteristics of the CBRNe threat, 2) develop basic response measures, 3) cooperate with authorities and train with specialised first responders, 4) improve public awareness about this threat, and 5) optimise crisis communication. In line with these, project PROACTIVE will further help update rail crisis management plans with practical recommendations concerning the CBRNe threat.
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http://dx.doi.org/10.1016/j.apergo.2022.103752DOI Listing
July 2022

A Mistake Not to Be Repeated: What Can We Learn from the Underutilization of Statin Therapy for Efficient Dissemination of Cardioprotective Glucose Lowering Agents?

Curr Cardiol Rep 2022 06 29;24(6):689-698. Epub 2022 Mar 29.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

Purpose Of Review: To review the factors contributing to underutilization of guideline-directed therapies, identify strategies to alleviate these factors, and apply these strategies for effective and timely dissemination of novel cardioprotective glucose-lowering agents.

Recent Findings: Recent analyses demonstrate underutilization of cardioprotective glucose lowering agents despite guideline recommendations for their use. Major contributors to underutilization of guideline-directed therapies include therapeutic inertia, perceptions about side effects, and factors found at the level of the clinicians, patients, and the healthcare system. The recent emergence of several novel therapies, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, for use in cardiovascular disease provides a unique avenue to improve patient outcomes. To effectively utilize novel cardioprotective glucose lowering agents to improve cardiovascular outcomes, clinicians must recognize and learn from prior barriers to application of guideline-directed therapies. Further endeavors are prudent to ensure uptake of novel agents.
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http://dx.doi.org/10.1007/s11886-022-01694-5DOI Listing
June 2022

Purpose, Subject, and Consumer Comment on "Perceived Burden Due to Registrations for Quality Monitoring and Improvement in Hospitals: A Mixed Methods Study".

Int J Health Policy Manag 2022 04 1;11(4):539-543. Epub 2022 Apr 1.

VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.

Zegers and colleagues' study codifies the perceived burden of quality monitoring and improvement stemming from the work by clinicians of registering (documenting) quality information in the medical record. We agree with Zegers and colleagues' recommendation that a smaller, more effective and curated set of measures is needed to reduce burden, confusion, and expense. We further note that focusing on validity of clinical evidence behind individual measures is critical, but insufficient. We therefore extend Zegers and colleagues' work through a pragmatic, tripartite heuristic. To assess the value of and curate a targeted set of performance measures, we propose concentrating on the relationships among three factors: (1) The of the performance measure, (2) the being evaluated, and (3) the using information for decision-making. Our proposed tripartite framework lays the groundwork for executing the evidence-based recommendations proposed by Zegers et al, and provides a path forward for more effective healthcare performance-measurement systems.
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http://dx.doi.org/10.34172/ijhpm.2022.6495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9309954PMC
April 2022

An evidence-based, structured, expert approach to selecting essential indicators of primary care quality.

PLoS One 2022;17(1):e0261263. Epub 2022 Jan 18.

Penn State Health West Campus Health and Wellness Center, Hershey, Pennsylvania, United States of America.

Background: The purpose of this article is to illustrate the application of an evidence-based, structured performance measurement methodology to identify, prioritize, and (when appropriate) generate new measures of health care quality, using primary care as a case example. Primary health care is central to the health care system and health of the American public; thus, ensuring high quality is essential. Due to its complexity, ensuring high-quality primary care requires measurement frameworks that can assess the quality of the infrastructure, workforce configurations, and processes available. This paper describes the use of the Productivity Measurement and Enhancement System (ProMES) to compile a targeted set of such measures, prioritized according to their contribution and value to primary care.

Methods: We adapted ProMES to select and rank existing primary care measures according to value to the primary care clinic. Nine subject matter experts (SMEs) consisting of clinicians, hospital leaders and national policymakers participated in facilitated expert elicitation sessions to identify objectives of performance, corresponding measures, and priority rankings.

Results: The SMEs identified three fundamental objectives: access, patient-health care team partnerships, and technical quality. The SMEs also selected sixteen performance indicators from the 44 pre-vetted, currently existing measures from three different data sources for primary care. One indicator, Team 2-Day Post Discharge Contact Ratio, was selected as an indicator of both team partnerships and technical quality. Indicators were prioritized according to value using the contingency functions developed by the SMEs.

Conclusion: Our article provides an actionable guide to applying ProMES, which can be adapted to the needs of various industries, including measure selection and modification from existing data sources, and proposing new measures. Future work should address both logistical considerations (e.g., data capture, common data/programming language) and lingering measurement challenges, such as operationalizating measures to be meaningful and interpretable across health care settings.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0261263PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8765671PMC
February 2022

Utilization Rates of SGLT2 Inhibitors and GLP-1 Receptor Agonists and Their Facility-Level Variation Among Patients With Atherosclerotic Cardiovascular Disease and Type 2 Diabetes: Insights From the Department of Veterans Affairs.

Diabetes Care 2022 02;45(2):372-380

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX.

Objective: There is mounting evidence regarding the cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) among patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes mellitus (T2DM). There is paucity of data assessing real-world practice patterns for these drug classes. We aimed to assess utilization rates of these drug classes and facility-level variation in their use.

Research Design And Methods: We used the nationwide Veterans Affairs (VA) health care system data set from 1 January 2020 to 31 December 2020 and included patients with established ASCVD and T2DM. Among these patients, we assessed the use of SGLT2i and GLP-1 RA and the facility-level variation in their use. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of SGLT2i and GLP-1 RA in patients with ASCVD and T2DM.

Results: Among 537,980 patients with ASCVD and T2DM across 130 VA facilities, 11.2% of patients received an SGLT2i while 8.0% of patients received a GLP-1 RA. Patients receiving these cardioprotective glucose-lowering drug classes were on average younger and had a higher proportion of non-Hispanic Whites. Overall, median (10th-90th percentile) facility-level rates were 14.92% (9.31-22.50) for SGLT2i and 10.88% (4.44-17.07) for GLP-1 RA. There was significant facility-level variation among SGLT2i use-MRRunadjusted: 1.41 (95% CI 1.35-1.47) and MRRadjusted: 1.55 (95% CI 1.46 -1.63). Similar facility-level variation was observed for use of GLP-1 RA-MRRunadjusted: 1.34 (95% CI 1.29-1.38) and MRRadjusted: 1.78 (95% CI 1.65-1.90).

Conclusions: Overall utilization rates of SGLT2i and GLP-1 RA among eligible patients are low, with significantly higher residual facility-level variation in the use of these drug classes. Our results suggest opportunities to optimize their use to prevent future adverse cardiovascular events among these patients.
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http://dx.doi.org/10.2337/dc21-1815DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8914426PMC
February 2022

Evaluation of Factors Underlying Sex-Based Disparities in Cardiovascular Care in Adults With Self-reported Premature Atherosclerotic Cardiovascular Disease.

JAMA Cardiol 2022 Mar;7(3):341-345

Section of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.

Importance: There are limited data regarding sex-based differences in physical and mental health domains and health care access in adults with premature atherosclerotic cardiovascular disease (ASCVD).

Objective: To study the association of sex with physical and mental health domains as well as health care access-related factors among adults with self-reported premature ASCVD.

Design, Setting, And Participants: Retrospective cohort analysis of 748 090 adults aged 18 to 55 years in the Behavioral Risk Factor Surveillance System 2016 to 2019 in the US. Data were analyzed from June to July 2021.

Exposures: Self-reported ASCVD, defined as having a history of coronary artery disease, myocardial infarction, or stroke.

Main Outcomes And Measures: Self-reported physical and mental health and measures of health care access, including self-reported cost-related medication nonadherence and inability to see a physician due to cost.

Results: Between 2016 and 2019, 748 090 adults aged 18-55 years were identified, of whom 28 522 (3.3%) had self-reported premature ASCVD. Of these, 14 358 (47.0%) were women. Compared with men, women with premature ASCVD were more likely to report being clinically depressed (odds ratio [OR], 1.73; 95% CI, 1.41-2.14; P < .001), have cost-related medication nonadherence (OR, 1.42; 95% CI, 1.11-1.82; P = .005), have not seen a physician due to cost-related issues (OR, 4.52; 95% CI, 2.24-9.13; P < .001), and were more likely to report overall poor physical health (OR, 1.39; 95% CI, 1.09-1.78; P = .008) despite being more likely to have health care coverage (85.3% vs 80.8%; P = .04) and a primary care physician (84.2% vs 75.7%; P < .001).

Conclusions And Relevance: Results from this study indicate that women with premature ASCVD were more likely to report worse overall physical and mental health, inability to see a physician due to cost, and cost-related medical nonadherence. Interventions addressing mental health and out-of-pocket costs are needed in adults with premature ASCVD.
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http://dx.doi.org/10.1001/jamacardio.2021.5430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8733863PMC
March 2022

Current practice patterns and gaps in guideline-concordant breast cancer survivorship care.

J Cancer Surviv 2021 Dec 30. Epub 2021 Dec 30.

David Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA, USA.

Purpose: Breast cancer-specific survivorship care guidelines for the more than 3.8 million survivors in the U.S. are available, but implementation in clinical practice remains challenging. We examined current practice patterns and factors associated with guideline-concordant survivorship care among oncologists.

Methods: A national sample of medical oncologists, recruited using two databases, participated in a survey focused on practice patterns for breast cancer survivorship care. A "survivorship care composite score" was calculated for each respondent based on provision of services recommended in the survivorship guidelines. Descriptive statistics and multivariable linear regression analyses examined associations between physician and practice characteristics and composite scores.

Results: The survey was completed by 217 medical oncologists, with an overall response rate of 17.9% and eligibility rate of 56.9% for those who responded. Oncologists reported high engagement in evaluation of disease recurrence (78%). Performed less frequently were the provision of survivorship care plans (46%), assessment of psychosocial long-term and late effects (34%), and screening for subsequent cancers (34%). Lack of survivorship care training (p = 0.038) and not routinely informing patients about potential late effects (p = 0.003) were significantly associated with poorer survivorship care composite scores.

Conclusions: Despite the availability of disease-specific survivorship care guidelines, adherence to their recommendations in clinical practice is suboptimal. Survey results identified key gaps in survivorship care for breast cancer survivors, particularly related to subsequent primary cancers and psychosocial long-term and late effects.

Implications For Cancer Survivors: Improving the delivery of comprehensive survivorship care for the growing population of breast cancer survivors is a high priority. Disease-specific clinical guidelines for cancer survivorship provide valuable recommendations, but innovative strategies are needed to integrate them into the care of long-term breast cancer survivors.
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http://dx.doi.org/10.1007/s11764-021-01152-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9243187PMC
December 2021

Correlates of SGLT-2-inhibitiors use among patients with atherosclerotic cardiovascular disease and type 2 diabetes mellitus: Insights from the department of veterans affairs.

Am Heart J 2022 06 27;248:160-162. Epub 2021 Dec 27.

Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX; Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX; Department of Medicine, Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX. Electronic address:

This study using data from the Veterans Affairs (VA) administrative and clinical dataset examined determinants of sodium-glucose cotransporter-2 inhibitors (SGLT-2i) use among patients with concomitant atherosclerotic cardiovascular disease (ASCVD) and diabetes mellitus. The aim of the present analysis was to identify barriers and facilitators associated with SGLT-2i in a real-world contemporary patient population in order to improve utilization of these guideline-directed agents.
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http://dx.doi.org/10.1016/j.ahj.2021.12.006DOI Listing
June 2022

Leveraging structured and unstructured electronic health record data to detect reasons for suboptimal statin therapy use in patients with atherosclerotic cardiovascular disease.

Am J Prev Cardiol 2022 Mar 3;9:100300. Epub 2021 Dec 3.

Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, Texas; and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.

Objective: To determine whether natural language processing (NLP) of unstructured medical text can improve identification of ASCVD patients not using high-intensity statin therapy (HIST) due to statin-associated side effects (SASEs) and other reasons.

Methods: Reviewers annotated reasons for not prescribing HIST in notes of 1152 randomly selected patients from across the VA healthcare system treated for ASCVD but not receiving HIST. Developers used reviewer annotations to train the Canary NLP tool to detect and extract notes containing one or more of these reasons. Negative predictive value (NPV), sensitivity, specificity and Area Under the Curve (AUC) were used to assess accuracy at detecting documents containing reasons when using structured data, NLP-extracted unstructured data, or both data sources combined.

Results: At least one documented reason for not prescribing HIST occurred in 47% of notes. The most frequent reasons were SASEs (41%) and general intolerance (20%). When identifying notes containing any documented reason for not using HIST, adding NLP-extracted, unstructured data significantly (<0.05) increased sensitivity (0.69 (95% confidence interval [CI] 0.60-0.76) to 0.89 (95% CI 0.81-0.93)), NPV (0.90 (95% CI 0.87 to 0.93) to 0.96 (95% CI 0.93-0.98)), and AUC (0.84 (95% confidence interval [CI] 0.81-0.88) to 0.91 (95% CI 0.90-0.93)) compared to structured data alone.

Conclusions: NLP extraction of data from unstructured text can improve identification of reasons for patients not being on HIST over structured data alone. The additional information provided through NLP of unstructured free text should help in tailoring and implementing system-level interventions to improve HIST use in patients with ASCVD.
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http://dx.doi.org/10.1016/j.ajpc.2021.100300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8671496PMC
March 2022

Association of patient, provider and facility related characteristics with statin associated side effects and statin use: Insight from the Veteran's Affairs healthcare system.

J Clin Lipidol 2021 Nov-Dec;15(6):832-839. Epub 2021 Oct 2.

Health Services Research and Development Center for Innovations in Quality Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston TX, United States; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States. Electronic address:

Background: Statin associated side effects (SASE) are a leading cause of statin discontinuation.

Objective: We evaluated patient, provider, and facility characteristics associated with SASEs and whether these characteristics impact statin utilization.

Methods: Patients with atherosclerotic cardiovascular disease (ASCVD) receiving care across the Veterans Affairs healthcare system from October 1, 2014 to September 30, 2015 were included. Multivariable logistic regression analyses were performed to determine (a) factors associated with SASE and (b) factors associated with statin use in those with SASE.

Results: Our cohort included 1,225,576 patients with ASCVD. Of these, 171,189 (13.7%) had at least 1 reported SASE since year 2000. The most significant odds for SASEs were observed with female sex (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.36, 1.45), White race (OR 1.43, 95% CI 1.41, 1.45), hypertension (OR 1.37, 95% CI 1.33, 1.41) and ischemic heart disease (IHD: OR 1.45, 95% CI 1.43, 1.47). Lower odds were noted with care at a teaching facility (OR 0.89, 95% CI 0.88, 0.90). Factors most associated with being on a statin among patients with SASE included having diabetes (OR 1.18, 95% CI 1.15, 1.20), IHD (OR 1.39, 95% CI 1.35, 1.43) and a higher number of cardiology visits (OR 1.08, 95% CI 1.07, 1.09), while female sex was associated with lower odds (OR 0.65, 95% CI 0.61, 0.69).

Conclusion: There are significant disparities in statin use by sex, ASCVD type, and comorbidities among secondary prevention patients with SASE, which represent areas for improvement in optimizing statin utilization.
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http://dx.doi.org/10.1016/j.jacl.2021.09.050DOI Listing
March 2022

Social vulnerability and COVID-19: An analysis of CDC data.

Prog Cardiovasc Dis 2021 Sep 22. Epub 2021 Sep 22.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services, Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.

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http://dx.doi.org/10.1016/j.pcad.2021.09.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8455239PMC
September 2021

Gender disparities in difficulty accessing healthcare and cost-related medication non-adherence: The CDC behavioral risk factor surveillance system (BRFSS) survey.

Prev Med 2021 12 3;153:106779. Epub 2021 Sep 3.

Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, United States of America; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America. Electronic address:

Ensuring healthcare access is critical to maintain health and prevent illness. Studies demonstrate gender disparities in healthcare access. Less is known about how these vary with age, race/ethnicity, and atherosclerotic cardiovascular disease. We utilized cross-sectional data from 2016 to 2019 CDC Behavioral Risk Factor Surveillance System (BRFSS), a U.S. telephone-based survey of adults (≥18 years). Measures of difficulty accessing healthcare included absence of healthcare coverage, delay in healthcare access, absence of primary care physician, >1-year since last checkup, inability to see doctor due to cost, and cost-related medication non-adherence. We studied the association between gender and these variables using multivariable-adjusted logistic regression models, stratifying by age, race/ethnicity, and atherosclerotic cardiovascular disease status. Our population consisted of 1,737,397 individuals; 54% were older (≥45 years), 51% women, 63% non-Hispanic White, 12% non-Hispanic Black,17% Hispanic, 9% reported atherosclerotic cardiovascular disease. In multivariable-adjusted models, women were more likely to report delay in healthcare access: odds ratio (OR) and (95% confidence interval): 1.26 (1.11, 1.43) [p < 0.001], inability to see doctor due to cost: 1.29 (1.22, 1.36) [p < 0.001], cost-related medication non-adherence: 1.24 (1.01, 1.50) [p = 0.04]. Women were less likely to report lack of healthcare coverage: 0.71 (0.66, 0.75) [p < 0.001] and not having a primary care physician: 0.50 (0.48, 0.52) [p < 0.001]. Disparities were pronounced in younger (<45 years) and Black women. Identifying these barriers, particularly among younger women and Black women, is crucial to ensure equitable healthcare access to all individuals.
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http://dx.doi.org/10.1016/j.ypmed.2021.106779DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9291436PMC
December 2021

Association of APOE4 genotype and treatment with cognitive outcomes in breast cancer survivors over time.

NPJ Breast Cancer 2021 Sep 3;7(1):112. Epub 2021 Sep 3.

Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA.

This prospective longitudinal study of breast cancer survivors (n = 167) examined the association of apolipoprotein ε4 (APOE ε4) genotype with cognition and interactions with chemotherapy or endocrine therapy up to 6 years after treatment. In general, we found no effects of ε4 across timepoints and treatment exposures; post hoc analysis at 3-6 years suggested a trend towards worse cognition in the domains of attention and learning among ε4 carriers exposed to endocrine therapy. Further study is needed.
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http://dx.doi.org/10.1038/s41523-021-00327-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8417038PMC
September 2021

Targeting Depressive Symptoms in Younger Breast Cancer Survivors: The Pathways to Wellness Randomized Controlled Trial of Mindfulness Meditation and Survivorship Education.

J Clin Oncol 2021 11 18;39(31):3473-3484. Epub 2021 Aug 18.

UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA.

Purpose: Younger women are at risk for depression and related symptoms following breast cancer. The Pathways to Wellness study, a randomized, multi-institution, three-arm trial, tested the efficacy of two behavioral interventions for younger breast cancer survivors with elevated depressive symptoms: mindful awareness practices (MAPs) and survivorship education (SE) (Clincaltrials.gov identifier: NCT03025139).

Methods: Women diagnosed with breast cancer at or before 50 years of age who had completed treatment and had elevated depressive symptoms were randomly assigned to 6 weeks of MAPs, SE, or wait-list control (WLC). Assessments were conducted preintervention and postintervention and at 3-month and 6-month postintervention follow-ups. Analyses compared each intervention to WLC using linear mixed models. The primary outcome was change in depressive symptoms from preintervention to postintervention on the Center for Epidemiologic Studies-Depression Scale; secondary outcomes included change in fatigue, insomnia, and vasomotor symptoms.

Results: Two hundred forty-seven women (median age = 46 years) were randomly assigned to MAPs (n = 85), SE (n = 81), or WLC (n = 81). MAPs and SE led to significant decreases in depressive symptoms from preintervention to postintervention relative to WLC (mean change relative to WLC [95% CI]: MAPs, -4.7 [-7.5 to -1.9]; SE, -4.0 [-6.9 to -1.1]), which persisted at 6-month follow-up for MAPs (mean change relative to WLC [95% CI]: MAPs, -3.7 [-6.6 to -0.8]; SE, -2.8 [-5.9 to 0.2]). MAPs, but not SE, also had beneficial effects on fatigue, insomnia, and vasomotor symptoms that persisted at 6-month follow-up ( < .05).

Conclusion: Mindfulness meditation and SE reduced depressive symptoms in younger breast cancer survivors. These interventions can be widely disseminated over virtual platforms and have significant potential benefit for quality of life and overall survivorship in this vulnerable group.
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http://dx.doi.org/10.1200/JCO.21.00279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8547916PMC
November 2021

Will the American Rescue Plan Overcome Opposition to Medicaid Expansion?

J Gen Intern Med 2021 11 11;36(11):3550-3552. Epub 2021 Aug 11.

The Center for Innovations in Quality, Effectiveness and Safety (IQuESt) at the Michael E. DeBakey VA Medical Center, Houston, TX, USA.

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http://dx.doi.org/10.1007/s11606-021-07084-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356545PMC
November 2021

Prevalence and predictors of cost-related medication nonadherence in individuals with cardiovascular disease: Results from the Behavioral Risk Factor Surveillance System (BRFSS) survey.

Prev Med 2021 12 7;153:106715. Epub 2021 Jul 7.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, United States of America; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America. Electronic address:

Medication nonadherence is highly prevalent among patients with chronic cardiovascular disease. Poor adherence has been associated with increased morbidity and mortality. Medication cost is a major driver for medication nonadherence. Utilizing data from the 2016 to 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey, we estimated the prevalence of cost-related medication nonadherence (CRMNA) among the overall population and among individuals who reported a history of diabetes, atherosclerotic cardiovascular disease (ASCVD), or hypertension. We then performed multivariable logistic regression to analyze sociodemographic factors associated with CRMNA. Our study population consisted of 142,577 individuals of whom 24% were older than 65 years, 47% were men, 66% were White, 17% Black, 35% had hypertension, 13% had diabetes mellitus, and 10% had ASCVD. CRMNA was reported in 10% of the overall population, 12% among those with hypertension, 17% among those with diabetes, and 17% among those with ASCVD. Age below 65 years, female gender, unemployment, lower income, lower educational attainment, having at least 1 comorbidity, and living in a state that did not expand Medicaid were independently associated with CRMNA. The prevalence of CRMNA increased with greater number of these high-risk sociodemographic factors. We conclude that the prevalence of CRMNA is 10% among U.S. adults overall and is higher among those with common chronic diseases. Risk factors associated with CRMNA should be addressed in order to improve adherence rates and health outcomes among high-risk individuals.
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http://dx.doi.org/10.1016/j.ypmed.2021.106715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9125503PMC
December 2021

Prevalence and Determinants of Difficulty in Accessing Medical Care in U.S. Adults.

Am J Prev Med 2021 10 4;61(4):492-500. Epub 2021 Jul 4.

Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Health Policy, Quality & Informatics Program, Center for Innovations in Quality, Effectiveness and Safety, U.S. Department of Veterans Affairs, Houston, Texas; Research & Development, Michael E. DeBakey VA Medical Center, U.S. Department of Veterans Affairs, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, U.S. Department of Veterans Affairs, Houston, Texas; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas. Electronic address:

Introduction: Ensuring adequate access to health care is essential for timely delivery of preventive services. It is important to evaluate the prevalence and determinants of difficulty in accessing medical care in the overall U.S. population and among those with high-risk chronic conditions.

Methods: The study utilized cross-sectional data from the 2016-2019 Behavioral Risk Factor Surveillance System, a nationally representative telephone-based survey of adults aged ≥18 years. The prevalence and sociodemographic characteristics associated with difficulty in receiving medical care were assessed, including regional variations across U.S. states.

Results: The prevalence of difficulty in accessing medical care was 14% overall, 15% among those with hypertension, 15% among those with diabetes mellitus, and 17% among those with atherosclerotic cardiovascular disease. Age 18-34 years, having less than high school education, having annual household income <$75,000, unemployment, and living in a state without Medicaid expansion were all associated with a higher risk of not accessing medical care. The prevalence of difficulty in accessing medical care was 27% among individuals with ≥3 of these sociodemographic characteristics. There was regional variation across the U.S. states in the distribution of difficulty in accessing medical care with a median of 13.6% (IQR=11.3%-15.9%) for the overall population: 16.3% (IQR=14.1%-19.0%) among those living in states without Medicaid expansion versus 12.7% (IQR=10.9%-15.6%) among those living in states with Medicaid expansion (p=0.01).

Conclusions: In total, 1 in 7 adults report difficulty in accessing medical care. This prevalence is nearly 1 in 4 adults with ≥3 sociodemographic characteristics related to difficulty in accessing medical care. There are regional variations in the distribution of the difficulty in accessing medical care, especially among individuals living in states that have not undergone Medicaid expansion.
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http://dx.doi.org/10.1016/j.amepre.2021.03.026DOI Listing
October 2021

Screening for Depression in Younger Breast Cancer Survivors: Outcomes From Use of the 9-item Patient Health Questionnaire.

JNCI Cancer Spectr 2021 06 8;5(3). Epub 2021 Feb 8.

UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA, USA.

Background: Major cancer organizations recommend depression screening in patients and survivors. The 9-item Patient Health Questionnaire (PHQ-9) is often suggested, with limited information about its use.

Methods: Enrollment data collected from younger breast cancer survivors participating in a behavioral intervention trial were used to examine the relationship between PHQ-9 scores (range = 0-27), patient characteristics, and responses to standardized psychosocial assessment tools. Major depressive disorder criterion was met if responses to the first 2 PHQ-9 items (range = 0-6) were 3 or greater. The sample was categorized by total PHQ-9 scores: less than 5 (minimal depressive symptoms), 5-9 (mild to moderate depressive symptoms), and 10 or greater (moderate to severe depression). PHQ-9 category associations with medical, demographic, psychosocial, and behavioral characteristics were examined using analysis of variance for continuous variables and χ tests for categorical variables.

Results: A total of 231 women met the study prescreening eligibility criterion of mild depressive symptoms and enrolled in the study. On average, they were 45.2 years old and 2.6 years since diagnosis. At enrollment, 22.1% met the screening criterion for possible major depressive disorder; among those with PHQ-9 scores of 10 or greater, 58.3% met this criterion. Anxiety, fatigue, insomnia, and intrusive thoughts about cancer were frequent and were associated with depressive symptom severity (all < .001). In contrast, neither demographic nor cancer treatment characteristics were associated with depressive symptoms.

Conclusions: Depressive symptoms in this selected sample of younger breast cancer survivors were independent of demographic characteristics or cancer treatment history, suggesting that depression screening is necessary to detect uncontrolled depressive symptoms.
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http://dx.doi.org/10.1093/jncics/pkab017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216636PMC
June 2021

Social Determinants of Health and Comorbidities Among Individuals with Atherosclerotic Cardiovascular Disease: The Behavioral Risk Factor Surveillance System Survey.

Popul Health Manag 2022 02 14;25(1):39-45. Epub 2021 Jun 14.

Section of Cardiology and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.

Individuals with atherosclerotic cardiovascular disease (ASCVD) often have a high burden of comorbidities. Social determinants of health (SDOH) may complicate adherence to treatment in these patients. This study assessed the association of comorbidities and SDOH among individuals with ASCVD. Cross-sectional data from the 2016 to 2019 Behavioral Risk Factor Surveillance System, a nationally representative US telephone-based survey of adults ages ≥18 years, were used. Cardiovascular comorbidities included hypertension, hyperlipidemia, diabetes mellitus, current cigarette smoking, and chronic kidney disease. Non-cardiovascular comorbidities included chronic obstructive pulmonary disease, asthma, arthritis, cancer, and depression. SDOH associated with being at or above the 75 percentile of comorbidity burden were analyzed using multivariable adjusted logistic regression models. The study population included 387,044 individuals, 9% of whom had ASCVD. The mean (SD) numbers of total, cardiovascular, and non-cardiovascular comorbidities were 1.97 (1.27), 1.28 (0.74), 0.69 (0.91) among those without ASCVD and 3.28 (1.62), 1.73 (0.91), and 1.54 (1.22) among those with ASCVD, respectively ( < 0.001 for all comparisons). Female gender, household income ≤$75,000, being unemployed, and difficulty accessing health care were significantly associated with a higher burden of comorbidities among those with ASCVD. The mean (SD) numbers of comorbidities for those with 0, 1, 2, and ≥3 of the aforementioned SDOH were 2.89 (1.45), 2.86 (1.47), 3.39 (1.58), and 4.01 (1.73), respectively ( < 0.001). Among persons with ASCVD, the burden of cardiovascular and non-cardiovascular comorbidities is directly proportional to SDOH in any given individual. Clinicians should address SDOH when managing high-risk individuals.
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http://dx.doi.org/10.1089/pop.2021.0084DOI Listing
February 2022

Health care costs associated with primary care physicians versus nurse practitioners and physician assistants.

J Am Assoc Nurse Pract 2021 05 31;33(11):967-974. Epub 2021 May 31.

Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center for Innovations, Houston, Texas.

Background: Significant primary care provider (PCP) shortage exists in the United States. Expanding the scope of practice for nurse practitioners (NPs) and physician assistants (PAs) can help alleviate this shortage. The Department of Veterans' Affairs (VA) has been a pioneer in expanding the role of NPs and PAs in primary caregiving.

Purpose: This study evaluated the health care costs associated with VA patients cared for by NPs and PAs versus primary care physicians (physicians).

Methods: A retrospective data analysis using two separate cohorts of VA patients, one with diabetes and the other with cardiovascular disease (CVD), was performed. The associations between PCP type and health care costs were analyzed using ordinary least square regressions with logarithmically transformed costs.

Results: The analyses estimated 12% to 13% (US dollars [USD] 2,626) and 4% to 5% (USD 924) higher costs for patients assigned to physicians as compared with those assigned to NPs and PAs, after adjusting for baseline patient sociodemographics and disease burden, in the diabetes and CVD cohort, respectively. Given the average patient population size of a VA medical center, these cost differences amount to a total difference of USD 14 million/year per center and USD 5 million/year per center for diabetic and CVD patients, respectively.

Implications For Practice: This study highlights the potential cost savings associated with primary caregiving by NPs and PAs. In light of the PCP shortage, the study supports increased involvement of NPs and PAs in primary caregiving. Future studies examining the reasons for these cost differences by provider type are required to provide more scientific evidence for regulatory decision making in this area.
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http://dx.doi.org/10.1097/JXX.0000000000000555DOI Listing
May 2021

An Alternative Method of Public Reporting of Comparative Hospital Quality and Performance Data for Transparency Initiatives.

Med Care 2021 09;59(9):816-823

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center.

Background: Hospital performance comparisons for transparency initiatives may be inadequate if peer comparison groups are poorly defined.

Objective: The objective of this study was to evaluate a new approach identifying hospital peers for comparison.

Design/setting: We used Mahalanobis distance as a new method of developing peer-specific groupings for hospitals to incorporate both external and internal complexity. We compared the overlap in groups with an existing method used by the Veterans' Health Administration's Office for Productivity, Efficiency, and Staffing (OPES).

Participants: One hundred twenty-two acute-care Veterans' Health Administration's Medical Facilities as defined in the OPES fiscal year 2014 report.

Measures: Using 15 variables in 9 categories developed from expert input, including both hospital internal measures and community-based external measures, we used principal components analysis and calculated Mahalanobis distance between each hospital pair. This method accounts for correlation between variables and allows for variables having different variances. We identified the 50 closest hospitals, then eliminated any potential peer whose score on the first component was >1 SD from the reference hospital. We compared overlap with OPES measures.

Results: Of 15 variables, 12 have SDs exceeding 25% of their means. The first 2 components of our analysis explain 24.8% and 18.5% of variation among hospitals. Eight of 9 variables scaling positively on the first component measure internal complexity, aligning with OPES groups. Four of 5 variables scaling positively on the second component but not the first are factors from the policy environment; this component reflects a dimension not considered in OPES groups.

Conclusion: Individualized peers that incorporate external complexity generate more nuanced comparators to evaluate quality.
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http://dx.doi.org/10.1097/MLR.0000000000001567DOI Listing
September 2021

Comparative Effectiveness of Risk-adjusted Cumulative Sum and Periodic Evaluation for Monitoring Hospital Perioperative Mortality.

Med Care 2021 07;59(7):639-645

Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center.

Background: National surgical quality improvement (QI) programs use periodic, risk-adjusted evaluation to identify hospitals with higher than expected perioperative mortality. Rapid, accurate identification of poorly performing hospitals is critical for avoiding potentially preventable mortality and represents an opportunity to enhance QI efforts.

Methods: Hospital-level analysis using Veterans Affairs (VA) Surgical Quality Improvement Program data (2011-2016) to compare identification of hospitals with excess, risk-adjusted 30-day mortality using observed-to-expected (O-E) ratios (ie, current gold standard) and cumulative sum (CUSUM) with V-mask. Various V-mask slopes and radii were evaluated-slope of 2.5 and radius of 1.0 was used as the base case.

Results: Hospitals identified by CUSUM and quarterly O-E were identified midway into a quarter [median 47 days; interquartile range (IQR): 24-61 days before quarter end] translating to a median of 129 (IQR: 60-187) surgical cases and 368 (IQR: 145-681) postoperative inpatient days occurring after a CUSUM signal, but before the quarter end. At hospitals identified by CUSUM but not O-E, a median of 2 deaths within a median of 5 days triggered a signal. In some cases, these clusters extended beyond CUSUM identification date with as many as 8 deaths undetected using O-E. Sensitivity and negative predictive values for CUSUM relative to O-E were 71.9% (95% confidence interval: 66.2%-77.1%) and 95.5% (94.4%-96.4%), respectively.

Conclusions: CUSUM evaluation identifies hospitals with clusters of mortality in excess of expected more rapidly than periodic analysis. CUSUM represents an analytic tool national QI programs could utilize to provide participating hospitals with data that could facilitate more proactive implementation of local interventions to help reduce potentially avoidable perioperative mortality.
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http://dx.doi.org/10.1097/MLR.0000000000001559DOI Listing
July 2021

Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease.

JAMA Cardiol 2021 07;6(7):782-790

Health Policy, Quality and Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas.

Importance: There is a paucity of data regarding secondary prevention care disparities in women with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), defined as an ASCVD event at 55 years or younger and 40 years or younger, respectively.

Objective: To evaluate sex-based differences in antiplatelet agents, any statin, high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD.

Design, Setting, And Participants: This was a cross-sectional, multicenter, nationwide VA health care system-based study with patients enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. The study assessed patients who had at least 1 primary care visit in the Veterans Affairs (VA) health care system from October 1, 2014, to September 30, 2015. Participants included 147 600 veteran patients with premature ASCVD, encompassing ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD).

Exposures: Women vs men with premature and extremely premature ASCVD.

Main Outcomes And Measures: Antiplatelet use, any statin use, HIS use, and statin adherence (proportion of days covered [PDC] ≥0.8).

Results: We identified 10 413 women and 137 187 men with premature ASCVD (age ≤55 years) and 1340 women and 8145 men with extremely premature (age ≤40 years) ASCVD. Among patients with premature and extremely premature ASCVD, women represented 7.1% and 14.1% of those groups, respectively. When compared with men, women with premature ASCVD had a higher proportion of African American patients (36.1% vs 23.8%) and lower proportions of Asian patients (0.5% vs 0.7%) and White patients (56.1% vs. 68.1%). In the extremely premature ASCVD group, women had a comparatively higher proportion of African American patients (36.8% vs 23.2%) and lower proportion of White patients (55.0% vs 67.8%) and Asian patients (1.3% vs 1.5%) than men. Among patients with premature IHD, women received less antiplatelet (adjusted odds ratio [AOR], 0.47, 95% CI, 0.45-0.50), any statin (AOR, 0.62; 95% CI, 0.59-0.66), and HIS (AOR, 0.63; 95% CI, 0.59-0.66) therapy and were less statin adherent (mean [SD] PDC, 0.68 [0.34] vs 0.73 [0.31]; β coefficient: -0.02; 95% CI, -0.03 to -0.01) compared with men. Similarly, women with premature ICVD and premature PAD received comparatively less antiplatelet agents, any statin, and HIS. Among patients with extremely premature ASCVD, women also received less antiplatelet therapy (AOR, 0.61; 95% CI, 0.53-0.70), any statin therapy (AOR,0.51; 95% CI, 0.44-0.58), and HIS therapy (AOR, 0.45; 95% CI, 0.37-0.54) than men. There were no sex-associated differences in statin adherence among patients with premature ICVD, premature PAD, or extremely premature ASCVD.

Conclusions And Relevance: This cross-sectional study revealed that women veterans with premature ASCVD and extremely premature ASCVD receive less optimal secondary prevention cardiovascular care in comparison with men. Women with premature ASCVD, particularly those with IHD, were also less statin adherent. Multidisciplinary and patient-centered interventions are needed to improve these disparities in women.
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http://dx.doi.org/10.1001/jamacardio.2021.0683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8060887PMC
July 2021

Possible Effects on VA Outpatient Care of Expanding Medicaid: Implications of Having Access to Overlapping Publicly Funded Health Care Services.

Mil Med 2022 05;187(5-6):e735-e741

Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, U.S. Veterans' Health Administration, Houston, TX 77030, USA.

Background: Because veterans who use Veterans Health Administration (VA) health care retain VA eligibility while enrolling in Medicaid, increasing Medicaid eligibility may create improved health system access but also create unique challenges for the quality and coordination of health care for veterans. We analyze how pre-Affordable Care Act (ACA) state Medicaid expansions influence VA and Medicaid-funded outpatient care utilization.

Materials And Methods: This study uses Difference-in-difference analysis to evaluate association between pre-ACA 2001 Medicaid expansions and VA utilization in a natural experiment. Veterans aged 18-64 years living in a study state during the study period were the participants. Dependent variables included participants' proportion of outpatient care received at the VA, whether a participant recorded care with both Medicaid and the VA, and total outpatient utilization. We analyzed changes between two states that expanded Medicaid in 2001 against three similar states that did not from 1999 to 2006. We adjusted for age, non-White race, gender, disease burden, and distance to VA facilities. This study was approved by the Baylor College of Medicine Institutional Review Board (IRB), protocol number H-40441.

Results: In total, 346,364 VA-enrolled veterans lived in the five study states during the time of our study, 70,987 of whom were enrolled in Medicaid for at least 1 month. For low-income veterans, Medicaid expansion was associated with a 2.88 percentage-point decline in the VA proportion of outpatient services (99% CI -3.26 to -2.49), and a 2.07-point increase (1.80 to 2.35) in the percentage of patients using both VA and Medicaid services. Results also showed small increases in total (VA plus Medicaid) annual per-capita outpatient visits among low-income veterans. We estimate that this corresponds to an annual reduction of 80,338 VA visits across study states (66,155-94,521).

Conclusions: This study shows usage shifts when Medicaid expansion allows veterans to gain access to non-VA care. It highlights increased potential for care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional public health insurance options, as well as programs like CHOICE and the MISSION Act that increase veteran choices of traditional VA and community care providers.
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http://dx.doi.org/10.1093/milmed/usab094DOI Listing
May 2022

Premature Atherosclerotic Cardiovascular Disease Risk Among Patients with Inflammatory Bowel Disease.

Am J Med 2021 08 1;134(8):1047-1051.e2. Epub 2021 Apr 1.

Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas. Electronic address:

Background: Recent literature has shown an association between atherosclerotic cardiovascular disease and inflammatory bowel disease, potentially mediated through chronic inflammatory pathways. However, there is a paucity of data demonstrating this relationship among young patients with premature atherosclerotic cardiovascular disease.

Methods: Using data from the nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed the association between extremely premature and premature atherosclerotic cardiovascular disease (age at diagnosis: ≤40 years and ≤55 years, respectively) and inflammatory bowel disease. Patients were compared with age-matched controls without atherosclerotic cardiovascular disease. Multivariable regression models adjusted for traditional risk factors.

Results: We identified 147,600 patients and 9485 patients with premature and extremely premature atherosclerotic cardiovascular disease, respectively. Compared with controls, there was a higher prevalence of overall inflammatory bowel disease among premature (0.96% vs 0.84%; odds ratio [OR] 1.14; 95% confidence interval [CI], 1.08-1.21) and extremely premature (1.36% vs 0.75%; OR 1.82; 95% CI, 1.52-2.17) patients. After adjustment, these associations attenuated in both premature and extremely premature groups (OR 1.07; 95% CI, 1.00-1.14 and OR 1.61; 95% CI, 1.34-1.94, respectively).

Conclusion: Inflammatory bowel disease is associated with higher odds of extremely premature atherosclerotic cardiovascular disease, especially for those age ≤40 years. With increasing age, this risk is attenuated by traditional cardiometabolic factors such as obesity, hypertension, diabetes, smoking, and dyslipidemia. Prospective studies are needed to assess the role of early intervention to decrease cardiovascular risk among young patients with inflammatory bowel disease.
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http://dx.doi.org/10.1016/j.amjmed.2021.02.029DOI Listing
August 2021
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