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Introduction Vibration therapy has been widely used and published in alleviating muscle fatigue. However, reports on applying vibration therapy based on the holisitic theory of traditional Chinese medicine (TCM) remains limited. This study is to evaluate the immediate effect of vibration therapy on exercise-induced muscle fatigue. Methods For this retrospective parallel controlled study, all data were from a previously approved and completed clinical trial. Participants (n=40) in the clinical trial included local Greco-Roman wrestling and Judo athletes in south China. The participants were equally randomly divided into the intervention group (n=20) and control group (n=20). The intervention group received a seven-week vibration intervention-based TCM holistic theory combined with conventional therapy, such as stretching, massage, and flapping, while the control group only received the conventional therapy. Surface electromyography (sEMG) of the lumbar segment of erector spinae was measured for each participant pre- and postintervention, and the two-point discrimination thresholds of the data were differentiated and compared with panel data analysis. Results For the control group, the pre- and postintervention sEMG measure showed no significant difference (p=0.333), whereas significant difference (p=0.004) was observed for the intervention group. Further, the pre- and postintervention two-point discrimination test also showed a significant difference (p=0.016) for the intervention group. Discussion The application of vibration therapy based on TCM holistic theory may have an immediate effect in reducing sport-induced muscle fatigue from intensive training. Future larger sample size and robust designed clinical trial is warranted to evaluate the long-term effect of the intervention.

Background: Kidney Disease Education (KDE) has been shown to improve informed dialysis selection and home dialysis use, two long-held but underachieved goals of US nephrology community. In 2010, the Center for Medicare and Medicaid Services launched a policy of KDE reimbursements for all Medicare beneficiaries with advanced chronic kidney disease. However, the incorporation of KDE service in real-world practice and its association with the home dialysis utilization has not been examined. Methods: Using the 2016 US Renal Data System linked to end-stage renal disease (ESRD) and pre-ESRD Medicare claim data, we identified all adult incident ESRD patients with active Medicare benefits at their first-ever dialysis during the study period (1 January 2010 to 31 December 2014). From these, we identified those who had at least one KDE service code before their dialysis initiation (KDE cohort) and compared them to a parsimoniously matched non-KDE control cohort in 1:4 proportions for age, gender, ESRD network, and the year of dialysis initiation. The primary outcome was home dialysis use at dialysis initiation, and secondary outcomes were home dialysis use at day 90 and anytime through the course of ESRD. Results: Of the 369,968 qualifying incident ESRD Medicare beneficiaries with their first-ever dialysis during the study period, 3469 (0.9%) received KDE services before dialysis initiation. African American race, Hispanic ethnicity, and the presence of congestive heart failure and hypoalbuminemia were associated with significantly lower odds of receiving KDE services. Multivariate analyses showed that KDE recipients had twice the odds of initiating dialysis with home modalities (15.0% vs. 6.9%; adjusted odds ratio (aOR):95% confidence interval (CI) 2.0:1.7–2.4) and had significantly higher odds using home dialysis throughout the course of ESRD (home dialysis use at day 90 (17.6% vs. 9.9%, aOR:CI 1.7:1.4–1.9) and cumulatively (24.7% vs. 15.1%, aOR:CI 1.7:1.5–1.9)). Conclusions: Utilization of pre-ESRD KDE services is associated with significantly greater home dialysis utilization in the incident ESRD Medicare beneficiaries. The very low rates of utilization of these services suggest the need for focused systemic evaluations to identify and address the barriers and facilitators of this important patient-centered endeavor.

Background Informed dialysis selection and greater home dialysis use are the two long-desired, underachieved targets of advanced chronic kidney disease (CKD) care in the US healthcare system. Observational institutional studies have shown that comprehensive pre-kidney failure, conventionally referred to as end stage kidney disease education (CPE) can improve both these outcomes. However, lack of validated protocols, well-controlled studies, and systemic models have limited wide-spread adoption of CPE in the US. We hypothesized that a universal CPE and patient-centered initiation of kidney replacement therapy can improve multiple clinical, patient-centered and health service outcomes in advanced CKD and kidney failure requiring dialysis therapy. Methods Trial to Evaluate and Assess the effects of CPE on Home dialysis in Veterans (TEACH-VET) is a multi-method randomized controlled trial aimed to evaluate the effects of a system-based approach for providing CPE to all Veterans with advanced CKD across a regional healthcare System. The study will randomize 544 Veterans with non-dialysis stage 4 and 5 CKD in a 1:1 allocation stratified by their annual family income and the stage of CKD to an intervention (CPE) arm or control arm. Intervention arm will receive a two-phase CPE in an intent-to-teach manner. Control arm will receive usual clinical care supplemented by resources for the freely-available kidney disease information. Participants will be followed after intervention/control for the duration of the study or until 90-days post-kidney failure, whichever occurs earlier. Results The primary outcome will assess the proportion of Veterans using home dialysis at 90-days post-kidney failure, and secondary outcomes will include post-intervention/control CKD knowledge, confidence in dialysis decision and home dialysis selection. Qualitative arm of the study will use semi-structured interviews to in-depth assess Veterans’ satisfaction with the intervention, preference for delivery, and barriers and facilitators to home dialysis selection and use. Several post-kidney failure clinical, patient-centered and health services outcomes will be assessed 90-days post-kidney failure as additional secondary outcomes. Conclusion The results will provide evidence regarding the need and efficacy of a system-based, patient-centered approach towards universal CPE for all patients with advanced CKD. If successful, this may provide a blueprint for developing such programs across the similar healthcare infrastructures throughout the country. Trial registration NCT04064086.

Purpose Telerehabilitation (TR) is increasingly being used to meet the rehabilitation needs of individuals living in rural areas. Nevertheless, reports on TR implementation for rural patients remain limited. As part of a broader evaluation, this study investigated barriers and facilitators to the implementation of a national TR program to meet the needs of rural Veterans Health Administration (VHA) patients. Methods This study applied a qualitative approach to the RE-AIM framework to investigate barriers and facilitators impacting TR implementation. We conducted in-depth, semi-structured interviews with ten program managers and medical directors within the VHA at three time points during the first 18 months of implementation. Interviews were analyzed using thematic analysis. Results Three themes were identified describing key cultural, infrastructural and logistical, and environmental barriers impacting the reach, adoption, and implementation of TR. Within the themes, facilitators for TR were also identified to include, allowing providers flexibility in implementing TR, mentorship and development of creative approaches to TR training, overcoming infrastructural and logistical TR barriers through championing, and continuous sharing of lessons learned in a community of practice. Discussion This study explicates salient barriers and facilitators encountered during the first 18 months of implementation of a TR program within a national healthcare system in the United States. Implementing TR to meet the rehabilitation needs of Veterans in resource-limited rural environments requires creative approaches and flexibility, as well as perseverance and consistent championing in order to overcome cultural challenges. This, in combination with infrastructural challenges, such as lack of broadband, adds greater complexity to meeting the needs of rural patients. This study provides new and in-depth understanding of the processes by which TR is implemented in a large healthcare system and points to practical real-world lessons in implementing TR for rural patients.

Background Appropriate home modifications (HMs) can make the home environment accessible and relatively safe by reducing the risk of falls. Of special concern are individuals living alone, living in rural communities, and/or living in substandard housing. The Home Improvements and Structural Alterations (HISA) is a Veterans Health Administration (VHA) benefit program providing HMs for veterans with disabilities. Methods The objective of this study was to detail the profile of rural veteran (RV) HISA users and report on national HISA utilization patterns. We compare use at US Department of Veterans Affairs (VA) medical centers of varying complexity levels, and in VA regions. An examination of the relationship between travel time/distance and HISA utilization is also provided. This retrospective database study uses GeoSpatial analyses and 3 VA sources: The National Prosthetics Patient Database, the VHA Medical Inpatient Dataset, and the VHA Outpatient Dataset. Results From 2015 through 2018, 10,810 RVs used HISA with a mean age of 70.9 years. A majority of participants were White (79.5%), married (74.3%), and male (96.5%) veterans. They traveled a mean of 79.8 miles for 94.5 minutes to reach a facility where they received a HISA prescription. Nearly 75% of HISA users were able to receive a HISA prescription from their nearest facility, while about one-quarter traveled to a facility farther away, of which 43% travelled between 100 and 200 miles to obtain the HISA benefit. The top categories of diagnoses were musculoskeletal (19.1%), neurologic (12.5%), and cardiovascular (5.4%). There were about 11,166 HM prescriptions afforded to rural HISA users during the period, including bathroom (82.4%), doorway (4.9%), and railing (3.6%) modifications. Conclusions This study documents the national demographics and clinical characteristics of rural HISA users, data that may be useful to policy makers, HM service providers and advocate as well as HISA administrators in predicting future use and users.

Background Suicide is the 10th leading cause of death in the US, primarily from drug overdose. In 2017, 67.8% of drug overdoses were with prescription opioids. The rate of opioid use disorder among patients in the Veterans Health Administration (VHA) is 7 times higher than that of non-VHA enrollees. This study compares the incidence of overdose and suicide across facility, regional, and national levels in the VHA system in the context of a multispecialty opioid risk reduction program at the North Florida/South Georgia Veteran Health System (NF/SGVHS). Methods This retrospective study used fiscal years 2012 to 2016 overdose and suicide aggregate data from the US Department of Veterans Affairs (VA) Support Service Center medical diagnosis cube and VA Suicide Prevention Program. Overdose data were aggregated by facility and fiscal year, and overdose rates (per 1,000 individuals) were calculated. Results The average annual rate of overdose diagnosis at NF/SGVHS during the study period was slightly higher (16.8 per 1,000) compared with its region (16.0 per 1,000), and VHA national (15.3 per 1,000) rates. The NF/SGVHS had the lowest average annual rate of suicide (9.1 per 100,000) during the study period, which was one-quarter of the VHA national rate. Conclusions NF/SGVHS developed and implemented a biopsychosocial model of pain treatment that includes primary care integrated with mental health and addiction services. The presence of this program during a period when the facility was tapering opioid prescriptions could explain the relative reduced suicide rate.

Supplemental Material, Supplemental_DocumentR3 for Utilization of CMS pre-ESRD Kidney Disease Education services and its associations with the home dialysis therapies by Ashutosh M Shukla, Shahab Bozorgmehri, Rupam Ruchi, Rajesh Mohandas, Jennifer L Hale-Gallardo, Tezcan Ozrazgat-Baslanti, Tatiana Orozco, Mark S Segal and Huanguang Jia in Peritoneal Dialysis International

Inaccessible living environments are problematic for some US Veterans, due to injuries sustained in service or attributed to aging, but can be addressed through home modification (HM) afforded by the Home Improvements and Structural Alterations (HISA) program. The retrospective national assessment of HISA, considering a 50% expected increase in Veterans enrollees over a 10-year time span (2013–23) and a 48% increase in dementia patients by 2033, demonstrates the need for attention to major shifts in HM health services demand. Utilizing data from the National Prosthetics Patient Database and the VA National Medical Outpatient Database, the analyses provide key information to support functional independence in the home by providing data about the HISA program. These include filling a data gap (e.g., Veteran demographic and clinical characteristics, modifications cost comparisons, and regional patterns of HISA utilization) for medically prescribed HM and assess underutilization of HM health services.

Jennifer Hale-Gallardo,1 Huanguang Jia,1 Tony Delisle,2 Charles E Levy,1,3–5 Valentina Osorio,1 Jennifer A Smith,1 Elizabeth M Hannold,1,† 1Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, 2Center for Independent Living of North Central Florida, 3Physical Medicine and Rehabilitation Service, North Florida/South Georgia Veterans Health Service, 4The Department of Occupational Therapy, College of Public Health and Health Professions, 5The Center for the Arts in Medicine, College of the Arts, University of Florida, Gainesville, FL, USA †Elizabeth M Hannold passed away on September 28, 2015. Abstract: The number of US veterans with disabilities has increased in recent years as service members have returned home with extensive injuries and veterans from previous wars acquire functional limitations as a consequence of aging with chronic diseases. Veterans with severe disabilities need assistance and support to maintain independence at home and to avoid institutionalization. The US Department of Veterans Affairs (VA) strives to network with community organizations to achieve the best possible outcomes for veterans. Key community resources in the US for individuals with disabilities are Centers for Independent Living (CILs) that provide a wide range of services, promoting independent living and well-being for people across disabilities. The widespread availability and services of CILs nationwide suggest their potential as a community-based resource for veterans, particularly for those with limited access to VA care. In this article, we discuss long-term needs of veterans with disabilities, efforts to address veterans’ rehabilitation needs at the VA and opportunities for leveraging the strengths of community-based organizations for veterans. More research is warranted to investigate CIL services and potential for CIL–VA partnerships. Keywords: rehabilitation, community engagement, community reintegration, functional limitations

BACKGROUND Effective poststroke rehabilitation care can speed patient recovery and minimize patient functional disabilities. Veterans affairs (VA) community living centers (CLCs) and VA-contracted community nursing homes (CNHs) are the 2 major sources of institutional long-term care for Veterans with stroke receiving care under VA auspices. OBJECTIVES This study compares rehabilitation therapy and restorative nursing care among Veterans residing in VA CLCs versus those Veterans in VA-contracted CNHs. RESEARCH DESIGN Retrospective observational. SUBJECTS All Veterans diagnosed with stroke, newly admitted to the CLCs or CNHs during the study period who completed at least 2 Minimum Data Set assessments postadmission. MEASURES The outcomes were numbers of days for rehabilitation therapy and restorative nursing care received by the Veterans during their stays in CLCs or CNHs as documented in the Minimum Data Set databases. RESULTS For rehabilitation therapy, the CLC Veterans had lower user rates (75.2% vs. 76.4%, P=0.078) and fewer observed therapy days (4.9 vs. 6.4, P

Huanguang Jia,1 Qinglin Pei,1 Charles T Sullivan,1 Diane C Cowper Ripley,1 Samuel S Wu,1 W Bruce Vogel,1 Xinping Wang,1 Douglas E Bidelspach,2 Jennifer L Hale-Gallardo,1 Barbara E Bates3 1Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL, 2Physical Medicine and Rehabilitation Service, Department of Veterans Affairs, Washington, DC, 3Aleda E. Lutz VA Medical Center, Saginaw, MI, USA Introduction: Effective post-acute multidisciplinary rehabilitation therapy improves stroke survivors’ functional recovery and daily living activities. The US Department of Veterans Affairs (VA) places veterans needing post-acute institutional care in private community nursing homes (CNHs). These placements are made under the same rules and regulations across the VA health care system and through individual per diem contracts between local VA facilities and CNHs. However, there is limited information about utilization of these veterans’ health services as well as the geographic variation of the service utilization. Aim: The aims of this study were to determine rehabilitation therapy and restorative nursing care utilization by veterans with stroke in VA-contracted CNHs and to assess risk-adjusted regional variations in the utilization of rehabilitation therapy and restorative nursing care. Methods: This retrospective study included all veterans diagnosed with stroke residing in VA-contracted CNHs between 2006 and 2009. Minimum Dataset (a health status assessment tool for CNH residents) for the study CNHs was linked with veterans’ inpatient and outpatient data within the VA health care system. CNHs were grouped into five VA-defined geographic regions: the North Atlantic, Southeast, Midwest, Continental, and Pacific regions. A two-part model was applied estimating risk-adjusted utilization probability and average weekly utilization days. Two dependent variables were rehabilitation therapy and restorative nursing care utilization by veterans during their CNH stays. Results: The study comprised 6,206 veterans at 2,511 CNHs. Rates for utilization of rehabilitation therapy and restorative nursing care were 75.7% and 30.1%, respectively. Veterans in North Atlantic and Southeast CNHs were significantly (p

The Department of Veterans Affairs (VA) manages the largest healthcare system under a single management structure in the United States. Providing access to high quality healthcare to the VA’s nearly 9 million enrollees is a mission priority for the Veterans Health Administration (VHA), the arm of the VA that oversees all medical facilities and operations. Geographic Information Systems (GIS) tools enable analysts to construct data-driven recommendations to policy makers for providing the best and most timely healthcare to those individuals who have honorably served their country. This paper illustrates how GIS is being used by the VHA and provides the example of acute stroke care access for Veterans in one Veterans Integrated Service Network (VISN) within the VHA.

Purpose Differences in stroke care quality for patients in rural and urban locations have been suggested, but whether differences exist across Veteran Administration Medical Centers (VAMCs) is unknown. This study examines whether rural-urban disparities exist in inpatient quality among veterans with acute ischemic stroke. Methods In this retrospective study, inpatient stroke care quality was assessed in a national sample of veterans with acute ischemic stroke using 14 quality indicators (QIs). Rural-Urban Commuting Areas codes defined each VAMC's rural-urban status. A hierarchical linear model assessed the rural-urban differences across the 14 QIs, adjusting for patient and facility characteristics, and clustering within VAMCs. Findings Among 128 VAMCs, 18 (14.1%) were classified as rural VAMCs and admitted 284 (7.3%) of the 3,889 ischemic stroke patients. Rural VAMCs had statistically significantly lower unadjusted rates on 6 QIs: Deep vein thrombosis (DVT) prophylaxis, antithrombotic at discharge, antithrombotic at day 2, lipid management, smoking cessation counseling, and National Institutes of Health Stroke Scale completion, but they had higher rates of stroke education, functional assessment, and fall risk assessment. After adjustment, differences in 2 QIs remained significant—patients treated in rural VAMCs were less likely to receive DVT prophylaxis, but more likely to have documented functional assessment. Conclusions After adjustment for key demographic, clinical, and facility-level characteristics, there does not appear to be a systematic difference in inpatient stroke quality between rural and urban VAMCs. Future research should seek to understand the few differences in care found that could serve as targets for future quality improvement interventions.

Purpose: To assess the association between Veterans Affairs (VA) stroke patients’ poststroke rehabilitation utilization and their residential settings by using 2 common rural-urban taxonomies. Methods: This retrospective study included all VA stroke inpatients in 2001 and 2002. Rehabilitation utilization referred to rehabilitation therapy received 12-months poststroke hospitalization. Patients’ urban, rural, or isolated/highly rural status was determined using the Rural-Urban Commuting Areas (RUCA) and VA Rural Urban (VARU) definitions based on patient residential ZIP code. Logistic regression models were fit for the rehabilitation outcome, adjusting for potential risk factors. Findings: Among the 8,296 stroke patients, 69.6%/61.1% were categorized as urban, 21.3%/37.5% as rural, and 9.1%/1.4% as isolated/highly rural by the RUCA/VARU definitions, respectively. Compared with their urban counterparts, the rural and/or isolated/highly rural patients were significantly more likely to be older, white, married, living further from the VA hospitals, not hospitalized for stroke directly from home, and not intubated. Compared with the rural patients, odds of receiving rehabilitation therapy were 1.2 times (RUCA) and 1.1 times (VARU) by the urban patients, and 0.53 times (VARU only) by the highly rural patients, after risk adjustment. The above comparisons were significant at P < .05. Conclusions: With both taxonomies, the rural patients were less likely to receive postacute stroke rehabilitant therapy than their urban counterparts. With the VARU, the highly rural patients were less likely to receive rehabilitation care than their rural counterparts. Different taxonomy may lead to different rural-urban classification yields and different yields may lead to different outcomes and conclusions.

Background: Studies generally do not examine patients' prestroke depression diagnoses and treatments. Objective: To examine the association of depression diagnosis and prestroke and/or poststroke selective serotonin reuptake inhibitor (SSRI) treatment with poststroke mortality. Methods: We conducted a retrospective study of the medical records of a cohort of veterans with a stroke diagnosis between July 31, 2000, and September 30, 2001. Data regarding demographics, comorbidities, depression diagnosis, and treatment were abstracted from automated databases and electronic medical records for 6 months before and 1 year after the stroke index date. The survival rates of veterans who received an SSRI before and/or after the stroke were estimated using Kaplan-Meier survival analysis. Time-dependent Cox proportional hazards regression model was used to assess the association between risk factors and mortality. Results: Among 870 veterans, 80 died less than 60 days after their stroke. Among the remaining 790, 12% died within 1 year, 26% died by the end of follow-up (May 1, 2007), and more than 62% were alive at the end of follow-up. Veterans were 3 times as likely to die if they had been treated for depression with an SSRI only before their stroke (hazard ratio [HR], 3.12; 95% CI 1.60 to 6.09). In the time-dependent model, SSRI treatment both before and after the stroke was protective compared with no SSRI treatment during the year following the stroke (HR 0.31; 95% CI 0.11 to 0.86). However, the survival curves crossed over and SSRI treatment before and after stroke conferred greater risk at the end of 7 years (HR 1.36; 95% CI 1.00 to 1.87). Depression diagnosis was associated with greater risk of mortality (HR 1.87; 95% CI 1.24 to 2.82). Conclusions: Poststroke SSRI treatment was associated with longer survival even though depression diagnosis was associated with earlier mortality in the unadjusted model. After a stroke, SSRI initiation or resumption of treatment should be considered as part of a medication therapy management service, especially if the patient has a history of depression or was taking an SSRI before the stroke.

Objectives: To 1) describe the prevalence of before the stroke depression (BSD) and poststroke depression (PSD) and 2) serotonin selective reuptake inhibitor (SSRI) treatment patterns. Design: Naturalistic, retrospective cohort design. Setting: Veterans Healthcare System. Participants: Seven hundred ninety veterans with confirmed stroke during fiscal year 2001. Measurements: Diagnosis of depression and dispensing for antidepressants before and after stroke. Results: A depression diagnosis was noted for nearly 10% (N = 74) of veterans before their stroke and nearly 26% afterward (N = 205). Among those with a BSD diagnosis, 75.7% received a PSD diagnosis after their stroke. Only 20.9% of the veterans without a BSD diagnosis received a PSD diagnosis afterward (odds ratio [OR] = 9.5, 95% confidence interval [CI] = 5.4–16.5). Nearly 32% were dispensed a SSRI. Veterans receiving an SSRI before their stroke were more likely to receive one afterward (OR = 31.9, 95% CI: 17.4–58.4). Nearly 48% of those with a BSD diagnosis were dispensed an SSRI ≤30 days if they had a PSD diagnosis ≤30 days, but 48% without a PSD diagnosis were still dispensed an SSRI ≤30 days if they had a BSD diagnosis. Conversely, among those without a BSD diagnosis, 39.4% were dispensed an SSRI ≤30 days if they had a PSD diagnosis but only 7.2% without a PSD diagnosis in ≤30 days with no BSD diagnosis. Conclusion: Patients' depression status before the stroke is a significant predictor of PSD and providers' SSRI prescribing behavior but not age. Given the deleterious effects of PSD, physicians may be tending toward prophylaxis or early treatment even before the evidence to support such treatment leads to standard practice recommendations.

Objectives Post-stroke depression (PSD) is prevalent, often undiagnosed, and undertreated. The accuracy of detecting patients with post-stroke depression in administrative databases has not been examined.The objective was to validate a case-finding algorithm for post-stroke depression (PSD) among veteran stroke survivors. Methods We conducted a retrospective cohort study of veterans admitted to two local VHA facilities for an inpatient episode of care for acute ischemic stroke. Our cohort included all patients from two medical centers who were identified in the fiscal year (FY) 2001 VHA inpatient database using high specificity stroke ICD-9 codes. FY 2002 VHA and Medicare inpatient, outpatient, and pharmacy data were used to examine the patients' 12-month PSD status by using ICD-9 depression codes and antidepressant use. We assessed our accuracy about patients' PSD from the administrative databases through standardized chart reviews. Results Of our 185 subject cohort, 50 (27%) were identified as having PSD. The most sensitive case-finding algorithm for PSD included having an ICD-9 code diagnosis for depression or receiving a prescription for an approved-dosage of antidepressant medication. However, the algorithm of receiving an ICD-9 code for primary or secondary diagnoses of depression revealed the largest positive predictive value. Conclusions A case-finding algorithm using outpatient ICD-9 codes or medication was the most sensitive in identifying cases of PSD. The use of ICD-9 codes alone may be adequate for characterizing a cohort with PSD. Intention for use should be considered when choosing an algorithm to detect PSD. Copyright © 2007 John Wiley & Sons, Ltd.

This study compared the characteristics of community nursing homes where veterans received their care with those of facilities that did not treat veterans from 1999 to 2002 using the Centers for Medicare and Medicaid Services (CMS) Online Survey Certification and Reporting system data merged with the CMS Minimum Data Set. A structure, process, and outcome model was used to examine whether the presence of per diem veterans had any impact on multidimensional quality measures. Facilities with any veterans were less likely to meet recommended nurse staffing standards; more likely to have patients with tube feeding, new catheterizations, and mobility restraints; and more likely to have actual harm citations and new pressure sores, plus quality-of-care, quality-of-life, and total deficiencies, than facilities without veterans. The implications of this study are that the U.S. Department of Veterans Affairs may need to examine its contracting policies with community facilities to understand both quality and selection effects that may be occurring.

Background and Purpose—Poststroke depression (PSD) is common among stroke survivors, and it is associated with worse functional outcomes and increased poststroke mortality. Limited information is available about its impact on healthcare use. This study assessed the impact of PSD on healthcare use by veterans with acute stroke.Methods—In this retrospective, observational national study, 5825 veterans with acute stroke were identified from Veterans Affairs’ (VA) inpatient databases. To determine the patients’ comprehensive PSD and use status, VA and Medicare fee-for-service inpatient and outpatient as well as VA pharmacy data were used. PSD was established if a patient had an inpatient or outpatient depression diagnosis or if a patient received one of the antidepressants within the VA 12 months postindex stroke. Healthcare use referred to the number of hospital stays, outpatient visits, and cumulative length of inpatient stays under both VA and Medicare fee-for-service programs. Poisson regression was fitted to estimate the impact of PSD on use controlling for sociodemographic, clinical, and disease severity factors.Results—Forty-one percent of the sample had PSD. After adjusting for patient demographic and clinical factors, we found that the patients with stroke with PSD had significantly (PConclusions—Patients with PSD had greater 12-month poststroke healthcare use even when controlling for other demographic and clinical variables. Early detection and appropriate management of PSD for veterans with acute stroke may help reduce their poststroke healthcare use.

Background Potential cardiovascular (CV) risks of testosterone replacement therapy (TRT) are currently a topic of intense interest. However, no studies have addressed CV risk as a function of the route of administration of TRT. Methods Two meta-analyses were conducted, one of CV adverse events (AEs) in 35 randomized controlled trials (RCTs) of TRT lasting 12 weeks or more, and one of 32 studies reporting the effect of TRT on serum testosterone and dihydrotestosterone (DHT). Results CV risks of TRT: Of 2,313 studies identified, 35 were eligible and included 3,703 mostly older men who experienced 218 CV-related AEs. No significant risk for CV AEs was present when all TRT administration routes were grouped (relative risk (RR) = 1.28, 95% confidence interval (CI): 0.76 to 2.13, P = 0.34). When analyzed separately, oral TRT produced significant CV risk (RR = 2.20, 95% CI: 1.45 to 3.55, P = 0.015), while neither intramuscular (RR = 0.66, 95% CI: 0.28 to 1.56, P = 0.32) nor transdermal (gel or patch) TRT (RR = 1.27, 95% CI: 0.62 to 2.62, P = 0.48) significantly altered CV risk. Serum testosterone/DHT following TRT: Of 419 studies identified, 32 were eligible which included 1,152 men receiving TRT. No significant difference in the elevation of serum testosterone was present between intramuscular or transdermal TRT. However, transdermal TRT elevated serum DHT (5.46-fold, 95% CI: 4.51 to 6.60) to a greater magnitude than intramuscular TRT (2.20-fold, 95% CI: 1.74 to 2.77). Conclusions Oral TRT produces significant CV risk. While no significant effects on CV risk were observed with either injected or transdermal TRT, the point estimates suggest that further research is needed to establish whether administration by these routes is protective or detrimental, respectively. Differences in the degree to which serum DHT is elevated may underlie the varying CV risk by TRT administration route, as elevated serum dihydrotestosterone has been shown to be associated with CV risk in observational studies. Electronic supplementary material The online version of this article (doi:10.1186/s12916-014-0211-5) contains supplementary material, which is available to authorized users.

In a prospective cohort study between February 2001 and January 2004, baseline and 12-month follow-up data were collected on 226 and 197 men with HIV infection at three infectious disease clinics in a southern state, respectively. While many studies have provided important information on the correlates of health-related quality of life (HRQOL) during HIV infection, little research attention has been directed toward examining the impact of factors on change in HRQOL over time. This study evaluated changes in HRQOL, and examined whether baseline active coping, family social support, depressive symptoms and CD4 cell counts predicted HRQOL changes over time among men with HIV infection. Patients' HRQOL, social support and depressive symptoms were measured with the HIV Cost and Services Utilization Study tool, Coping with HIV Questionnaire, Social Support Appraisals Scale, and Centers for Epidemiological Studies Depression instrument. Multivariate linear regression analyses were conducted to determine the time-related effects of the psychosocial variables and CD4 cell counts on each HRQOL dimension. Our results indicated that higher family support and CD4 cell counts at baseline were predictive of improved changes in physical and social functioning over time, and higher depressive symptoms at baseline were predictive of diminished role functioning, emotional well-being, and general health perception. These findings underline the importance of enhancing family social support, identifying and treating depression, and improving immune function to optimize HRQOL among men with HIV infection.

Background: Patients with irritable bowel syndrome (IBS) have reduced pain thresholds for rectal distension. In addition, the prevalence of sexual/physical abuse in referred IBS patients is high and is associated with greater pain reporting, poorer health status, and poorer outcome. This lead to a hypothesis that abuse history may sensitise patients to report pain at a lower threshold. Aim: To compare rectal pain thresholds in women with IBS who had a history of severe abuse to IBS women with no history of abuse. Methods: We studied 74 IBS patients with a history of severe physical and/or sexual abuse and 85 patients with no history of abuse. Abuse history was assessed by a previously validated self-report abuse screening questionnaire. Rectal sensory thresholds were assessed using an electronic barostat and determined by the ascending method of limit (AML) and by the tracking technique. Results: IBS patients with a history of severe abuse had significantly higher rectal pain thresholds, as measured by AML (F (1, 111) = 6.06; p = 0.015) and the tracking technique (F (1, 109) = 5.21; p = 0.024). Patients with a history of severe abuse also reported a significantly higher threshold for urgency to defecate (F (1, 113) = 11.23; p = .001). Conclusion: Severe sexual/physical abuse is associated with higher urge and pain thresholds for rectal distension in IBS patients. This suggests that the greater pain reporting and poorer health status in IBS patients with abuse history are not related to increased rectal pain sensitivity. Further studies are needed to determine the causes of these findings.

Background & aims: Studies of antidepressants and psychological treatments in functional bowel disorders (FBD) are methodologically limited. The aim of this study was to assess the clinical efficacy and safety of cognitive-behavioral therapy (CBT) against education (EDU) and desipramine (DES) against placebo (PLA) in female patients with moderate to severe FBD (irritable bowel syndrome, functional abdominal pain, painful constipation, and unspecified FBD). We also evaluated the amenability of clinically meaningful subgroups to these treatments. Methods: This randomized, comparator-controlled, multicenter trial enrolled 431 adults from the University of North Carolina and the University of Toronto with moderate to severe symptoms of FBD. Participants received psychological (CBT vs. EDU) or antidepressant (DES vs. PLA) treatment for 12 weeks. Clinical, physiologic, and psychosocial assessments were performed before and at the end of treatment. Results: The intention-to-treat analysis showed CBT as significantly more effective than EDU ( P = 0.0001; responder rate, 70% CBT vs. 37% EDU; number needed to treat [NNT ], 3.1). DES did not show significant benefit over PLA in the intention-to-treat analysis ( P = 0.16; responder rate, 60% DES vs. 47% PLA; NNT, 8.1) but did show a statistically significant benefit in the per-protocol analysis ( P = 0.01; responder rate, 73% DES vs. 49% PLA; NNT, 5.2), especially when participants with nondetectable blood levels of DES were excluded ( P = 0.002). Improvement was best gauged by satisfaction with treatment. Subgroup analyses showed that DES was beneficial over PLA for moderate more than severe symptoms, abuse history, no depression, and diarrhea-predominant symptoms; CBT was beneficial over EDU for all subgroups except for depression. Conclusions: For female patients with moderate to severe FBD, CBT is effective and DES may be effective when taken adequately. Certain clinical subgroups are more or less amenable to these treatments.

This study examined functional outcomes, health-related quality of life (HRQoL), and satisfaction in a group of Veterans who received physical therapy via an in-home video telerehabilitation program, the Rural Veterans TeleRehabilitation Initiative (RVTRI). A retrospective, pre-post study design was used. Measures obtained from 26 Veterans who received physical therapy in the RVTRI program between February 22, 2010, and April 1, 2011, were analyzed. Outcomes were the Functional Independence Measure (FIM); Quick Disabilities of the Arm, Shoulder, and Hand measure; Montreal Cognitive Assessment (MoCA); and the 2-minute walk test (2MWT). HRQoL was assessed using the Veterans RAND 12-Item Health Survey (VR-12), and program satisfaction was evaluated using a telehealth satisfaction scale. Average length of participation was 99.2 +/- 43.3 d and Veterans, on average, received 15.2 +/- 6.0 therapeutic sessions. Significant improvement was shown in the participants' FIM (p < 0.001, r = 0.63), MoCA (p = 0.01, r = 0.44), 2MWT (p = 0.006, r = 0.73), and VR-12 (p = 0.02, r = 0.42). All Veterans reported satisfaction with their telerehabilitation experiences. Those enrolled in the RVTRI program avoided an average of 2,774.7 +/- 3,197.4 travel miles, 46.3 +/- 53.3 hr of driving time, and $1,151.50 +/- $1,326.90 in travel reimbursement. RVTRI provided an effective real-time, home-based, physical therapy.

There has been growing interest in the investigation of health-related quality of life (HRQOL) among patients with gastrointestinal (GI) disorders. We recently reported on the development and preliminary validation of the IBS-QOL, a specific quality-of-life measure for irritable bowel syndrome (IBS). The aim of this study was to determine the longitudinal construct validity (responsiveness) of the IBS-QOL.Female patients enrolled in a multicenter treatment trial for functional bowel disorders were studied pre- and posttreatment with the IBS-QOL and other health status measures. Based on the response to treatment for several variables (pain/14-day score, daily function, and days in bed/3 months), patients were stratified into Responders, Partial Responders, and Nonresponders. Change scores in the IBS-QOL were then statistically compared with changes in the other variables to determine their correlation and whether Responders were significantly different from non- and Partial Responders on the IBS-QOL.There was a significant correlation between change scores on the IBS-QOL and the other measures of treatment effect (Pain/14 days, r = 0.25, p0.002; Sickness Impact Profile [SIP] Total Score, r = 0.28, p0.0004). In addition, the IBS-QOL scores significantly differentiated Responders from Nonresponders for most of the variables tested (regression trend test for Pain/14 days, p0.04; SIP Total, p0.0001; SIP Physical, p0.0001; SIP Psychosocial, p0.002, and SIP Eating, p0.04).The IBS-QOL is responsive to treatment in a referral-based clinical population of patients with functional bowel disorders.

INTRODUCTION Older age is one of the most common nonmodifiable risk factors for ischemic stroke [1]. Approximately two-thirds of all strokes occur in those over 65 yr [1]. However, recent research found that stroke rates are increasing in younger patients compared with older patients [2]. Robust evidence supports the application of a variety of poststroke interventions for the prevention of recurrent vascular events (e.g., hypertension management) across the spectrum of age groups [3]. Although older patients derive as much, if not more, benefit from acute stroke treatments and prevention strategies (e.g., warfarin and thrombolysis) than younger patients [4-6], some studies have found that older stroke patients are less likely to receive interventions than younger patients [7-9]. A few studies have examined age disparities in stroke management. A Canadian study found that rates of antiplatelet and warfarin for atrial fibrillation at discharge were similar across age groups [10]. On the other hand, individuals in the older age groups (60-69, 70-79, and 80 yr) were significantly more likely than their younger counterparts to be discharged with antihypertensive treatment. A separate study found that older individuals (85+ yr) were less likely to receive secondary prevention (e.g., documented measure of blood cholesterol) [11]. Using a nationally representative telephone self-report survey to explore disparities in 11 stroke secondary prevention services (e.g., serum glycosylated hemoglobin [HbA1c] measurement; serum cholesterol measurement), Ross and colleagues reported that individuals younger than 65 were less likely than those 65-79 to report receipt of recommended services (e.g., serum cholesterol measurement) [12]. Still yet a separate study found that the oldest hypertension patients, despite worse blood pressure control, were being treated less aggressively with fewer medications than their younger counterparts [13]. In sum, some previous studies have found age differences in the process of care, but whether the same differences exist in Department of Veterans Affairs (VA) stroke care is unclear. Recent data indicate that the Veterans Health Administration (VHA) treats a sizable number of veterans with stroke in the ambulatory care setting. In the United States, approximately 7 million individuals have experienced a stroke. Each year, nearly 795,000 people experience a new or recurrent stroke. In the VHA for 2007, nearly 6,000 veterans were admitted to a VA facility with a primary discharge diagnosis of ischemic stroke and more than 61,000 unique patients had an outpatient visit with stroke listed as the primary diagnosis [2]. The VHA is the largest healthcare system in the United States and has a record of providing high-quality care; however, little data are available regarding the existence of age differences in postdischarge stroke care quality. The purpose of this study was to examine whether age differences exist in performance on postdischarge stroke care quality indicators (QIs) among VHA stroke survivors. VHA traditionally has not dealt with the frontline care of stroke victims and tends to treat stroke patients in the rehabilitation setting. METHODS Materials and Patients The data were obtained from a retrospective cohort of veterans who were admitted to a VA medical center (VAMC) with an ischemic stroke during fiscal year 2007 (October 1, 2006-September 30, 2007). Medical record review was performed on a sample of 5,000 patients; the sample was constructed by including 100 percent of patients from smaller volume medical centers and an 80 percent sample from larger volume medical centers. Patients were excluded if they were admitted for elective carotid endarterectomy, admitted only for poststroke rehabilitation, initially admitted for a nonstroke condition when the ischemic stroke event occurred, or admitted to a VAMC that did not use the VHA electronic medical record system. …

Background Stroke mortality has been found to be much higher among residents in the stroke belt region than in the rest of United States, but it is not known whether differences exist in the quality of stroke care provided in Department of Veterans Affairs medical centers in states inside and outside this region. Objective We compared mortality and inpatient stroke care quality between Veterans Affairs medical centers inside and outside the stroke belt region. Methods Study patients were veterans hospitalized for ischemic stroke at 129 Veterans Affairs medical centers. Inpatient stroke care quality was assessed by 14 quality indicators. Multivariable logistic regression models were fit to examine differences in quality between facilities inside and outside the stroke belt, adjusting for patient characteristics and Veterans Affairs medical centers clustering effect. Results Among the 3909 patients, 28·1% received inpatient ischemic stroke care in 28 stroke belt Veterans Affairs medical centers, and 71·9% obtained care in 101 non-stroke belt Veterans Affairs medical centers. Patients cared for in stroke belt Veterans Affairs medical centers were more likely to be younger, Black, married, have a higher stroke severity, and less likely to be ambulatory pre-stroke. We found no statistically significant differences in short- and long-term post-admission mortality and inpatient care quality indicators between the patients cared for in stroke belt and non-stroke belt Veterans Affairs medical centers after risk adjustment. Conclusions These data suggest that a stroke belt does not exist within the Veterans Affairs health care system in terms of either post-admission mortality or inpatient care quality.

Background Some studies have found that older individuals are not as likely as their younger counterparts to be treated with some guideline-based stroke therapies. We examined whether age-related differences in inpatient quality of care exist among US veterans with ischemic stroke. Methods This was a retrospective study of a national sample of veterans admitted to 129 Veterans Affairs medical centers for ischemic stroke during fiscal year 2007. Inpatient stroke care quality was examined across 14 inpatient processes of care, including dysphagia screening, National Institutes of Health Stroke Scale (NIHSS) score documentation, thrombolysis, deep venous thrombosis prophylaxis, antithrombotic therapy by hospital day 2 and at discharge, early ambulation, fall risk assessment, pressure ulcer risk assessment, rehabilitation needs assessment, atrial fibrillation management, lipid management, smoking cessation counseling, and stroke education. Results Among the 3939 veterans with ischemic stroke, the mean age was 67.8 years (standard deviation, 11.5). The overall performance rate was >70% for 10 of the 14 quality indicators. In unadjusted analyses, older patients were less likely to receive lipid management, smoking cessation, NIHSS documentation, and early ambulation compared with younger patients; conversely, older patients were more likely to receive dysphagia screening and stroke education. After adjusting for demographic, clinical, and hospital level characteristics, the age-related differences in processes of care were less consistent; however, the youngest patients were more likely to receive smoking cessation counseling and the oldest patients were less likely to receive lipid management. Conclusions Risk-adjusted inpatient stroke care quality varies little with age for veterans admitted to a Veterans Affairs medical center for acute ischemic stroke.

Objective To examine the association between dispensing of a selective serotonin reuptake inhibitor (SSRI) antidepressant medication and inpatient and outpatient service use in a cohort of veterans with confirmed acute stroke. Design Retrospective study. Setting Southeastern U.S. Veterans Health Administration (VHA) network, from October 1, 2000, to September 30, 2001. Patients 785 veterans with confirmed acute stroke. Intervention VHA and Medicare databases were used to obtain outcome information during the 12 months after the index stroke date. Main outcome measures Number of inpatient admissions, length of inpatient stays, and number of outpatient clinic stops for all causes. Results Among the study cohort (n = 785), 12% had an SSRI dispensed 30 days or less poststroke, 19% had an SSRI dispensed between 31 and 365 days poststroke, and 69% were not dispensed an SSRI poststroke. After adjusting for risk factors, no significant association was found between time to first SSRI dispensing and inpatient use. However, patients with an early SSRI dispensing were more likely to have a greater number of all-cause outpatient stops compared with patients with later or no SSRI dispensing. Regardless of time to first dispensing, patients dispensed an SSRI had more outpatient clinic stops than patients without the medication. Conclusion SSRI dispensing was not predictive of inpatient use but was a strong predictor of all-cause outpatient clinic stops.

We assessed the effects of a care coordination home-telehealth (CCHT) programme on health service utilization. The subjects ( n = 387 for each group) were US veterans diagnosed with diabetes and followed for 48 months. The service utilization measures were numbers of all-cause inpatient stays and outpatient visits during the follow-up period. We used generalized linear mixed models to estimate the adjusted effects of the CCHT programme on service use over time. Compared with the controls, the CCHT clients were less likely to be admitted for inpatient care during the first ( P < 0.001) and second ( P < 0.01) six-month follow-up period, and were consistently more likely to visit outpatient clinics ( P < 0.001) during the whole 48-month follow-up period. The likelihood of increase in outpatient utilization tended to decline over time. The findings suggest that the CCHT programme helped to reduce overall inpatient and outpatient use by the clients over the 48-month follow-up period.

Objectives Post-stroke depression (PSD) is common among stroke survivors and is associated with increased morbidity and mortality. Little is understood about racial/ethnic differences in PSD detection. This study assessed the racial/ethnic disparities in PSD detection in a national cohort of Department of Veterans Affairs (VA) acute stroke patients. Methods The study included VA patients who: received inpatient care for acute stroke within 2001; survived >60 days post-index hospitalization; had an index stay

We assessed a home monitoring/care coordination programme for veterans with diabetes. Patients enrolled in the programme ( n = 387) were followed for four years and compared with a retrospective control group ( n = 387). Each patient in the intervention group used a messaging device in the home that was connected by a conventional telephone line. Care coordinators monitored the answers from the devices daily so that early interventions could be made. There were significantly more deaths in the control group ( n = 102, 26%) compared with the intervention group ( n = 75, 19%). There was longer survival for the intervention group versus the control group (mean survival time 1348 vs 1278 days; P = 0.015). A multivariate analyses indicated that the telemonitoring programme was associated with reduced 4-year all-cause mortality (hazard ratio = 0.7, 95% CI 0.5–0.9, P = 0.013). The results suggest that daily management of patients with diabetes through home monitoring by a registered nurse reduces mortality.

This study compared patterns of poststroke depression (PSD) detection among veterans with acute stroke in eight U.S. geographic regions. Department of Veterans Affairs (VA) medical and pharmacy data as well as Medicare data were used. International Classification of Diseases-9th Revision depression codes and antidepressant medication dispensing were applied to define patients' PSD status 12 months poststroke. Logistic regression models were fit to compare VA PSD diagnosis and overall PSD detection between the regions. The use of VA medical data alone may underestimate the rate of PSD. Geographic variation in PSD detection depended on the data used. If VA medical data alone were used, we found no significant variation. If VA medical data were used along with Medicare and VA pharmacy data, we observed a significant variation in overall PSD detection across the regions after adjusting for potential risk factors. VA clinicians and policy makers need to consider enrollees' use of services outside the system when conducting program evaluation. Future research on PSD among veteran patients should use VA medical data in combination with Medicare and VA pharmacy data to obtain a comprehensive understanding of patients' PSD.

Hypogonadism is prevalent in older men and testosterone replacement therapy (TRT) for older hypogonadal men is a promising therapy. However, a number of important clinical concerns over TRT safety remain unsolved due to a lack of large-scale randomized clinical trials directly comparing the health risks of untreated hypogonadism vs long-term use of TRT. Meta-analyses of clinical trials of TRT as of 2010 have identified three major adverse events resulting from TRT: polycythemia, an increase in prostate-related events, and a slight reduction in serum high-density lipoprotein cholesterol. There are other purported health risks but their incidence can be neither confirmed nor denied based on the small number of subjects that have been studied to date. Furthermore, subsequent literature is equivocal with regard to the safety and utility of TRT and this topic has been subject to contentious debate. Since January 2014, the United States Food and Drug Administration has released two official announcements regarding the safety of TRT and clinical monitoring the risks in TRT users. Additionally, the health risks related to the clinical presentation of low or declining testosterone levels not been resolved in the current literature. Because TRT is prescribed in the context of putative risks resulting from reduced testosterone levels, we reviewed the epidemiology and reported risks of low testosterone levels. We also highlight the current information about TRT utilization, the risks most often claimed to be associated with TRT, and current or emerging alternatives to TRT.

Background and Purpose— Many Veteran Health Administration (VHA) enrollees receive health services outside the VHA system. However, limited information is available about poststroke utilization and mortality by veterans who used multiple sources of health care. This study assessed the likelihood of 12-month poststroke rehospitalization and mortality of veterans who used VHA only versus those who used multiple sources of care. Methods— Our retrospective observational study examined veterans living in Florida and diagnosed with acute stroke. We categorized users into 4 groups: VHA-only, VHA-Medicare, VHA-Medicaid, and VHA-Medicare-Medicaid based on their use of each health care program. Logistic regression models were fitted for 12-month poststroke general rehospitalization, recurrent stroke readmission, and mortality, adjusting for sociodemographic and clinical factors. Results— The sample consisted of 29% VHA-only users, 61% VHA-Medicare users, 3% VHA-Medicaid users, and 7% VHA-Medicare-Medicaid triple users. Compared with the VHA-only users, multiple system users were significantly more likely to be rehospitalized for any cause and for recurrent stroke 12-months postindex. Mortality outcomes depended on when the outcome was measured; at the index admission date, we found no significant difference in mortality across the user groups; at the index discharge date, the VHA-only users was less likely to die within the first 12 months than the users of the 2 dual groups (VHA-Medicare and VHA-Medicaid). Conclusions— Multiple health care source use was common among VHA enrollees with acute stroke in Florida. Multiple system users were more likely to be rehospitalized and the mortality outcomes were dependent on when the outcome was measured.

This is the third study in a line of research which is designed to increase scientific understanding of the predictors of health-related quality of life (HRQOL) among men with HIV infection using data collected in large, prospective cohort study. Building on two prior investigations, this study examined the time-dependent relationships of psychosocial and clinical variables (active coping strategies, social support, CD4 cell count, comorbidity, and duration of HIV infection) and 10 HRQOL dimensions at two time points (baseline and 12 months). Using linear mixed models, we found that most relationships between the psychosocial and clinical variables and HRQOL dimensions were consistent across time. However, there were interactions between time and CD4 cell count and some HRQOL dimensions. Specifically, increased active coping and social support were positively related, whereas more comorbid conditions and longer HIV infection duration were negatively related with multiple HRQOL dimensions at both baseline and 12 months. CD4 cell count was positively associated with emotional well-being at both time points, but the associations between CD4 cell count and five HRQOL dimensions were negative at baseline but positive at 12 months. These findings provide additional support for the recommendation that clinicians and health planners should continually strive to enhance active coping strategies and social support, manage comorbid conditions, and incorporate duration of HIV diagnoses in their treatment plans. Because the relationships between CD4 cell count and HRQOL dimensions varied over time, it is important to recognize that results from laboratory tests (i.e., CD4 cell count) may have differential quality of life implications for patients at various times in their disease trajectories.

Background and Purpose— Evidence for ethnic disparities in stroke incidence, severity, and mortality has continued to mount in recent years. However, the picture for disparities in acute management and rehabilitation remains more ambiguous. The objective of this report is to summarize current evidence from stroke epidemiology and studies focusing on disparities in stroke care and disability, suggesting courses for action. Methods— A comprehensive search of current literature on ethnic/racial variation in stroke incidence, mortality, and severity, as well as acute and postacute patient care was performed. Results— Recent evidence unambiguously reaffirms a greater burden of disease in stroke, greater mortality, and greater severity of strokes for blacks. Evidence for disparities in acute and postacute care is less conclusive, as is the evidence for disparities among other ethnic groups. Evidence for health disparities in stroke care across settings, regions, and the continuum of care varies considerably. Conclusions— Minority ethnic groups have higher rates or more severe stroke, but variations in prognosis for clinical outcomes other than mortality remain less certain. There is considerable need for more studies that take into account regional ethnic variations in treatment and outcomes, and for better documentation of stroke outcomes among groups in addition to blacks. Dealing with ethnic disparities in stroke will be served by sustained attention to quality improvement in high-impact areas in stroke care, complemented by initiatives that promote cultural competence.

In a prospective cohort study, baseline data were collected on 226 males with HIV infection attending three infectious disease clinics in a southern state. As a result of advances in HIV treatment, understanding the association between psychosocial factors and health-related quality of life has become an important area of study. The purpose of this study was to assess the total effects of social support and coping as well as the direct and indirect effects of these factors through depression on health-related quality of life. Subjects were interviewed and answered the following standardized questionnaires: The HIV Cost and Services Utilization Study tool, Coping with HIV Questionnaire, Social Support Appraisals Scale, and Centers for Epidemiological Studies Depression instrument. Path models with strictly ordered relationships were fitted to study the effects of the psychosocial variables on each quality of life subscale. We found that coping and social support had total effects on some, but not all dimensions of health-related quality of life, whereas depression was associated with all dimensions of health-related quality of life. Furthermore, the effects of both social support and coping were mainly through the intermediate variable, depression. In the era of highly active antiretroviral therapy (HAART), when quality of life issues are of paramount importance, strategies to improve social support, coping, and particularly, depressive symptoms are strongly encouraged.

Little is know about the relationship of abuse history and other risk factors with being overweight and obese among gastrointestinal patients. The purpose of this study was to assess the relative risk of abuse history on being overweight and obese among 239 female gastrointestinal patients. Forty-one percent of the patients were found to be overweight or obese, 49% reported a history of physical abuse, and 42% had a sexual abuse history. A history of physical abuse (odds ratio = 1.34, P < 0.03), being nonwhite (odds ratio = 2.66, P < 0.01), being older (odds ratio = 1.03 for each year older, P < 0.02), and having fewer years of schooling (odds ratio = 1.11, P < 0.05) were found to be strongly associated with being overweight and/or obese. Among the female patients referred for gastrointestinal disorders at a university-based gastrointestinal clinic, a high proportion was overweight or obese. Physical abuse history and several demographic factors were significantly related to being overweight and obese in this clinical population.

Background: Anxiety, discomfort, and high levels of concern can affect patient attitude toward endoscopic procedures as well as compliance and adherence to current recommendations for the examination. This study evaluated how patients perceive flexible sigmoidoscopy. Methods: A prospective study was conducted at two sites of 764 patients presenting for GI endoscopy (flexible sigmoidoscopy 175, colonoscopy 384, EGD 205). Before these procedures, patients rated their anticipated (preprocedure) difficulty and degree of concern for each of 30 specific concerns. After the procedure, the patients rated their actual (postprocedure) difficulty. Patients' levels of concerns and difficulty were compared before and after the procedure and among the 3 procedure types. Results: Before the procedure, patients who were to undergo flexible sigmoidoscopy had fewer concerns and lower scores for the severity of the concerns than did patients having colonoscopy or EGD. After the procedure, patients who had flexible sigmoidoscopy rated it as more difficult than patients who had colonoscopy or EGD. Patients who had colonoscopy and EGD graded their actual difficulty as less than their anticipated difficulty. However, patients who had flexible sigmoidoscopy rated the actual difficulty the same as the anticipated difficulty. Conclusions: Although patients have fewer concerns regarding flexible sigmoidoscopy than for the other endoscopic procedures, after the procedure they rate sigmoidoscopy as more difficult compared with postprocedure ratings by patients who underwent colonoscopy or EGD. This suggests that it may be necessary to change the perception of flexible sigmoidoscopy as being the best tolerated of the endoscopic procedures. (Gastrointest Endosc 2002;55:315-20.)

OBJECTIVE: For patients with painful functional bowel disorders (FBD), physicians frequently make diagnostic and treatment decisions based on the severity of the pain reported; patients with severe painful complaints may receive extensive diagnostic tests and treatments. Therefore, it would be important to determine what clinical factors contribute to the judgment of severity among patients with FBD. The aim of this study was to identify the psychosocial, behavioral, and physiological (visceral sensitivity) factors that predicted severity in patients with moderate to severe FBD. METHODS: Two hundred eleven female patients with moderate or severe FBD, as determined by the Functional Bowel Disorder Severity Index, entered a multicenter treatment trial at the University of North Carolina and the University of Toronto. Patients filled out diary cards and were given questionnaires and physiological testing (rectal sensitivity using barostat). Analysis of covariance and logistic regression adjusting for demographic factors were performed to determine which factors distinguished patients at study entry with moderate from those with severe FBD. RESULTS: Patients with severe FBD were characterized by greater depression and psychological distress, poorer physical functioning and health-related quality of life, more maladaptive coping strategies, and greater health care utilization. There was a trend for patients with severe FBD to have lower rectal sensation thresholds. Regression analysis indicated that severity was best predicted by behavioral features: poorer daily physical function, difficulties related to eating, more phone calls to the physician, and more days in bed for GI symptoms. CONCLUSIONS: We conclude that patient illness behaviors are best correlated with severity in FBD. The use of psychopharmacological agents (e.g., antidepressants) and psychological treatments to treat psychiatric comorbidity and to improve behavioral coping styles is recommended. Training to help medical physicians identify and respond to psychosocial and behavioral features of these conditions is likely to improve patient satisfaction with their care and the clinical outcome.

In this study, we assessed the longitudinal effect of a Department of Veterans Affairs (VA) patient-centered Care Coordination Home Telehealth (CCHT) program on preventable hospitalization use by veterans with diabetes mellitus (DM) at four VA medical centers. We used a matched treatment-control design (n = 387 for both groups). All patients were followed for 4 years. We operationalized ambulatory care-sensitive conditions (ACSCs) by applying Agency for Healthcare Research and Quality criteria to VA inpatient databases to determine preventable hospitalization use. We used a generalized linear mixed model to estimate the adjusted effect of the CCHT program on preventable hospitalization use over time. During the initial 18 months of follow-up, CCHT enrollees were less likely to be admitted for a preventable hospitalization than their nonenrollee counterparts, and this difference diminished during the rest of the 4-year follow-up period. The VA CCHT program for DM patients reduced preventable hospitalizations. These findings are some of the first that have systematically examined the extent to which home telehealth programs have a long-term effect on preventable hospitalization use.

Misclassification of race and ethnicity in administrative data may produce misleading results if it is overlooked or ignored. In this study, we examined the racial/ethnic classifications of 1,084 veterans with stroke in Florida who received inpatient and outpatient services within the Department of Veterans Affairs (VA) healthcare system and who were also eligible for Medicare between 2000 and 2001. We compared the reliability of racial/ethnic classifications between VA inpatient data, VA outpatient data, and Medicare data. Our results showed that (1) the rate of unknown racial/ethnic classification in VA outpatient and inpatient data was high, (2) minimizing the unknowns by substituting known values from other data when available would greatly enhance the overall and individual classification reliability, (3) black and white classifications in the VA data had stronger agreement with Medicare data, and (4) Medicare data may under-represent Hispanic patients. Key words: administrative data, ethnicity, Department of Veterans Affairs, Medicare, race, racial/ethnic classification, reliability, Social Security Administration, stroke, validity, veterans. INTRODUCTION Stroke is one of the leading causes of death and major cause of serious and long-term disability in the United States population [1] as well as in the veteran population [2-3]. Numerous studies have shown racial/ ethnic disparities in stroke. In a recent study using a continuous annual household-based survey of the United States population from 1999 to 2001, McGruder et al. reported that racial/ethnic disparities existed in stroke prevalence, risk behaviors, and medical history [4]. In a recent selective review of literature published between 1991 and 2003, Stansbury et al. provided a broad perspective on race/ethnicity across the continuum of stroke care [5]. Their review confirmed the increased stroke incidence and mortality among black Americans and demonstrated the higher prevalence of hypertension among black and Hispanic patients and atrial fibrillation among non-Hispanic white stroke patients. Within the Department of Veterans Affairs (VA) healthcare system, Jones et al. examined racial variation and initial stroke severity among 982 veteran patients who received acute stroke care [6]. Using the Canadian Neurological Scale, Jones et al. showed that unadjusted scores were significantly lower for black patients than for white patients (7.96 vs 9.32, p = 0.04), which indicated greater stroke severity among black patients. Reports on racial/ethnic disparities in the use of stroke-related procedures and services showed mixed results. In an earlier study among a national sample of veterans with ischemic stroke, Oddone et al. reported that the likelihood of angiography for black patients was 47 percent that of white patients and Hispanic patients were only 75 percent as likely as non-Hispanic white patients to receive the procedure [7]. On the contrary, Goldstein et al. found no significant differences between white and nonwhite patients in the use of a variety of stroke-related procedures and services among 1,073 veterans diagnosed with acute ischemic stroke [8]. In two separate studies on racial/ethnic disparities in poststroke rehabilitation outcomes, Horner et al. showed that black veteran patients had greater residual physical deficits from stroke than white patients [9] and that low-income black veteran patients experienced poorer functional recovery over a 12-month period [10]. Most of these studies were based on data extracted from the VA inpatient and/or outpatient databases. Less, however, is known about the agreement of racial/ethnic classification for stroke patients between the VA inpatient and outpatient databases and Medicare data. Although the overall veteran population has been declining, VA healthcare enrollees have been increasing. The number of veteran patients age 65 and over is projected to increase rapidly in the next 10 years. …