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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.

This study compares the characteristics of state veterans' nursing homes and community nursing homes with VA per-diem residentes between 1999 - 2002. A structure, process, and outcome model was used to examine whether there was any difference in the multi-dimensional quality measures among the three types of community nursing homes (for profit, not-for-profit, and government) and state veterans' nursing homes. For profit community nursing homes were less likely to achieve nurse staffing standards while government facilities were more likely to achieve CNA staffing standards when compared to the state veterans' homes. All community nursing homes had a lower prevelance of tube feeds and catheterization when compared to state veterans' nursing homes. Only government community nursing homes had significantly lower quality of life deficiencies and pressure sore prevelance when compared to state veterans' nursing homes. Vigilant monitoring of all long-term care facilities utilized by veterans is needed.

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.

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.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.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.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.

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. …