Publications by authors named "Mary A Whooley"

259 Publications

Applying Mobile Technology to Sustain Physical Activity After Completion of Cardiac Rehabilitation: Acceptability Study.

JMIR Hum Factors 2021 Sep 2;8(3):e25356. Epub 2021 Sep 2.

Department of Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, CA, United States.

Background: Many patients do not meet the recommended levels of physical activity after completing a cardiac rehabilitation (CR) program. Wearable activity trackers and mobile phone apps are promising potential self-management tools for maintaining physical activity after CR completion.

Objective: This study aims to evaluate the acceptability of a wearable device, mobile app, and push messages to facilitate physical activity following CR completion.

Methods: We used semistructured interviews to assess the acceptability of various mobile technologies after participation in a pilot randomized controlled trial. Intervention patients in the randomized controlled trial wore the Fitbit Charge 2, used the Movn mobile app, and received push messages on cardiovascular disease prevention and physical activity for over 2 months. We asked 26 intervention group participants for feedback about their experience with the technology and conducted semistructured individual interviews with 7 representative participants. We used thematic analysis to create the main themes from individual interviews.

Results: Our sample included participants with a mean age of 66.7 (SD 8.6) years; 23% (6/26) were female. Overall, there were varying levels of satisfaction with different technology components. There were 7 participants who completed the satisfaction questionnaires and participated in the interviews. The Fitbit and Movn mobile app received high satisfaction scores of 4.86 and 4.5, respectively, whereas push messages had a score of 3.14 out of 5. We identified four main themes through the interviews: technology use increased motivation to be physically active, technology use served as a reminder to be physically active, recommendations for technology to improve user experience, and desire for personal feedback.

Conclusions: By applying a wearable activity tracker, mobile phone app, and push messages, our study showed strong potential for the adoption of new technologies by older adults to maintain physical activity after CR completion. Future research should include a larger sample over a longer period using a mixed methods approach to assess the efficacy of technology use for promoting long-term physical activity behavior in older adults.
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http://dx.doi.org/10.2196/25356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8446842PMC
September 2021

Epidemiology of Idiopathic Pulmonary Fibrosis Among U.S. Veterans, 2010 - 2019.

Ann Am Thorac Soc 2021 Jul 27. Epub 2021 Jul 27.

San Francisco VA Medical Center, 19980, San Francisco, California, United States.

Rationale: The development of novel therapies for idiopathic pulmonary fibrosis (IPF) has brought increased attention to the population burden of disease. However, little is known about the epidemiology of IPF among United States Veterans.

Objectives: This study examines temporal trends in incidence and prevalence, patient characteristics, and risk factors associated with IPF among a national cohort of United States Veterans.

Methods: We used data from Veterans Health Administration (VHA) electronic health record system to describe the incidence, prevalence, and geographic distribution of IPF between January 2010 and December 2019. We evaluated patient characteristics associated with IPF using multivariate logistic regression.

Results: Among 10.7 million Veterans who received care from the VHA between 2010 and 2019, 139,116 (1.26%) were diagnosed with IPF. Using a narrow case definition of IPF, the prevalence increased from 276 cases per 100,000 in 2010 to 725 cases per 100,000 in 2019. The annual incidence increased from 73 cases per 100,000 person-years in 2010 to 210 cases per 100,000 person-years in 2019. Higher absolute incidence and prevalence rates were noted when a broader case definition of IPF was used. Risk factors associated with IPF among Veterans included older age, White race, tobacco use, and rural residence. After accounting for interactions, the average marginal difference in IPF prevalence between males and female sex was small. There was significant geographic heterogeneity of disease across the U.S.

Conclusions: This study is the first comprehensive epidemiologic analysis of IPF among the U.S. Veteran population. The incidence and prevalence of IPF among Veterans has increased over the past decade. The effect of sex on risk of IPF was attenuated once accounting for other risk factors. The geographic distribution of disease is heterogenous across the U.S with rural residence associated with a higher odds of IPF. The reason for these trends deserves further study.
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http://dx.doi.org/10.1513/AnnalsATS.202103-295OCDOI Listing
July 2021

Cardiac Rehabilitation: Under-Utilized Globally.

Curr Cardiol Rep 2021 07 16;23(9):118. Epub 2021 Jul 16.

US Department of Veterans Affairs Quality Enhancement Research Initiative, San Francisco, USA.

Purpose Of Review: Cardiac rehabilitation (CR) is grossly under-utilized. This review summarizes current knowledge about degree of CR utilization, reasons for under-utilization, and strategies to increase use.

Recent Findings: ICCPR's global CR audit quantified for the first time the number of additional CR spots needed per year to treat indicated patients, so there are programs they may use. The first randomized trial of automatic/systematic CR referral has shown it results in significantly greater patient completion. Moreover, the recent update of the Cochrane review on interventions to increase use has provided unequivocal evidence on the significant impact of clinician CR encouragement at the bedside; a course is now available to train clinicians. The USA is leading the way in implementing automatic referral with inpatient-clinician CR discussions. Suggestions to triage patients based on risk to less resource-intensive, unsupervised program models could simultaneously expand capacity and support patient adherence.
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http://dx.doi.org/10.1007/s11886-021-01543-xDOI Listing
July 2021

Hepatitis C infection and complication rates after total shoulder arthroplasty in United States veterans.

JSES Int 2021 Jul 20;5(4):699-706. Epub 2021 Apr 20.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA.

Background: Few studies have evaluated the effect of hepatitis C (HCV) on primary total shoulder arthroplasty (TSA). Our purpose was to determine if HCV infection is associated with increased complication rates after TSA in United States (US) veterans and, secondarily, to determine if preoperative HCV treatment with direct-acting antivirals (DAAs) affects postoperative complication rates.

Methods: US Department of Veterans Affairs (VA) data sets were used to retrospectively identify patients without HCV, patients with untreated HCV, and patients with HCV treated with DAAs who underwent TSA from 2014 to 2019. Medical and surgical complications were assessed using International Classification of Diseases codes. Complication rates between patients with HCV (treated and untreated) and patients without HCV and between HCV-treated patients and HCV-untreated patients were compared at 90 days and 1 year after surgery.

Results: We identified 5774 primary TSAs that were performed at VA hospitals between 2014 and 2019. A minority (9.5%) of TSA patients had HCV, 23.4% of whom were treated preoperatively with DAAs. On multivariate analysis, HCV patients had increased odds of 1-year medical complications (odds ratio, 1.39; 95% confidence interval, 1.06-1.81,  = .016), when compared with patients without HCV. No statistically significant difference in complication rates was observed between HCV-treated and HCV-untreated patients.

Discussion: US veterans with a history of HCV are at an increased risk of developing medical but not surgical complications within the first year after TSA. Larger studies are necessary to evaluate the effects of DAA treatment on complication rates.
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http://dx.doi.org/10.1016/j.jseint.2021.02.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245977PMC
July 2021

Mobile Health Intervention Promoting Physical Activity in Adults Post Cardiac Rehabilitation: Pilot Randomized Controlled Trial.

JMIR Form Res 2021 Apr 16;5(4):e20468. Epub 2021 Apr 16.

Departments of Medicine and Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, United States.

Background: Cardiac rehabilitation (CR) is an exercise-based program prescribed after cardiac events associated with improved physical, mental, and social functioning; however, many patients return to a sedentary lifestyle leading to deteriorating functional capacity after discharge from CR. Physical activity (PA) is critical to avoid recurrence of cardiac events and mortality and maintain functional capacity. Leveraging mobile health (mHealth) strategies to increase adherence to PA is a promising approach. Based on the social cognitive theory, we sought to determine whether mHealth strategies (Movn mobile app for self-monitoring, supportive push-through messages, and wearable activity tracker) would improve PA and functional capacity over 2 months.

Objective: The objectives of this pilot randomized controlled trial were to examine preliminary effects of an mHealth intervention on group differences in PA and functional capacity and group differences in depression and self-efficacy to maintain exercise after CR.

Methods: During the final week of outpatient CR, patients were randomized 1:1 to the intervention group or usual care. The intervention group downloaded the Movn mobile app, received supportive push-through messages on motivation and educational messages related to cardiovascular disease (CVD) management 3 times per week, and wore a Charge 2 (Fitbit Inc) activity tracker to track step counts. Participants in the usual care group wore a pedometer and recorded their daily steps in a diary. Data from the 6-minute walk test (6MWT) and self-reported questionnaires were collected at baseline and 2 months.

Results: We recruited 60 patients from 2 CR sites at a community hospital in Northern California. The mean age was 68.0 (SD 9.3) years, and 23% (14/60) were female; retention rate was 85% (51/60). Our results from 51 patients who completed follow-up showed the intervention group had a statistically significant higher mean daily step count compared with the control (8860 vs 6633; P=.02). There was no difference between groups for the 6MWT, depression, or self-efficacy to maintain exercise.

Conclusions: This intervention addresses a major public health initiative to examine the potential for mobile health strategies to promote PA in patients with CVD. Our technology-based pilot mHealth intervention provides promising results on a pragmatic and contemporary approach to promote PA by increasing daily step counts after completing CR.

Trial Registration: ClinicalTrials.gov NCT03446313; https://clinicaltrials.gov/ct2/show/NCT03446313.
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http://dx.doi.org/10.2196/20468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087971PMC
April 2021

Adenoma Detection Rate (ADR) Irrespective of Indication Is Comparable to Screening ADR: Implications for Quality Monitoring.

Clin Gastroenterol Hepatol 2021 09 19;19(9):1883-1889.e1. Epub 2021 Feb 19.

Richard L. Roudebush VA Medical Center, Indiana University, Indianapolis, Indiana.

Background & Aims: Adenoma detection rate (ADR) is a key measure of colonoscopy quality. However, efficient measurement of ADR can be challenging because many colonoscopies are performed for non-screening purposes. Measuring ADR without being restricted to screening indication may likely facilitate more widespread implementation of quality monitoring. We hypothesized that the ADR for all colonoscopies, irrespective of the indication, would be equivalent to the ADR for screening colonoscopies.

Methods: We reviewed consecutive colonoscopies at two Veterans Affairs centers performed by 21 endoscopists over 6 months in 2015. We calculated the ADR for screening exams, non-screening (surveillance and diagnostic) exams, and all exams (irrespective of indication), correcting for within-endoscopist correlation. We then performed simulation modeling to calculate the ADRs under 16 hypothetical scenarios of various indication distributions. We simulated 100,000 trials with 3,000 participants, randomly assigned indication (screening, surveillance, diagnostic, and FIT+) from a multinomial distribution, randomly drew adenoma using the observed ADRs per indication, and calculated 95% confidence intervals of the mean differences in ADR of screening and non-screening indications.

Results: Among 2628 colonoscopies performed by 21 gastroenterologists, the indication was screening in 28.9%, surveillance in 48.2% and diagnostic in 22.9%. There was no significant difference in the ADR, 50% (95%CI: 45-56%) for all colonoscopies vs 49% (95%CI: 43-56%) for screening exams (p=.55). ADRs were 56% for surveillance and 38% for diagnostic exams. In our simulation modeling, only one out of 16 scenarios (screening 10%, surveillance 70%, diagnostic 10% and FIT+ 10%) resulted in a significant difference between the calculated ADRs for screening and non-screening indications.

Conclusions: In our study, the overall ADR computed from all colonoscopies was not significantly different than the conventional ADR based on screening colonoscopies. Assessing ADR for colonoscopy irrespective of indication may be adequate for quality monitoring, and could facilitate the implementation of quality measurement and reporting. Future prospective studies should evaluate the validity of using overall ADR for quality reporting in other jurisdictions before adopting this method in clinical practice.
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http://dx.doi.org/10.1016/j.cgh.2021.02.028DOI Listing
September 2021

Impact of Longitudinal Virtual Primary Care on Diabetes Quality of Care.

J Gen Intern Med 2021 09 22;36(9):2585-2592. Epub 2021 Jan 22.

Department of Medicine, University of Colorado, Aurora, CO, USA.

Background: Lack of healthcare access to due to physician shortages is a significant driver of telemedicine expansion in rural areas. Telemedicine is effective for management of chronic conditions such as diabetes but its effectiveness in primary care settings is unknown.

Objective: To evaluate differences in diabetes care before and after implementation of a longitudinal virtual primary care program.

Design: Propensity score-matched cohort study utilizing difference-in-differences analysis.

Participants: Patients with diabetes who received care at VA primary care clinics between January 2018 and December 2019 where the Virtual Integrated Multisite Patient Aligned Care Teams (V-IMPACT) program was implemented.

Exposure: Patient participation in at least one V-IMPACT visit while usual care patients did not participate in V-IMPACT.

Main Measures: The primary outcome was change in hemoglobin A1C (HbA1C) and secondary outcomes included change in the proportion of patients meeting diabetes quality indicators: blood pressure control, statin use, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEi/ARB) use, and annual microalbuminuria testing.

Key Results: Our propensity-matched cohort included 9010 patients split evenly between those who participated in V-IMPACT and those who remained in usual in-person care. Among individuals with diabetes who participated in V-IMPACT, the change in mean HbA1C was - 0.055% (95% CI - 0.088 to - 0.022%) while those in usual care had a - 0.047% (95% CI - 0.080 to - 0.014%) change before and after program implementation. We observed a 5.1% (95% CI 2.4 to 7.7%) absolute increase in the proportion prescribed statins in the V-IMPACT group, a 5.3% (95% CI 2.5 to 8.2%) increase prescribed ACE/ARBs, and a 4.6% (95% 1.7 to 7.5%) increase in completed yearly microalbuminuria testing. V-IMPACT was not associated with a significant difference in the proportion with controlled blood pressure at < 140/90 or < 130/90 mmHg thresholds.

Conclusions: Quality of diabetes care delivered by a longitudinal virtual primary care model was similar if not better than traditional in-person care.
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http://dx.doi.org/10.1007/s11606-020-06547-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822396PMC
September 2021

Leveraging Telehealth to improve access to care: a qualitative evaluation of Veterans' experience with the VA TeleSleep program.

BMC Health Serv Res 2021 Jan 21;21(1):77. Epub 2021 Jan 21.

San Francisco VA Medical Center, 4150 Clement Street, 151-R, San Francisco, CA, 94121, USA.

Background: Obstructive sleep apnea is common among rural Veterans, however, access to diagnostic sleep testing, sleep specialists, and treatment devices is limited. To improve access to sleep care, the Veterans Health Administration (VA) implemented a national sleep telemedicine program. The TeleSleep program components included: 1) virtual clinical encounters; 2) home sleep apnea testing; and 3) web application for Veterans and providers to remotely monitor symptoms, sleep quality and use of positive airway pressure (PAP) therapy. This study aimed to identify factors impacting Veteran's participation, satisfaction and experience with the TeleSleep program as part of a quality improvement initiative.

Methods: Semi-structured interview questions elicited patient perspectives and preferences regarding accessing and engaging with TeleSleep care. Rapid qualitative and matrix analysis methods for health services research were used to organize and describe the qualitative data.

Results: Thirty Veterans with obstructive sleep apnea (OSA) recruited from 6 VA telehealth "hubs" participated in interviews. Veterans reported positive experiences with sleep telemedicine, including improvements in sleep quality, other health conditions, and quality of life. Access to care improved as a result of decreased travel burden and ability of both clinicians and Veterans to remotely monitor and track personal sleep data. Overall experiences with telehealth technology were positive. Veterans indicated a strong preference for VA over non-VA community-based sleep care. Patient recommendations for change included improving scheduling, continuity and timeliness of communication, and the equipment refill process.

Conclusions: The VA TeleSleep program improved patient experiences across multiple aspects of care including a reduction in travel burden, increased access to clinicians and remote monitoring, and patient-reported health and quality of life outcomes, though some communication and continuity challenges remain. Implementing telehealth services may also improve the experiences of patients served by other subspecialties or healthcare systems.
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http://dx.doi.org/10.1186/s12913-021-06080-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818059PMC
January 2021

Does Community Outsourcing Improve Timeliness of Care for Veterans With Obstructive Sleep Apnea?

Med Care 2021 02;59(2):111-117

San Francisco Veterans Affairs Healthcare System.

Background: Providing timely access to care has been a long-standing priority for the Veterans Affairs Healthcare System. Recent strategies to reduce long wait times have focused on purchasing community care by a fee-for-service model. Whether outsourcing Veterans Affairs (VA) specialty care to the community improves access is unclear.

Objectives: We compared time from referral to treatment among Veterans whose care was provided by VA versus community care purchased by the VA, using obstructive sleep apnea as an example condition.

Methods: This was a retrospective cohort study of Northern California Veterans seeking sleep apnea care through the San Francisco VA Healthcare System between 2012 and 2018. We used multivariable linear regression with propensity score matching to investigate the relationship between time to care delivery and care setting (VA provided vs. VA-purchased community care). A total of 1347 Northern California Veterans who completed sleep apnea testing within the VA and 88 Veterans who completed sleep apnea testing in the community had complete data for analysis.

Results: Among Northern California Veterans with obstructive sleep apnea, outsourcing of care to the community was associated with longer time from referral to therapy (mean±SD, 129.6±82.8 d with VA care vs. 252.0±158.8 d with community care, P<0.001) and greater loss to follow-up.

Conclusions: These findings suggest that purchasing community care may lead to care fragmentation and not improve wait times nor improve access to subspecialty care for Veterans.
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http://dx.doi.org/10.1097/MLR.0000000000001472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899214PMC
February 2021

Feasibility of a Telemedicine Urgent Care Program to Address Patient Complaints on First Contact.

Emerg Med Int 2020 28;2020:8875644. Epub 2020 Oct 28.

San Francisco Veterans Affairs Health Care System, San Francisco, USA.

Many health systems employ nurse telephone advice services to facilitate remote triage of patients to appropriate level of care. However, the effectiveness of these programs to reduce ED and subsequent health care utilization remains to be demonstrated. We describe a novel virtual urgent care program implemented within a Veterans Affairs (VA) health care system that interfaces with a nurse telephone advice line and leverages telemedicine tools to rapidly address and resolve nonemergent conditions. During a 4-month pilot period, 104 unique patients received care through the program, and over 85% of patients achieved timely resolution for their urgent complaints on first contact with the health care system. Demonstrating feasibility for such a program has potential implications for the optimization of remote triage and urgent care services to improve health care utilization and outcomes.
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http://dx.doi.org/10.1155/2020/8875644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644327PMC
October 2020

Simplifying Measurement of Adenoma Detection Rates for Colonoscopy.

Dig Dis Sci 2021 09 8;66(9):3149-3155. Epub 2020 Oct 8.

Measurement Science QUERI, San Francisco, CA, USA.

Background: Adenoma detection rate (ADR) is the colonoscopy quality metric with the strongest association to interval or "missed" cancer. Accurate measurement of ADR can be laborious and costly.

Aims: Our aim was to determine if administrative procedure codes for colonoscopy and text searches of pathology results for adenoma mentions could estimate ADR.

Methods: We identified US Veterans with a colonoscopy using Current Procedure Terminology (CPT) codes between January 2013 and December 2016 at ten Veterans Affairs sites. We applied simple text searches using Microsoft SQL Server full-text searches to query all pathology notes for "adenoma(s)" or "adenomatous" text mentions to calculate ADRs. To validate our identification of colonoscopy procedures, endoscopists of record, and adenoma detection from the electronic health record, we manually reviewed a random sample of 2000 procedure and pathology notes from the 10 sites.

Results: Structured data fields were accurate in identification of colonoscopies being performed (PPV = 0.99; 95% CI 0.99-1.00) and identifying the endoscopist of record (PPV of 0.95; 95% CI 0.94-0.96) for ADR measurement. Simple text searches of pathology notes for adenoma mentions had excellent performance statistics as follows: sensitivity 0.99 (95% CI 0.98-1.00), specificity 0.93 (95% CI 0.92-0.95), NPV 0.99 (95% CI 0.98-1.00), and PPV 0.93 (0.91-0.94) for measurement of ADR. There was no clinically significant difference in the estimates of overall ADR vs. screening ADR (p > 0.05).

Conclusions: Measuring ADR using administrative codes and text searches from pathology results is an efficient method to broadly survey colonoscopy quality.
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http://dx.doi.org/10.1007/s10620-020-06627-2DOI Listing
September 2021

Effects of Home-Based Cardiac Rehabilitation on Time to Enrollment and Functional Status in Patients With Ischemic Heart Disease.

J Am Heart Assoc 2020 10 21;9(19):e016456. Epub 2020 Sep 21.

Department of Medicine VA Pittsburgh Healthcare System Pittsburgh PA.

Background Cardiac rehabilitation is an established performance measure for adults with ischemic heart disease, but patient participation is remarkably low. Home-based cardiac rehabilitation (HBCR) may be more practical and feasible, but evidence regarding its efficacy is limited. We sought to compare the effects of HBCR versus facility-based cardiac rehabilitation (FBCR) on functional status in patients with ischemic heart disease. Methods and Results This was a pragmatic trial of 237 selected patients with a recent ischemic heart disease event, who enrolled in HBCR or FBCR between August 2015 and September 2017. The primary outcome was 3-month change in distance completed on a 6-minute walk test. Secondary outcomes included rehospitalization as well as patient-reported physical activity, quality of life, and self-efficacy. Characteristics of the 116 patients enrolled in FBCR and 121 enrolled in HBCR were similar, except the mean time from index event to enrollment was shorter for HBCR (25 versus 77 days; <0.001). As compared with patients undergoing FBCR, those in HBCR achieved greater 3-month gains in 6-minute walk test distance (+95 versus +41 m; <0.001). After adjusting for demographics, comorbid conditions, and indication, the mean change in 6-minute walk test distance remained significantly greater for patients enrolled in HBCR (+101 versus +40 m; <0.001). HBCR participants reported greater improvements in quality of life and physical activity but less improvement in exercise self-efficacy. There were no deaths or cardiovascular hospitalizations. Conclusions Patients enrolled in HBCR achieved greater 3-month functional gains than those enrolled in FBCR. Our data suggest that HBCR may safely derive equivalent benefits in exercise capacity and overall program efficacy in selected patients. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02105246.
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http://dx.doi.org/10.1161/JAHA.120.016456DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792373PMC
October 2020

Preoperative Medical Testing and Falls in Medicare Beneficiaries Awaiting Cataract Surgery.

Ophthalmology 2021 02 11;128(2):208-215. Epub 2020 Sep 11.

Department of Medicine, Informatics, and Health Policy & Management, Schools of Medicine and Public Health and Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota; Minneapolis VA Medical Center, Minneapolis, Minnesota.

Purpose: Delaying cataract surgery is associated with an increased risk of falls, but whether routine preoperative testing delays cataract surgery long enough to cause clinical harm is unknown. We sought to determine whether the use of routine preoperative testing leads to harm in the form of delayed surgery and falls in Medicare beneficiaries awaiting cataract surgery.

Design: Retrospective, observational cohort study using 2006-2014 Medicare claims.

Participants: Medicare beneficiaries 66+ years of age with a Current Procedural Terminology claim for ocular biometry.

Methods: We measured the mean and median number of days between biometry and cataract surgery, calculated the proportion of patients waiting ≥ 30 days or ≥ 90 days for surgery, and determined the odds of sustaining a fall within 90 days of biometry among patients of high-testing physicians (testing performed in ≥ 75% of their patients) compared with patients of low-testing physicians. We also estimated the number of days of delay attributable to high-testing physicians.

Main Outcome Measures: Incidence of falls occurring between biometry and surgery, odds of falling within 90 days of biometry, and estimated delay associated with physician testing behavior.

Results: Of 248 345 beneficiaries, 16.4% were patients of high-testing physicians. More patients of high-testing physicians waited ≥ 30 days and ≥ 90 days to undergo surgery (31.4% and 8.2% vs. 25.0% and 5.5%, respectively; P < 0.0001 for both). Falls before surgery in patients of high-testing physicians increased by 43% within the 90 days after ocular biometry (1.0% vs. 0.7%; P < 0.0001). The adjusted odds ratio of falling within 90 days of biometry in patients of high-testing physicians versus low-testing physicians was 1.10 (95% confidence interval [CI], 1.03-1.19; P = 0.008). After adjusting for surgical wait time, the odds ratio decreased to 1.07 (95% CI, 1.00-1.15; P = 0.06). The delay associated with having a high-testing physician was approximately 8 days (estimate, 7.97 days; 95% CI, 6.40-9.55 days; P < 0.0001). Other factors associated with delayed surgery included patient race (non-White), Northeast region, ophthalmologist ≤ 40 years of age, and low surgical volume.

Conclusions: Overuse of routine preoperative medical testing by high-testing physicians is associated with delayed surgery and increased falls in cataract patients awaiting surgery.
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http://dx.doi.org/10.1016/j.ophtha.2020.09.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8443237PMC
February 2021

Implementation Strategies for Frontline Healthcare Professionals: People, Process Mapping, and Problem Solving.

J Gen Intern Med 2021 02 11;36(2):506-510. Epub 2020 Sep 11.

San Francisco Veterans Affairs Health Care System, San Francisco, USA.

Implementation science is focused on developing and evaluating methods to reduce gaps between research and practice. As healthcare organizations become increasingly accountable for equity, quality, and value, attention has been directed to identifying specific implementation strategies that can accelerate the adoption of evidence-based therapies into clinical practice. In this perspective, we offer three simple, practical strategies that can be used by frontline healthcare providers who are involved in on-the-ground implementation: people (stakeholder) engagement, process mapping, and problem solving. As a use case example, we describe the iterative application of these strategies to the implementation of a new home sleep apnea testing program for patients in the Veterans Health Administration (VA) healthcare system.
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http://dx.doi.org/10.1007/s11606-020-06169-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878661PMC
February 2021

Antibiotic-Laden Bone Cement Use and Revision Risk After Primary Total Knee Arthroplasty in U.S. Veterans.

J Bone Joint Surg Am 2020 Nov;102(22):1939-1947

Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.

Background: It is controversial whether the use of antibiotic-laden bone cement (ALBC) in primary total knee arthroplasty (TKA) affects periprosthetic joint infection (PJI) or revision rates. The impact of ALBC on outcomes of primary TKA have not been previously investigated in U.S. veterans, to our knowledge. The purposes of this study were to quantify utilization of ALBC among U.S. veterans undergoing primary TKA and to determine if ALBC usage is associated with differences in revision TKA rates.

Methods: Patients who had TKA with cement from 2007 to 2015 at U.S. Veterans Health Administration (VHA) hospitals with at least 2 years of follow-up were retrospectively identified. Patients who received high-viscosity Palacos bone cement with or without gentamicin were selected as the final study cohort. Patient demographic and comorbidity data were collected. Revision TKA was the primary outcome. All-cause revisions and revisions for PJI were identified from both VHA and non-VHA hospitals. Unadjusted and adjusted regression analyses were performed to identify variables that were associated with increased revision rates.

Results: The study included 15,972 patients who had primary TKA with Palacos bone cement at VHA hospitals from 2007 to 2015. Plain bone cement was used for 4,741 patients and ALBC was used for 11,231 patients. Utilization of ALBC increased from 50.6% in 2007 to 69.4% in 2015. At a mean follow-up of 5 years, TKAs with ALBC had a lower all-cause revision rate than those with plain bone cement (5.3% versus 6.7%; p = 0.0009) and a lower rate of revision for PJI (1.9% versus 2.6%; p = 0.005). On multivariable regression, ALBC use was associated with a lower risk of all-cause revision compared with plain bone cement (hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.68 to 0.92; p = 0.0019). Seventy-one primary TKAs needed to be implanted with ALBC to avoid 1 revision TKA.

Conclusions: The utilization of ALBC for primary TKAs performed at VHA hospitals has increased over time and was associated with a lower all-cause revision rate and a lower rate of revision for PJI.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.00102DOI Listing
November 2020

Comorbid depression in medical diseases.

Nat Rev Dis Primers 2020 08 20;6(1):69. Epub 2020 Aug 20.

Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt Universität zu Berlin, Berlin Institute of Health (BIH), Klinik für Psychiatrie und Psychotherapie, Campus Benjamin Franklin, Berlin, Germany.

Depression is one of the most common comorbidities of many chronic medical diseases including cancer and cardiovascular, metabolic, inflammatory and neurological disorders. Indeed, the prevalence of depression in these patient groups is often substantially higher than in the general population, and depression accounts for a substantial part of the psychosocial burden of these disorders. Many factors can contribute to the occurrence of comorbid depression, such as shared genetic factors, converging biological pathways, social factors, health behaviours and psychological factors. Diagnosis of depression in patients with a medical disorder can be particularly challenging owing to symptomatic overlap. Although pharmacological and psychological treatments can be effective, adjustments may need to be made for patients with a comorbid medical disorder. In addition, symptoms or treatments of medical disorders may interfere with the treatment of depression. Conversely, symptoms of depression may decrease adherence to treatment of both disorders. Thus, comprehensive treatment plans are necessary to optimize care.
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http://dx.doi.org/10.1038/s41572-020-0200-2DOI Listing
August 2020

Prevalence and management of sleep disorders in the Veterans Health Administration.

Sleep Med Rev 2020 12 20;54:101358. Epub 2020 Jul 20.

San Francisco VA Healthcare System, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA.

The prevalence of diagnosed sleep disorders among Veterans treated at Veterans Affairs (VA) medical facilities increased significantly during fiscal years (FY) 2012 through 2018. Specifically, the prevalence of sleep-related breathing disorders (SRBD) increased from 5.5% in FY2012 to 22.2% in FY2018, and the prevalence of insomnia diagnoses increased from 7.4% in FY2012 to 11.8% in FY2018. Consequently, Veterans' demand for sleep medicine services also increased significantly between FY2012-2018, with steady increases in the annual number of VA sleep clinic appointments during this period (<250,000 in FY 2012; >720,000 in FY2018). Common co-morbid conditions among Veterans diagnosed with sleep disorders include obesity, diabetes, congestive heart failure, depression, post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). To address this healthcare crisis, the Veterans Health Administration (VHA) developed and/or implemented numerous innovations to improve the quality and accessibility of sleep care services for Veterans. These innovations include a TeleSleep Enterprise-Wide Initiative to improve rural Veterans' access to sleep care; telehealth applications such as the Remote Veteran Apnea Management Platform (REVAMP), Clinical Video Telehealth, and CBT-i Coach; increased use of home sleep apnea testing (HSAT); and programs for Veterans who experience sleep disorders associated with obesity, PTSD, TBI and other conditions.
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http://dx.doi.org/10.1016/j.smrv.2020.101358DOI Listing
December 2020

Left Atrial End-Diastolic Volume Index as a Predictor of Cardiovascular Outcomes: The Heart and Soul Study.

Circ Cardiovasc Imaging 2020 04 20;13(4):e009746. Epub 2020 Apr 20.

Division of Cardiology, Department of Medicine (S.R.T., Q.F., N.B.S.), University of California, San Francisco.

Background: The left atrial end-systolic volume index (LAESVI) is a predictor of cardiovascular outcomes and is the recommended measurement of left atrial size. The left atrial end-diastolic volume index (LAEDVI), representing the minimum or residual left atrial volume, has not been fully evaluated as a predictor of cardiovascular events. This study evaluated the predictive power of LAEDVI compared with LAESVI for heart failure (HF) hospitalizations, a composite of HF hospitalizations, myocardial infarction, stroke, and heart disease death, and all-cause mortality.

Methods: We measured LAESVI and LAEDVI in subjects without atrial fibrillation or flutter or significant mitral valve disease. Using Cox proportional-hazard models, the association of LAESVI and LAEDVI with the stated outcomes was examined.

Results: After a mean of 7.3±2.6 years of follow-up, there were 147 HF hospitalizations, 118 myocardial infarctions, 45 strokes, 96 heart disease deaths, and 351 deaths from all causes in 938 subjects. When comparing the highest and the lowest quartiles of LAEDVI, there was a near 6-fold increase in the hazard ratio (HR) for HF hospitalization (HR, 5.96; <0.001). This was higher than what was seen with LAESVI (HR, 4.85; <0.001). Similar associations were noted for the composite cardiovascular outcome (HR for LAEDVI, 2.97; <0.001) and for all-cause mortality (HR for LAEDVI, 2.08; <0.001). In adjusted models, LAEDVI demonstrated equal or better predictive power than LAESVI for HF hospitalization and the composite cardiovascular outcome.

Conclusions: LAEDVI is a strong predictor of cardiovascular events in ambulatory patients with stable coronary heart disease and may merit routine use.
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http://dx.doi.org/10.1161/CIRCIMAGING.119.009746DOI Listing
April 2020

Association of Cardiac Rehabilitation With Survival Among US Veterans.

JAMA Netw Open 2020 03 2;3(3):e201396. Epub 2020 Mar 2.

San Francisco Veterans Affairs Medical Center, San Francisco, California.

Importance: Participation in cardiac rehabilitation (CR) programs at Veterans Affairs (VA) facilities is low. Most veterans receive CR through purchased care at non-VA programs. However, limited literature exists on the comparison of outcomes between VA and non-VA CR programs.

Objective: To compare 1-year mortality and 1-year readmission rates for myocardial infarction or coronary revascularization between VA vs non-VA CR participants.

Design, Setting, And Participants: This cohort study included 7320 patients hospitalized for myocardial infarction or coronary revascularization at the VA between 2010 and 2014 who did not die within 30 days of discharge and who participated in 2 or more CR sessions after discharge. The study excluded individuals hospitalized for ischemic heart disease after December 2014 when the VA Choice Act changed referral criteria for non-VA care. Data analysis was performed from November 2019 to January 2020.

Exposures: Participation in 2 or more CR sessions within 12 months of discharge at a VA or non-VA facility.

Main Outcomes And Measures: The 1-year all-cause mortality and 1-year readmission rates for myocardial infarction or coronary revascularization from date of discharge were compared between VA vs non-VA CR participants using Cox proportional hazards models with inverse probability treatment weighting.

Results: The 7320 veterans with ischemic heart disease who participated in CR programs had a mean (SD) age of 65.13 (8.17) years and were predominantly white (6005 patients [82.0%]), non-Hispanic (6642 patients [91.0%]), and male (7191 patients [98.2%]). Among these 7320 veterans, 2921 (39.9%) attended a VA facility, and 4399 (60.1%) attended a non-VA CR facility. Black and Hispanic veterans were more likely to attend CR programs at VA facilities (509 patients [17.4%] and 378 patients [12.9%], respectively), whereas white veterans were more likely to attend CR programs at non-VA facilities (3759 patients [85.5%]). After inverse probability treatment weighting, rates of 1-year mortality were 1.7% among VA CR participants vs 1.3% among non-VA CR participants (hazard ratio, 1.32; 95% CI, 0.90-1.94; P = .15). Rates of readmission for myocardial infarction or revascularization during the 12 months after discharge were 4.9% among VA CR participants vs 4.4% among non-VA CR participants (hazard ratio, 1.06; 95% CI, 0.83-1.35; P = .62).

Conclusions And Relevance: These findings suggest that rates of 1-year mortality and 1-year readmission for myocardial infarction or revascularization did not differ for participants in VA vs non-VA cardiac rehabilitation programs. Eligible patients with ischemic heart disease should participate in CR programs regardless of where they are provided.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.1396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7084171PMC
March 2020

Patient Perspectives on Declining to Participate in Home-Based Cardiac Rehabilitation: A MIXED-METHODS STUDY.

J Cardiopulm Rehabil Prev 2020 09;40(5):335-340

Divisions of Cardiology (Dr Schopfer), Geriatrics (Dr Nicosia), and General Internal Medicine (Dr Whooley), Department of Medicine, Institute for Health & Aging (Dr Nicosia), and School of Nursing (Dr Ottoboni), University of California San Francisco; San Francisco VA Health Care System, San Francisco, California (Drs Schopfer, Nicosia, and Whooley); and National Heart Lung & Blood Institute, National Institutes of Health, Bethesda, Maryland (Dr Schopfer).

Purpose: A minority of eligible patients participate in cardiac rehabilitation (CR) programs. Availability of home-based CR programs improves participation in CR, yet many continue to decline to enroll. We sought to explore among patients the rationale for declining to participate in CR even when a home-based CR program is available.

Methods: We conducted a mixed-methods evaluation of reasons for declining to participate in CR. Between August 2015 and August 2017, a total of 630 patients were referred for CR evaluation during index hospitalization (San Francisco VA Medical Center). Three hundred three patients (48%) declined to participate in CR. Of these, 171 completed a 14-item survey and 10 patients also provided qualitative data through semistructured phone interviews.

Results: The most common reason, identified by 61% of patients on the survey, was "I already know what to do for my heart." Interviews helped clarify reasons for nonparticipation and identified system barriers and personal barriers. These interviews further highlighted that declining to participate in CR was often due to competing life priorities, no memory of the initial CR consultation, and inadequate understanding of CR despite referral.

Conclusion: We identified that most patients declining to participate in a home-based CR program did not understand the benefits and rationale for CR. This could be related to the timing of the consultation or presentation method. Many patients also indicated that competing life priorities prevented their participation. Modifications in the consultation process and efforts to accommodate personal barriers may improve participation.
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http://dx.doi.org/10.1097/HCR.0000000000000493DOI Listing
September 2020

Association of Machine Learning-Derived Phenogroupings of Echocardiographic Variables with Heart Failure in Stable Coronary Artery Disease: The Heart and Soul Study.

J Am Soc Echocardiogr 2020 03 14;33(3):322-331.e1. Epub 2020 Jan 14.

Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California; Department of Medicine, San Francisco Veterans' Affairs Medical Center, San Francisco, California.

Background: Many individual echocardiographic variables have been associated with heart failure (HF) in patients with stable coronary artery disease (CAD), but their combined utility for prediction has not been well studied.

Methods: Unsupervised model-based cluster analysis was performed by researchers blinded to the study outcome in 1,000 patients with stable CAD on 15 transthoracic echocardiographic variables. We evaluated associations of cluster membership with HF hospitalization using Cox proportional hazards regression analysis.

Results: The echo-derived clusters partitioned subjects into four phenogroupings: phenogroup 1 (n = 85) had the highest levels, phenogroups 2 (n = 314) and 3 (n = 205) displayed intermediate levels, and phenogroup 4 (n = 396) had the lowest levels of cardiopulmonary structural and functional abnormalities. Over 7.1 ± 3.2 years of follow-up, there were 198 HF hospitalizations. After multivariable adjustment for traditional cardiovascular risk factors, phenogroup 1 was associated with a nearly fivefold increased risk (hazard ratio [HR] = 4.8; 95% CI, 2.4-9.5), phenogroup 2 was associated with a nearly threefold increased risk (HR = 2.7; 95% CI, 1.4-5.0), and phenogroup 3 was associated with a nearly twofold increased risk (HR = 1.9; 95% CI, 1.0-3.8) of HF hospitalization, relative to phenogroup 4.

Conclusions: Transthoracic echocardiographic variables can be used to classify stable CAD patients into separate phenogroupings that differentiate cardiopulmonary structural and functional abnormalities and can predict HF hospitalization, independent of traditional cardiovascular risk factors.
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http://dx.doi.org/10.1016/j.echo.2019.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7357873PMC
March 2020

Tracking Cardiac Rehabilitation Participation and Completion Among Medicare Beneficiaries to Inform the Efforts of a National Initiative.

Circ Cardiovasc Qual Outcomes 2020 01 14;13(1):e005902. Epub 2020 Jan 14.

Office of the Surgeon General, US Department of Health and Human Services, Washington, DC (J.W.).

Background: Despite cardiac rehabilitation (CR) being shown to improve health outcomes among patients with heart disease, its use has been suboptimal. In response, the Million Hearts Cardiac Rehabilitation Collaborative developed a road map to improve CR use, including increasing participation rates to ≥70% by 2022. This observational study provides current estimates to measure progress and identifies the populations and regions most at risk for CR service underutilization.

Methods And Results: We identified Medicare fee-for-service beneficiaries who were CR eligible in 2016, and assessed CR participation (≥1 CR session attended), timely initiation (participation within 21 days of event), and completion (≥36 sessions attended) through 2017. Measures were assessed overall, by beneficiary characteristics and geography, and by primary CR-qualifying event type (acute myocardial infarction hospitalization; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant). Among 366 103 CR-eligible beneficiaries, 89 327 (24.4%) participated in CR, of whom 24.3% initiated within 21 days and 26.9% completed CR. Eligibility was highest in the East South Central Census Division (14.8 per 1000). Participation decreased with increasing age, was lower among women (18.9%) compared with men (28.6%; adjusted prevalence ratio: 0.91 [95% CI, 0.90-0.93]) was lower among Hispanics (13.2%) and non-Hispanic blacks (13.6%) compared with non-Hispanic whites (25.8%; adjusted prevalence ratio: 0.63 [0.61-0.66] and 0.70 [0.67-0.72], respectively), and varied by hospital referral region and Census Division (range: 18.6% [East South Central] to 39.1% [West North Central]) and by qualifying event type (range: 7.1% [acute myocardial infarction without procedure] to 55.3% [coronary artery bypass surgery only]). Timely initiation varied by geography and qualifying event type; completion varied by geography.

Conclusions: Only 1 in 4 CR-eligible Medicare beneficiaries participated in CR and marked disparities were observed. Reinforcement of current effective strategies and development of new strategies will be critical to address the noted disparities and achieve the 70% participation goal.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.119.005902DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8091573PMC
January 2020

Association of Longitudinal Change in High-Sensitivity Troponin with All-Cause Mortality in Coronary Artery Disease: The Heart and Soul Study.

Cardiology 2020 7;145(2):63-70. Epub 2020 Jan 7.

Division of Cardiology, UCSF School of Medicine, San Francisco, California, USA.

Background: Serial increases in high-sensitivity cardiac troponin (hs-cTnT) have been associated with death in community-dwelling adults, but the association remains uninvestigated in those with coronary artery disease (CAD).

Methods: We measured hs-cTnT at baseline and after 5 years in 635 ambulatory Heart and Soul Study patients with CAD. We also performed echocardiography at rest and after treadmill exercise at baseline and after 5 years. Participants were subsequently followed for the outcome of death. We used a multivariable-adjusted Cox proportional hazards model to evaluate the association between 5-year change in hs-cTnT and subsequent all-cause mortality.

Results: Of the 635 subjects, there were 386 participants (61%) who had an increase in hs-cTnT levels between baseline and year 5 measurements (median increase 5.6 pg/mL, IQR 3.2-9.9 pg/mL). There were 182 deaths after a mean 4.2-year follow-up after the year 5 visit. After adjusting for clinical variables, a >50% increase in hs-cTnT between baseline and year 5 was associated with a nearly 2-fold increased risk of death from any cause (hazard ratio 1.7, 95% confidence interval 1.1-2.7). When addition of year 5 hs-cTnT was compared to a model including clinical variables and baseline hs-cTnT, there was a modest but statistically significant increase in C-statistic from 0.82 to 0.83 (p = 0.04).

Conclusion: In ambulatory patients with CAD, serial increases in hs-cTnT over time are associated with an increased risk of death.
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http://dx.doi.org/10.1159/000503954DOI Listing
November 2020

Association of Receipt of Positron Emission Tomography-Computed Tomography With Non-Small Cell Lung Cancer Mortality in the Veterans Affairs Health Care System.

JAMA Netw Open 2019 11 1;2(11):e1915828. Epub 2019 Nov 1.

Department of Radiology and Biomedical Imaging, University of California, San Francisco.

Importance: Positron emission tomography-computed tomography (PET-CT) has been increasingly used in the management of lung cancer, but its association with survival has not been convincingly documented.

Objective: To examine the association of the use of PET-CT with non-small cell lung cancer (NSCLC) mortality in the US Department of Veterans Affairs (VA) health care system from 2000 to 2013.

Design, Setting, And Participants: This cohort study included 64 103 veterans receiving care in the VA health care system who were diagnosed with incident NSCLC between September 2000 and December 2013. Data analysis took place in October 2018.

Exposure: Use of PET-CT before and/or after diagnosis.

Main Outcomes And Measures: All-cause and NSCLC-specific 5-year mortality; secondary outcome was receipt of stage-appropriate treatment.

Results: A total of 64 103 veterans with the diagnosis of NSCLC were evaluated; 62 838 (98.0%) were men, and 50 584 (78.9%) were white individuals. Among these, 51 844 (80.9%) had a PET-CT performed: 25 735 (40.1%) in the 12 months before diagnosis and 41 242 (64.3%) in the 5 years after diagnosis. Increased PET-CT use (597 of 978 veterans [59.2%] in 2000 vs 3649 of 3915 [93.2%] in 2013) and decreased NSCLC-specific 5-year mortality (879 of 978 veterans [89.9%] in 2000 vs 3226 of 3915 veterans [82.4%] in 2013) were found over time. Increased use of stage-appropriate therapy was also seen over time, from 346 of 978 veterans (35.4%) in 2000 to 2062 of 3915 (52.7%) in 2013 (P < .001). Increased PET-CT use was associated with higher-complexity level VA facilities (26 127 veterans [82.3%] at level 1a vs 1289 [75.2%] at level 3 facilities; P < .001) and facilities with on-site PET-CT compared with facilities without on-site PET-CT (33 081 [82.2%] vs 17 443 [80.3%]; P < .001). Use of PET-CT before diagnosis was associated with increased likelihood of stage-appropriate treatment for all stages of NSCLC (eg, veterans with stage 1 disease: 4837 of 7870 veterans [61.5%] who received PET-CT underwent surgical resection vs 4042 of 7938 veterans [50.9%] who did not receive PET-CT; P < .001) and decreased mortality in a risk-adjusted model among all participants and among veterans undergoing stage-appropriate treatment (all-cause mortality: hazard ratio [HR], 0.78; 95% CI, 0.77-0.79; NSCLC-specific mortality: HR, 0.78; 95% CI, 0.76-0.80). Facilities with on-site PET-CT and higher-complexity level facilities were associated with a mortality benefit, with 16% decreased mortality at level 1a vs level 3 facilities (HR, 0.84; 95% CI, 0.80-0.89) and a 3% decrease in all-cause mortality in facilities with on-site PET-CT (HR, 0.97; 95% CI, 0.96-0.99).

Conclusions: In this study, the use of PET-CT among veterans with NSCLC significantly increased from 2000 to 2013, coinciding with decreased 5-year mortality and an increase in stage-appropriate treatment. Variation in use of PET-CT was found, with the highest use at higher-complexity level facilities and those with PET-CT on-site. These facilities were associated with reduced all-cause and NSCLC-specific mortality.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.15828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902817PMC
November 2019

Association of Cardiac Rehabilitation With Decreased Hospitalization and Mortality Risk After Cardiac Valve Surgery.

JAMA Cardiol 2019 12;4(12):1250-1259

Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.

Importance: National guidelines recommend cardiac rehabilitation (CR) after cardiac valve surgery, and CR is covered by Medicare for this indication. However, few data exist regarding current CR enrollment after valve surgery.

Objective: To characterize CR enrollment after cardiac valve surgery and its association with outcomes, including hospitalizations and mortality.

Design, Setting, And Participants: This cohort study of patients undergoing valve surgery was conducted in calendar year 2014, with follow-up through 2015. The study included all fee-for-service Medicare beneficiaries undergoing open cardiac valve surgery in 2014. Patients identified by inpatient diagnosis codes for open aortic, mitral, tricuspid, and pulmonary valve surgery were included. Data analysis occurred from January 2018 to March 2019.

Exposures: Logistic regression was used to evaluate sociodemographic and clinical factors associated with CR enrollment.

Main Outcomes And Measures: We used Andersen-Gill models to evaluate the association of CR enrollment with 1-year hospitalization risk and Cox regression models to evaluate the association of CR enrollment with 1-year mortality risk.

Results: A total of 41 369 Medicare beneficiaries (median [interquartile range] age, 73 [68-79] years; 16 935 [40.9%] female) underwent open valve surgery in the United States in 2014. Fewer than half of patients (17 855 [43.2%]) who had valve surgery enrolled in CR programs. Several racial/ethnic groups had lower odds of enrolling in CR programs after valve surgery compared with white patients, including Asian patients (odds ratio [OR], 0.36 [95% CI, 0.28-0.47]), black patients (OR, 0.60 [95% CI, 0.54-0.67]), and Hispanic patients (OR, 0.36 [95% CI, 0.28-0.46]). Patients undergoing concomitant coronary artery bypass grafting had higher odds of CR enrollment (OR, 1.26 [95% CI, 1.20-1.31]) than those without the concomitant coronary artery bypass graft procedure, as did patients in the Midwest census region (OR, 2.40 [95% CI, 2.28-2.54]) compared with those in the South (reference). Cardiac rehabilitation enrollment was associated with fewer hospitalizations within 1 year of discharge (hazard ratio, 0.66 [95% CI, 0.63-0.69] after multivariable adjustment). Enrollment was also associated with a 4.2% absolute decrease in 1-year mortality risk (hazard ratio, 0.39 [95% CI, 0.35-0.44] after multivariable adjustment).

Conclusions And Relevance: Fewer than half of Medicare beneficiaries undergoing cardiac valve surgery enroll in CR programs, and there are marked racial/ethnic disparities among those that do. Cardiac rehabilitation is associated with decreased 1-year cumulative hospitalization and mortality risk after valve surgery. These results invite further study on barriers to CR enrollment in this population.
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http://dx.doi.org/10.1001/jamacardio.2019.4032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6813589PMC
December 2019

The Accuracy of the Patient Health Questionnaire-9 Algorithm for Screening to Detect Major Depression: An Individual Participant Data Meta-Analysis.

Psychother Psychosom 2020 8;89(1):25-37. Epub 2019 Oct 8.

Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China.

Background: Screening for major depression with the Patient Health Questionnaire-9 (PHQ-9) can be done using a cutoff or the PHQ-9 diagnostic algorithm. Many primary studies publish results for only one approach, and previous meta-analyses of the algorithm approach included only a subset of primary studies that collected data and could have published results.

Objective: To use an individual participant data meta-analysis to evaluate the accuracy of two PHQ-9 diagnostic algorithms for detecting major depression and compare accuracy between the algorithms and the standard PHQ-9 cutoff score of ≥10.

Methods: Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, Web of Science (January 1, 2000, to February 7, 2015). Eligible studies that classified current major depression status using a validated diagnostic interview.

Results: Data were included for 54 of 72 identified eligible studies (n participants = 16,688, n cases = 2,091). Among studies that used a semi-structured interview, pooled sensitivity and specificity (95% confidence interval) were 0.57 (0.49, 0.64) and 0.95 (0.94, 0.97) for the original algorithm and 0.61 (0.54, 0.68) and 0.95 (0.93, 0.96) for a modified algorithm. Algorithm sensitivity was 0.22-0.24 lower compared to fully structured interviews and 0.06-0.07 lower compared to the Mini International Neuropsychiatric Interview. Specificity was similar across reference standards. For PHQ-9 cutoff of ≥10 compared to semi-structured interviews, sensitivity and specificity (95% confidence interval) were 0.88 (0.82-0.92) and 0.86 (0.82-0.88).

Conclusions: The cutoff score approach appears to be a better option than a PHQ-9 algorithm for detecting major depression.
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http://dx.doi.org/10.1159/000502294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960351PMC
November 2020

National Expansion of Sleep Telemedicine for Veterans: The TeleSleep Program.

J Clin Sleep Med 2019 09;15(9):1355-1364

Dallas VA Medical Center, Dallas, Texas.

Study Objectives: (1) Review the prevalence and comorbidity of sleep disorders among United States military personnel and veterans. (2) Describe the status of sleep care services at Veterans Health Administration (VHA) facilities. (3) Characterize the demand for sleep care among veterans and the availability of sleep care across the VHA. (4) Describe the VA TeleSleep Program that was developed to address this demand.

Methods: PubMed and Medline databases (National Center for Biotechnology Information, United States National Library of Medicine) were searched for terms related to sleep disorders and sleep care in United States military and veteran populations. Information related to the status of sleep care services at VHA facilities was provided by clinical staff members at each location. Additional data were obtained from the VA Corporate Data Warehouse.

Results: Among United States military personnel, medical encounters for insomnia increased 372% between 2005-2014; encounters for obstructive sleep apnea (OSA) increased 517% during the same period. The age-adjusted prevalence of sleep disorder diagnoses among veterans increased nearly 6-fold between 2000-2010; the prevalence of OSA more than doubled in this population from 2005-2014.

Conclusions: Most VA sleep programs are understaffed for their workload and have lengthy wait times for appointments. The VA Office of Rural Health determined that the dilemma of limited VHA sleep health care availability and accessibility might be solved, at least in part, by implementing a comprehensive telehealth program in VA medical facilities. The VA TeleSleep Program is an expansion of telemedicine services to address this need, especially for veterans in rural or remote regions.

Citation: Sarmiento KF, Folmer RL, Stepnowsky CJ, Whooley MA, Boudreau EA, Kuna ST, Atwood CW, Smith CJ, Yarbrough WC. National expansion of sleep telemedicine for veterans: the telesleep program. J Clin Sleep Med. 2019;15(9):1355-1364.
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http://dx.doi.org/10.5664/jcsm.7934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6760390PMC
September 2019

National Expansion of Sleep Telemedicine for Veterans: The TeleSleep Program.

J Clin Sleep Med 2019 09;15(9):1355-1364

Dallas VA Medical Center, Dallas, Texas.

Study Objectives: (1) Review the prevalence and comorbidity of sleep disorders among United States military personnel and veterans. (2) Describe the status of sleep care services at Veterans Health Administration (VHA) facilities. (3) Characterize the demand for sleep care among veterans and the availability of sleep care across the VHA. (4) Describe the VA TeleSleep Program that was developed to address this demand.

Methods: PubMed and Medline databases (National Center for Biotechnology Information, United States National Library of Medicine) were searched for terms related to sleep disorders and sleep care in United States military and veteran populations. Information related to the status of sleep care services at VHA facilities was provided by clinical staff members at each location. Additional data were obtained from the VA Corporate Data Warehouse.

Results: Among United States military personnel, medical encounters for insomnia increased 372% between 2005-2014; encounters for obstructive sleep apnea (OSA) increased 517% during the same period. The age-adjusted prevalence of sleep disorder diagnoses among veterans increased nearly 6-fold between 2000-2010; the prevalence of OSA more than doubled in this population from 2005-2014.

Conclusions: Most VA sleep programs are understaffed for their workload and have lengthy wait times for appointments. The VA Office of Rural Health determined that the dilemma of limited VHA sleep health care availability and accessibility might be solved, at least in part, by implementing a comprehensive telehealth program in VA medical facilities. The VA TeleSleep Program is an expansion of telemedicine services to address this need, especially for veterans in rural or remote regions.

Citation: Sarmiento KF, Folmer RL, Stepnowsky CJ, Whooley MA, Boudreau EA, Kuna ST, Atwood CW, Smith CJ, Yarbrough WC. National expansion of sleep telemedicine for veterans: the telesleep program. J Clin Sleep Med. 2019;15(9):1355-1364.
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http://dx.doi.org/10.5664/jcsm.7934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6760390PMC
September 2019
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