Search

Purpose: The primary aim of this study was to examine the factors associated with long-term outcomes of postconcussive disruptive dizziness in Veterans of the post-9/11 wars. Method: For this observational cohort study, the Neurobehavioral Symptom Inventory--Vestibular subscale (NSI-V) score was used as an outcome measure for dizziness in 987 post-9/11 Veterans who indicated disruptive dizziness at an initial Veterans Health Administration Comprehensive Traumatic Brain Injury Evaluation (CTBIE). An NSI-V change score was calculated as the difference in the scores obtained at the initial CTBIE and on a subsequent survey. Differences in the NSI-V change scores were examined for demographics, injury characteristics, comorbidities, and vestibular and balance function variables, and multiple linear regression analyses were used to explore associations among the variables and the NSI-V change score. Results: The majority of Veterans (61%) demonstrated a decrease in the NSI-V score, suggesting less dizziness on the survey compared with the CTBIE; 16% showed no change; and 22% had a higher score. Significant differences in the NSI-V change score were observed for traumatic brain injury (TBI) status, diagnoses of post-traumatic stress disorder (PTSD), headache and insomnia, and vestibular function. Multivariate regressions revealed significant associations between the NSI-V change score and the initial CTBIE NSI-V score, education level, race/ ethnicity, TBI status, diagnoses of PTSD or hearing loss, and vestibular function. Conclusions: Postconcussive dizziness can continue for years following an injury. Factors associated with poor prognosis include TBI, diagnoses of PTSD or hearing loss, abnormal vestibular function, increased age, identification as a Black Veteran, and high school education level. [ABSTRACT FROM AUTHOR]

Purpose: To describe the prevalence of communication disorders in a cohort of 84,377 deployed post-9/11 veterans stratified by blast traumatic brain injury (TBI) exposure. Secondary aim was to evaluate the association between postconcussion symptoms, such as posttraumatic stress disorder, depression, anxiety, insomnia, pain, headache, substance use disorder, and auditory problems, among veterans with and without a communication disorder diagnosis. Method: This is a retrospective study of the prevalence of aphasia, apraxia of speech and dysarthria, cognitivecommunication disorder, fluency, and voice disorders among veterans, stratified by TBI severity and blast status. Data were obtained from the national Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn roster file provided by the Department of Veterans Affairs Office of Public Health and the Veterans Affairs' TBI screening and subsequent comprehensive TBI evaluation. Results: Cognitive-communication disorder was the most prevalent diagnosis, comprising 57.1% of all communication disorder diagnoses, followed by voice disorder (19%) and aphasia (16%). Increased age was significantly associated with higher rates of aphasia, apraxia of speech/dysarthria, and voice disorder. Conclusions: The current study shows that, while the overall total number of communication disorder diagnoses was higher in the blast groups than in the nonblast groups, TBI severity was a more significant risk factor for a diagnosis, with veterans in the more severe groups at a higher risk of being diagnosed with a communication disorder when compared to those with mild TBI and no blast exposure. In order to better inform rehabilitation and clinical management of communication conditions, it is critical to examine the influence of blast and postconcussive symptoms in post-9/ 11 veterans. [ABSTRACT FROM AUTHOR]

Objectives: To examine long-term outcomes of self-reported physical and mental health among Post-9/11 Veterans stratified by traumatic brain injury (TBI) severity, we hypothesized that more severe TBI would be associated with significantly poorer outcomes. Methods: A prospective longitudinal survey of physical and mental health status was conducted with a national cohort of Post-9/11 Veterans. We then used generalized linear models (GLM) to assess the unique contribution of TBI severity on long-term outcomes after controlling for socio-demographic characteristics, comorbidity phenotypes, and deployment experiences. Results: TBI of any severity was associated with significantly poorer outcomes relative to the No TBI group. However, the manifestation of these outcomes identified in our study differed meaningfully by TBI severity level. Conclusions: Veterans with any TBI exposure experience poorer long-term outcomes than those with no TBI even when covariates are considered. In particular, measures of somatization, PTSD symptom distress, and depression indicate pervasive and long-term health concerns among individuals with TBI. Additional research is required to fully explicate what appear to be complex relationships among TBI severity, physical and mental well-being, combat exposures, and socioeconomic resources in this population. [ABSTRACT FROM AUTHOR]

The age-adjusted prevalence of seizure disorder in United States veterans deployed in Iraq and Afghanistan conflicts (IAV) is 6.1 per 1,000 persons (1), compared with 7.1 to 10 per 1,000 persons in the general population (2,3). Persons with epilepsy are at risk of excess mortality in part because of comorbidity (4). Although patterns of comorbidity have been associated with mortality in IAV (5), the unique contribution of epilepsy to excess mortality in IAV is unknown. A cohort study was developed using inpatient, outpatient, and pharmacy data from the U.S. Department of Veterans Affairs, Veterans Health Administration (VA) to identify epilepsy, demographic characteristics, and baseline comorbidity for IAV who received VA care in 2010 and 2011. The VA's vital status records were used to identify 5-year mortality (2011-2015). The unadjusted Kaplan-Meier estimator and adjusted proportional hazards regression models tested the hypothesis that excess mortality is associated with epilepsy. IAV with epilepsy were more likely than those without epilepsy to have mental and physical comorbidity, and significantly higher mortality, even after controlling for demographic characteristics and other comorbid conditions (adjusted hazard ratio = 2.6; 95% confidence interval [CI] 2.1-3.2). IAV with epilepsy could benefit from evidence-based chronic disease self-management programs to reduce physical and psychiatric comorbidity, and linkages to VA clinical and other community health and social service providers. [ABSTRACT FROM AUTHOR]

Objectives To describe the prevalence and persistence of headache and associated conditions in an inception cohort of U.S. veterans of Iraq and Afghanistan wars. Background Iraq and Afghanistan war veterans (IAV) suffer from persistent and difficult-to-treat headaches that have been found to co-occur with traumatic brain injury (TBI) and other deployment related comorbidities. Methods This longitudinal retrospective cohort study used data from the national Veterans Health Administration (VA) data repository for IAV who first received VA care in 2008 (baseline) and also received care each year in 2009, 2010, and 2011. We used ICD-9-CM codes, to identify those treated for headache each year (2008-2011). Individuals with headache diagnosed each year were classified as having persistent headache. We also identified comorbidities that may be associated with baseline headache using algorithms validated for use with ICD-9-CM codes. Comorbidities included TBI, posttraumatic stress disorder (PTSD), depression, and conditions associated with these diagnoses (anxiety, memory/attention/cognition, neck pain, tinnitus/hyperacusis, photosensitivity/photo blurring, insomnia, malaise/fatigue, and vertigo/dizziness). Multivariable logistic regression analysis was used to determine characteristics associated with baseline headache as well as those associated with persistent headache. Results Among all IAV, 38,426 received their first year of VA care in 2008 and had care each year 2009-2011: 13.7% of these were diagnosed with headache in 2008. Veterans diagnosed with headache in 2008 were more likely than those without a headache diagnosis to also have a diagnosis of TBI alone (adjusted odds ratios [AOR] 6.75; 95% CI 5.79-7.86), TBI + depression (AOR 7.09; 95% CI 5.23-9.66), TBI + PTSD (AOR 10.16; 95% CI 8.96-11.53), TBI + PTSD + depression (AOR 9.40; 95% CI 8.12-10.09), and neck pain (AOR 2.44; 95% CI 2.14-2.77). Among those with headache diagnosis in 2008, 24.3% had a headache diagnosis each of the subsequent years of care (persistent headache). While diagnoses of TBI, PTSD, and/or depression at baseline were not associated with headache persistence, persistence was more likely for individuals with baseline tinnitus/hyperacusis (AOR 1.21; 95% CI 1.02-1.45), insomnia (AOR 1.19; 95% CI 1.02-1.39), and vertigo/dizziness (AOR 1.83; 95% CI 1.30-2.57). Conclusions Our results indicate that TBI alone is a strong predictor of headache in the first year of VA care among IAV and that comorbid psychiatric comorbidities increase the likelihood of headache among individuals with TBI. However, among those with baseline headache, only tinnitus, insomnia, and vertigo were baseline clinical predictors of headache persistence. These results suggest that attention to other symptoms and conditions early in the diagnosis and treatment of headaches may be important for understanding prognosis. These comorbidities offer potential targets for intervention strategies that may help address postdeployment headaches. [ABSTRACT FROM AUTHOR]

Objectives. We examined the association of posttraumatic stress disorder (PTSD), traumatic brain injury, and chronic pain—the polytrauma clinical triad (PCT)—independently and with other conditions, with suicide-related behavior (SRB) risk among Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF) veterans. Methods. We used Department of Veterans Affairs (VA) administrative data to identify OEF and OIF veterans receiving VA care in fiscal years 2009–2011; we used International Classification of Diseases, Ninth Revision, Clinical Modification codes to characterize 211 652 cohort members. Descriptive statistics were followed by multinomial logistic regression analyses predicting SRB. Results. Co-occurrence of PCT conditions was associated with significant increase in suicide ideation risk (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.5, 2.4) or attempt and ideation (OR = 2.6; 95% CI = 1.5, 4.6), but did not exceed increased risk with PTSD alone (ideation: OR = 2.3; 95% CI = 2.0, 2.6; attempt: OR = 2.0; 95% CI = 1.4, 2.9; ideation and attempt: OR = 1.8; 95% CI = 1.2, 2.8). Ideation risk was significantly elevated when PTSD was comorbid with depression (OR = 4.2; 95% CI = 3.6, 4.8) or substance abuse (OR = 4.7; 95% CI = 3.9, 5.6). Conclusions. Although PCT was a moderate SRB predictor, interactions among PCT conditions, particularly PTSD, and depression or substance abuse had larger risk increases. ( [ABSTRACT FROM AUTHOR]

Objectives To determine the effect of two variables not previously studied in the readmissions literature (frailty-related diagnoses and high-risk medications in the elderly ( HRME)) and one understudied variable (volume of primary care visits in the prior year). Design Retrospective cohort study using data from a study designed to examine outcomes associated with inappropriate prescribing in elderly adults. Setting All Veterans Affairs ( VA) facilities with acute inpatient beds in fiscal year 2006 ( FY06). Participants All veterans aged 65 and older by October 1, 2005, who received VA care at least once per year between October 1, 2004, and September 30, 2006, and were hospitalized at least once during FY06 on a medical or surgical unit. Measurements A generalized linear interactive risk prediction model included demographic and clinical characteristics (mental health and chronic medical conditions, frailty-related diagnoses, number of medications) in FY05; incident HRME in FY06 before index hospitalization or readmission; chronic HRME in FY05; and FY05 emergency department ( ED), hospital, geriatric, palliative, or primary care use. Facility-level variables were complexity, rural versus urban, and FY06 admission rate. Results The mean adjusted readmission rate was 18.3%. The new frailty-related diagnoses variable is a risk factor for readmission in addition to Charlson comorbidity score. Incident HRME use was associated with lower rates of readmission, as were higher numbers of primary care visits in the prior year. Conclusion Frailty-related diagnoses may help to target individuals at higher risk of readmission to receive more-intensive care transition services. HRME use does not help in this targeting. A higher number of face-to-face primary care visits in the prior year, unlike ED and hospital use, correlates with fewer readmissions and may be another avenue for targeting prevention strategies. [ABSTRACT FROM AUTHOR]

Objectives To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions ( ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics. Design Retrospective cohort. Setting Veterans Affairs Medical Centers. Participants Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006. Measurements Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications). Results Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio ( AOR) = 3.90, 95% confidence interval ( CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively). Conclusion ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the change in use of high-risk medications for the elderly (HRME), as defined by the National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) quality measure (HEDIS HRME), by older outpatient veterans over a 3-year period and to identify risk factors for HEDIS HRME exposure overall and for the most commonly used drug classes. DESIGN: Longitudinal retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Veterans aged 65 by October 1, 2003, and who received VA care at least once each year until September 30, 2006. MEASUREMENTS: Rates of use of HEDIS HRME overall and according to specific drug classes each year from fiscal year 2004 (FY04) to FY06. RESULTS: In a cohort of 1,567,467, high-risk medication exposure fell from 13.1% to 12.3% between FY04 and FY06 ( P<.001). High-risk antihistamines (e.g., diphenhydramine), opioid analgesics (e.g., propoxyphene), skeletal muscle relaxants (e.g., cyclobenzaprine), psychotropics (e.g., long half-life benzodiazepines), endocrine (e.g., estrogen), and cardiac medications (e.g., short-acting nifedipine) had modest but statistically significant ( P<.001) reductions (range −3.8% to −16.0%); nitrofurantoin demonstrated a statistically significant increase (+36.5%; P<.001). Overall HEDIS HRME exposure was more likely for men, Hispanics, those receiving more medications, those with psychiatric comorbidity, and those without prior geriatric care. Exposure was lower for individuals exempt from copayment. Similar associations were seen between ethnicity, polypharmacy, psychiatric comorbidity, access-to-care factors, and use of individual HEDIS HRME classes. CONCLUSION: HEDIS HRME drug exposure decreased slightly in an integrated healthcare system. Risk factors for exposure were not consistent across drug groups. Future studies should examine whether interventions to further reduce HEDIS HRME use improve health outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure. DESIGN: Cross-sectional retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006. MEASUREMENTS: Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status. RESULTS: Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS. CONCLUSION: The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults. [ABSTRACT FROM AUTHOR]