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Objectives: Veterans Health Administration encourages auricular acupuncture (Battlefield Acupuncture/BFA) as a nonpharmacologic approach to pain management. Qualitative reports highlighted a “gateway hypothesis”: providing BFA can lead to additional nonpharmacologic treatments. This analysis examines subsequent use of traditional acupuncture. Research Design: Cohort study of Veterans treated with BFA and a propensity score matched comparison group with a 3-month follow-up period to identify subsequent use of traditional acupuncture. Matching variables included pain, comorbidity, and demographics, with further adjustment in multivariate regression analysis. Subjects: We identified 41,234 patients who used BFA across 130 Veterans Health Administration medical facilities between October 1, 2016 and March 31, 2019. These patients were matched 2:1 on Veterans who used VA care but not BFA during the same period resulting in a population of 24,037 BFA users and a comparison cohort of 40,358 non-BFA users. Patients with prior use of traditional acupuncture were excluded. Results: Among Veterans receiving BFA, 9.5% subsequently used traditional acupuncture compared with 0.9% of non-BFA users (P

Background Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that (1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment and (2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer. Methods We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: (1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers’ and to published guidelines, (2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and (3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically distributed study sites. Discussion This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed. Trial registration CliniclTrials.gov NCT03445559. Prospectively registered on February 26, 2018

RESEARCH OBJECTIVE: VHA is piloting the Whole Health System of Care (WHS) at 18 sites to shift care from a disease‐focused “find‐it, fix‐it” model to one driven by patients’ personal health goals, to foster patient self‐management, and to improve well‐being. As part of the Comprehensive Addiction and Recovery Act, VHA initiated a demonstration program in 18 VA Medical Centers to implement WHS. We report on its impact on Veterans. STUDY DESIGN: A longitudinal survey of Veterans with chronic pain at the 18 flagship medical centers. Veterans were surveyed at baseline and 6 months using 12 patient‐reported outcome measures. Outcomes were compared between Veterans who did not use WHS services and Veterans with different levels of WHS service use, using standardized mean differences/Cohen’s D. We conducted a longitudinal cohort analysis of Veterans who started using WHS after April 2018. This analysis compared opioid dose levels using administrative pharmacy data (quarterly morphine equivalents) for the 6‐month period before using WHS to opioid levels one year later. This analysis included Veterans from the same time periods who did not use WHS services. POPULATION STUDIED: Survey: a random sample of Veterans with chronic musculoskeletal pain at 18 VA medical centers; we report on 3622 patients who completed baseline and 6‐month surveys (response rate: 49.3% baseline; 74.2% follow‐up). Administrative cohort analysis: 112 202 Veterans with chronic pain who received continuous VA care between October 2017 and March 2019 and used >2 WHS (without WHS services prior to April 2018) or no WHS throughout the evaluation period. PRINCIPAL FINDINGS: 46% of survey respondents and 5.9% of the administrative cohort used >2 WHS services. Effect sizes for survey measures were small overall; however, those who used WHS services reported greater improvements in perceptions of care, engagement in health care and self‐care, life meaning and purpose, pain, and perceived stress. Opioid use among Veterans using WHS decreased 23% compared with 11% decrease among those with no WHS use. CONCLUSIONS: WHS use, especially high levels of WHS use, was positively associated with improvements in several patient‐reported health and well‐being outcomes. While effect sizes were small for survey measures over this 6‐month period, they are promising for the future impact of VHA’s WHS initiative. Administrative data identified meaningful reductions in opioid use among WHS users. IMPLICATIONS FOR POLICY OR PRACTICE: The use of WHS services among Veterans with chronic pain has important implications for pain management, and Veteran health and well‐being. Implementing a system of care that is designed to provide these services to patients presents an opportunity to radically change the way health care is delivered and impact patients’ lives and not just fix their diseases. PRIMARY FUNDING SOURCE: Department of Veterans Affairs.

Rationale: Symptoms of insomnia and anxiety are common among patients with chronic obstructive pulmonary disease (COPD), especially among patients with comorbid mental health disorders such as post-traumatic stress disorder (PTSD). Benzodiazepines provide temporary relief of these symptoms, but guidelines discourage routine use of benzodiazepines because of the serious risks posed by these medications. A more thorough understanding of guideline-discordant benzodiazepine use will be critical to reduce potentially inappropriate prescribing and its associated risks. Objectives: Examine the national prevalence, variability, and center correlates of long-term benzodiazepine prescriptions for patients with COPD and comorbid PTSD. Methods: We identified patients with COPD and PTSD between 2010 and 2012 who received care within the Department of Veterans Affairs. We used a mixed-effects logistic regression model to assess center predictors of long-term benzodiazepine prescriptions (≥90 d), while accounting for patient characteristics. Results: Of 43,979 patients diagnosed with COPD and PTSD at 129 centers, 24.4% were prescribed benzodiazepines long term, with use varying from 9.5% to 49.4% by medical center. Patients with long-term prescriptions were more likely to be white (90.1% vs. 80.7%) and have other mental health comorbidities, including generalized anxiety disorder (31.3% vs. 16.5%). Accounting for patient mix and characteristics, long-term benzodiazepine use was associated with lower patient-reported access to mental health care (odds ratio, 0.54; 95% confidence interval, 0.37–0.80). Conclusions: Long-term benzodiazepine prescribing is common among patients at high risk for complications, although this practice varies substantially from center to center. Poor access to mental health care is a potential driver of this guideline inconsistent use.

Purpose Testosterone treatment of men with low testosterone is common and, although relatively short-term, has raised concern regarding an increased risk of prostate cancer (CaP). We investigated the association between modest-duration testosterone treatment and incident aggressive CaP. Materials and methods Retrospective inception cohort study of male Veterans aged 40 to 89 years with a laboratory-defined low testosterone measurement from 2002 to 2011 and recent prostate specific antigen (PSA) testing; excluding those with recent testosterone treatment, prostate or breast cancer, high PSA or prior prostate biopsy. Histologically-confirmed incident aggressive prostate cancer or any prostate cancer were the primary and secondary outcomes, respectively. Results Of the 147,593 men included, 58,617 were treated with testosterone. 313 aggressive CaPs were diagnosed, 190 among untreated men (incidence rate (IR) 0.57 per 1000 person years, 95% CI 0.49–0.65) and 123 among treated men (IR 0.58 per 1000 person years; 95% CI 0.48–0.69). After adjusting for age, race, hospitalization during year prior to cohort entry, geography, BMI, medical comorbidities, repeated testosterone and PSA testing, testosterone treatment was not associated with incident aggressive CaP (HR 0.89; 95% CI 0.70–1.13) or any CaP (HR 0.90; 95% CI 0.81–1.01). No association between cumulative testosterone dose or formulation and CaP was observed. Conclusions Among men with low testosterone levels and normal PSA, testosterone treatment was not associated with an increased risk of aggressive or any CaP. The clinical risks and benefits of testosterone treatment can only be fully addressed by large, longer-term randomized controlled trials.

Introduction: The frequency of neutropenia associated with lung cancer chemotherapy outside of randomized trials is largely unknown because administrative coding underestimates its prevalence. This study compared International Classification of Diseases (ICD) diagnosis codes and electronic laboratory results, alone and in combination, for identifying neutropenia events.Methods: Retrospective cohort study of 718 veterans receiving their first course of chemotherapy for non-small cell lung cancer. Incidence of neutropenia was assessed using electronic laboratory results and ICD-9 codes captured in the Department of Veterans Affairs (VA) electronic medical records (EMR).Results: A total of 118 of 718 patients (16.4 percent) were identified with an absolute neutrophil count (ANC) less than 1,000 cells/mm3, while only 49 of 718 patients (6.8 percent) had ICD-9 codes for neutropenia. Using the combination of laboratory results and diagnosis codes, 136 of 718 patients (18.9 percent) experienced a neutropenic event. Compared to laboratory results as a gold standard, diagnosis codes were specific (not present for individuals without a laboratory-documented low ANC), but not sensitive (missing for many individuals with a low ANC documented in their laboratory test results).Conclusion: Relying on ICD codes to identify neutropenia in administrative data likely results in under-reporting. The emerging availability of electronic laboratory results provides an opportunity to more accurately quantify patterns of neutropenia, identify individual risk factors, and assess clinical management practices—including use of colony-stimulating factor prophylaxis—in large community cohorts.

OBJECTIVE: To identify factors associated with antiretroviral therapy (ART) attrition among patients initiating therapy in 2005-2011 at two large, public-sector department-level hospitals, and to inform interventions to improve ART retention. METHODS: This retrospective cohort study used data from the iSanté electronic medical record (EMR) system. The study characterized ART attrition levels and explored the patient demographic, clinical, temporal, and service utilization factors associated with ART attrition, using time-to-event analysis methods. RESULTS: Among the 2 023 patients in the study, ART attrition on average was 17.0 per 100 person-years (95% confidence interval (CI): 15.8-18.3). In adjusted analyses, risk of ART attrition was up to 89% higher for patients living in distant communes compared to patients living in the same commune as the hospital (hazard ratio: 1.89, 95%CI: 1.54-2.33; P < 0.001). Hospital site, earlier year of ART start, spending less time enrolled in HIV care prior to ART initiation, receiving a non-standard ART regimen, lacking counseling prior to ART initiation, and having a higher body mass index were also associated with attrition risk. CONCLUSIONS: The findings suggest quality improvement interventions at the two hospitals, including: enhanced retention support and transportation subsidies for patients accessing care from remote areas; counseling for all patients prior to ART initiation; timely outreach to patients who miss ART pick-ups; "bridging services" for patients transferring care to alternative facilities; routine screening for anticipated interruptions in future ART pick-ups; and medical case review for patients placed on non-standard ART regimens. The findings are also relevant for policymaking on decentralization of ART services in Haiti.

Adherence to adjuvant endocrine therapy (AET) for estrogen receptor-positive breast cancer remains suboptimal, which suggests that women are not getting the full benefit of the treatment to reduce breast cancer recurrence and mortality. The majority of studies on adherence to AET focus on identifying factors among those women at the highest levels of adherence and provide little insight on factors that influence medication use across the distribution of adherence.To understand how factors influence adherence among women across low and high levels of adherence.A retrospective evaluation was conducted using the Truven Health MarketScan Commercial Claims and Encounters Database from 2007-2011. Privately insured women aged 18-64 years who were recently diagnosed and treated for breast cancer and who initiated AET within 12 months of primary treatment were assessed. Adherence was measured as the proportion of days covered (PDC) over a 12-month period. Simultaneous multivariable quantile regression was used to assess the association between treatment and demographic factors, use of mail order pharmacies, medication switching, and out-of-pocket costs and adherence. The effect of each variable was examined at the 40th, 60th, 80th, and 95th quantiles.Among the 6,863 women in the cohort, mail order pharmacies had the greatest influence on adherence at the 40th quantile, associated with a 29.6% (95% CI = 22.2-37.0) higher PDC compared with retail pharmacies. Out-of-pocket cost for a 30-day supply of AET greater than $20 was associated with an 8.6% (95% CI = 2.8-14.4) lower PDC versus $0-$9.99. The main factors that influenced adherence at the 95th quantile were mail order pharmacies, associated with a 4.4% higher PDC (95% CI = 3.8-5.0) versus retail pharmacies, and switching AET medication 2 or more times, associated with a 5.6% lower PDC versus not switching (95% CI = 2.3-9.0).Factors associated with adherence differed across quantiles. Addressing the use of mail order pharmacies and out-of-pocket costs for AET may have the greatest influence on improving adherence among those women with low adherence.This research was supported by a Ruth L. Kirschstein National Research Service Award for Individual Predoctoral Fellowship grant from the National Cancer Institute (grant number F31 CA174338), which was awarded to Farias. Additionally, Farias was funded by a Postdoctoral Fellowship at the University of Texas School of Public Health Cancer Education and Career Development Program through the National Cancer Institute (NIH Grant R25 CA57712). The other authors declare no conflicts of interest.The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health. Farias was primarily responsible for the study concept and design, along with Hansen and Zeliadt and with assistance from the other authors. Farias, Hansen, and Zeliadt took the lead in data interpretation, assisted by the other authors. The manuscript was written by Farias, along with Thompson and assisted by the other authors, and was revised by Ornelas, Li, and Farias, with assistance from the other authors.

Objective.It is unknown whether advanced imaging (AI) is associated with higher quality breast cancer (BC) care.Materials and Methods.Claims and Surveillance Epidemiology and End Results data were linked for women diagnosed with incident stage I-III BC between 2002 and 2008 in western Washington State. We examined receipt of preoperative breast magnetic resonance imaging (MRI) or AI (defined as computed tomography [CT]/positron emission tomography [PET]/PET/CT) versus mammogram and/or ultrasound (M-US) alone and receipt of guideline concordant care (GCC) using multivariable logistic regression.Results.Of 5247 women, 67% received M-US, 23% MRI, 8% CT, and 3% PET/PET-CT. In 2002, 5% received MRI and 5% AI compared to 45% and 12%, respectively, in 2008. 79% received GCC, but GCC declined over time and was associated with younger age, urban residence, less comorbidity, shorter time from diagnosis to surgery, and earlier year of diagnosis. Breast MRI was associated with GCC for lumpectomy plus radiation therapy (RT) (OR 1.55, 95% CI 1.08–2.26, andp=0.02) and AI was associated with GCC for adjuvant chemotherapy for estrogen-receptor positive (ER+) BC (OR 1.74, 95% CI 1.17–2.59, andp=0.01).Conclusion.GCC was associated with prior receipt of breast MRI and AI for lumpectomy plus RT and adjuvant chemotherapy for ER+ BC, respectively.

Background : On January 12, 2010, a devastating 7.0 magnitude earthquake struck the West Department of Haiti, killing more than 200,000 people and injuring or displacing many more. This disaster threatened continuity of HIV care and treatment services. Objectives : This case study examined the effect of the devastating 2010 earthquake in Haiti on attrition from the HIV antiretroviral therapy (ART) program. Design : The study triangulated retrospective data from existing sources, including: 1) individual-level longitudinal patient data from an electronic medical record for ART patients at two large public sector departmental hospitals differently affected by the earthquake; and 2) aggregate data on the volume of HIV-related services delivered at the two hospitals before and after the earthquake. Methods : The study compared ART attrition and service delivery in Jacmel, a site in the ‘very strong’ zone of earthquake impact, and in Jeremie, a site in the ‘light’ zone of earthquake impact. The analysis used time-to-event analysis methods for the individual-level patient data, and descriptive statistical methods for the aggregate service delivery data. Results : Adjusted ART attrition risk was lower at the hospital in Jacmel after vs. before the earthquake (HR=0.51; p =0.03), and was lower in Jacmel vs. Jeremie both before (HR=0.55; p =0.01) and after the earthquake (HR=0.35; p =0.001). The number of new ART patient enrollments, new HIV patient registrations, and HIV clinical visits dropped notably in Jacmel immediately after the earthquake, but then rapidly rebounded. On average, there was no change in new ART enrollments per month after vs. before the earthquake at either site. Conclusion : These findings underscore the resilience of Haitian ART providers and patients, and contribute evidence that it is possible to maintain continuity of ART services even in the context of a complex humanitarian crisis. Keywords : HIV/AIDS; antiretroviral therapy; attrition; Haiti; earthquake (Published: 5 August 2014) Citation : Glob Health Action 2014, 7 : 24572 - http://dx.doi.org/10.3402/gha.v7.24572

Introduction In this prospective study of localized prostate cancer patients and their partners, we analyzed how partner issues evolve over time, focusing on satisfaction with care, influence of cancer treatment, and its impact on relationship with patient, cancer worry, and personal activities. Aims Our study aims were twofold: (i) to determine whether the impact of treatment on patients and partners moderate over time and (ii) if receiving surgery (i.e., radical prostatectomy) influences partner issues more than other treatments. Methods Patients newly diagnosed with localized prostate cancer and their female partners were recruited from three states to complete surveys by mail at three time points over 12 months. Main Outcome Measures The four primary outcomes assessed in the partner analysis included satisfaction with treatment, cancer worry, and the influence of cancer and its treatment on their relationship (both general relationship and sexual relationship). Results This analysis included 88 patient–partner pairs. At 6 months, partners reported that cancer had a negative impact on their sexual relationship (39%—somewhat negative and 12%—very negative). At 12 months, this proportion increased substantially (42%—somewhat negative and 29%—very negative). Partners were significantly more likely to report that their sexual relationship was worse when the patient reported having surgery ( P = 0.0045, odds ratio = 9.8025, 95% confidence interval 2.076–46.296). A minority of partners reported significant negative impacts in other areas involving their personal activities (16% at 6 months and 25% at 12 months) or work life (6% at 6 months, which increased to 12% at 12 months). Conclusion From partners' perspectives, prostate cancer therapy has negative impact on sexual relationships and appears to worsen over time. Ramsey SD, Zeliadt SB, Blough DK, Moinpour CM, Hall IJ, Smith JL, Ekwueme DU, Fedorenko CR, Fairweather ME, Koepl LM, Thompson IM, Keane TE, and Penson DF. Impact of prostate cancer on sexual relationships: A longitudinal perspective on intimate partners' experiences. J Sex Med 2013;10:3135–3143.

Background/Aims A prostate specific antigen (PSA) level =4 ng/mL has historically been used as a screening threshold to recommend biopsy; however, guidelines have been changing to recommend lower cutoffs (2.5 ng/mL) and incorporate velocity in decisions to refer men to biopsy. Little is known about how physicians and patients respond to elevated PSA tests. Our objective was to examine trends in biopsy practices over the past decade to identify whether there has been a shift towards lowering PSA thresholds for biopsy referral.

Introduction Lung cancer mortality rates may vary with access to specialty providers and local resources. We sought to examine the effect of access to care, using density of lung cancer care providers, on lung cancer mortality among blacks and whites in the United States. Methods We examined U.S. county-level data for age-adjusted lung cancer mortality rates from 2003 to 2007. Our primary independent variable was per capita number of thoracic oncologic providers, adjusting for county-level smoking rates, socioeconomic status, and other geographic factors. Data were obtained from 2009 Area Resource File, National Center for Health Statistics, and the County Health Rankings Project. Results Providers of lung cancer care were unevenly distributed among the U.S. counties. For example, 41.4% of the U.S. population reside in counties with less than four thoracic surgeons per 100,000 people, 23.4% in counties with 4 to 15 surgeons per 100,000 people, and 35.3% in counties with more than 15 surgeons per 100,000 people. Geographically, 4.3% of whites compared with 11.2% of blacks lived in high lung cancer mortality zones. Lung cancer mortality did not vary by density of thoracic surgeons or oncology services; however, higher primary care provider density was associated with lung cancer mortality reduction of 4.1 per 100,000 for whites. Conclusion Variation in provider density for thoracic oncology in the United States was not associated with a difference in lung cancer mortality. Lower mortality associated with higher primary care provider density suggests that equitable access to primary care may lead to reduced cancer disparities.

ObjectivesTo explore an alternative approach to quantifying the burden of side effects at 1 year after treatment for prostate cancer among both patients and their partners.MethodsWe analyzed data from 75 couples in the Family and Cancer Therapy Selection study. Paired patients and family members were independently asked about their willingness to pay (WTP) for a hypothetical new treatment that cures prostate cancer without side effects if they could reconsider their treatment decision by indicating the maximum amount they would be willing to pay given 11 separate “bids” ranging from $0 to $1500 per month. Descriptive and regression analyses were conducted for patients and family members controlling for sociodemographic characteristics and health status; Spearman correlations were also examined.ResultsAmong 75 couples analyzed, the income-adjusted mean WTP estimates per month were $400.8 (standard error [SE] $54.3) for patients and $650.2 (SE 72.2) for family members. The WTP between patients and family members was correlated (Pearson ρ 0.30; P = 0.01). After adjusting for covariates, the adjusted mean WTP per month was $588.1 (SE 65.77) for patients and $819.4 (SE 74.33) for family members. Wanting to avoid side effects at baseline predicted higher WTP for patients (P = 0.010). Experiencing sexual side effects was predictive of higher WTP for family members (P = 0.047).ConclusionsFairly high WTP amounts for a hypothetical treatment without side effects suggests that patients and their partners are experiencing important burdens 1 year after treatment. The higher amounts partners are willing to pay and the correlation with sexual side effects suggest that they are perceptive of significant treatment burdens.

Background Approximately half of veterans with low-risk prostate cancer receive guideline-discordant imaging. Our objective was to identify and describe (1) physician knowledge, attitudes, and practices related to the use of imaging to stage prostate cancer, (2) patient attitudes and behaviors related to use of imaging, and (3) to compare responses across three VA medical centers (VAMCs). Methods A qualitative approach was used to explore patient and provider knowledge and behaviors relating to the use of imaging. We conducted 39 semi-structured interviews total—including 22 interviews with patients with newly diagnosed with prostate cancer and 17 interviews with physicians caring for them—between September 2014 and July 2015 at three VAMCs representing a spectrum of inappropriate imaging rates. After core theoretical concepts were identified, the Theoretical Domains Framework (TDF) was selected to explore linkages between themes within the dataset and existing domains within the framework. Interviews were audio-recorded, transcribed verbatim, and then coded and analyzed using Nvivo software. Results Themes from patient interviews were categorized within four TDF domains. Patients reported little interest in staging as compared to disease treatment (goals), and many could not remember if they had imaging at all (knowledge). Patients tended to trust their doctor to make decisions about appropriate tests (beliefs about capabilities). Some patients expressed a minor concern for radiation exposure, but anxiety about cancer outcomes outweighed these fears (emotion). Themes from physician interviews were categorized within five TDF domains. Most physicians self-reported that they know and trust imaging guidelines (knowledge) yet some were still likely to follow their own intuition, whether due to clinical suspicion or years of experience (beliefs about capabilities). Additionally, physicians reported that medico-legal concerns, fear of missing associated diagnoses (beliefs about consequences), influence from colleagues who image frequently (social influences), and the facility where they practice influences rates of imaging (environmental context). Conclusions Interviews with patients and physicians suggest that physicians are the primary (and in some cases only) decision-makers regarding staging imaging for prostate cancer. This finding suggests a physician-targeted intervention may be the most effective strategy to improve guideline-concordant prostate cancer imaging.