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Objective: To compare the economic impact of high-dose trivalent (HD) versus standard-dose trivalent (SD) influenza vaccination on direct medical costs for cardio-respiratory hospitalizations in adults aged 65 years or older enrolled in the United States (US) Veteran's Health Administration (VHA)., Methods: Leveraging a relative vaccine effectiveness study of HD versus SD over five respiratory seasons (2010/11 through 2014/15), we collected cost data for healthcare provided to the same study population both at VHA and through Medicare services. Our economic assessment compared the costs of vaccination and hospital care for patients experiencing acute cardio-vascular or respiratory illness., Results: We analyzed 3.5 million SD and 158,636 HD person-seasons. The average cost of HD and SD vaccination was $23.48 (95% CI: $21.29 - $25.85) and $12.21 (95% CI: $11.49 - $13.00) per recipient, respectively, while the hospitalization rates for cardio-respiratory disease in HD and SD recipients were 0.114 (95% CI: 0.108-0.121) and 0.132 (95% CI: 0.132-0.133) per person-season, respectively. Attributing the average cost per hospitalization of $11,796 (95% CI: $11,685 - $11,907) to the difference in hospitalization rates, we estimated savings attributable to HD to be $202 (95% CI: $115 - $280) per vaccinated recipient., Conclusions: For the five-season period of 2010/11 through 2014/15, HD influenza vaccination was associated with net cost savings due to fewer hospitalizations, and therefore lower direct medical costs, for cardio-respiratory disease as compared to SD influenza vaccination in the senior US VHA population., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Observational studies of the relative effectiveness of influenza vaccines are essential for public health decision making. Their estimates, however, are subject to bias due to unmeasured confounders. Instrumental variable (IV) methods can control for observed and unobserved confounders., Methods: We used linked electronic medical record databases in the Veterans Health Administration (VHA) as well as Medicare administrative files to examine the relative vaccine effectiveness (rVE) of high-dose influenza vaccine (HD) versus standard-dose influenza vaccines (SD) in preventing hospitalizations among VHA-enrolled Veterans ≥65 years of age during 5 influenza seasons (2010-2011 through 2014-2015). Using multivariable IV Poisson regression modeling to address unmeasured confounding and bias, we analyzed the data by each season and through longitudinal analysis of all five seasons., Findings: We included 3,638,924 person-influenza seasons of observation where 158,636 (4%) were among HD vaccine recipients and 3,480,288 (96%) were among SD vaccine recipients. Of the 1,728,562 Veterans, 1,702,824 (98.5%) were male and 1,299,412 (75%) were non-Hispanic white. Based on the longitudinal analysis of all five seasons, the IV-adjusted rVE estimate of HD vs. SD was 10% (95% CI, 8-12%) against all-cause hospitalization; 18% (95% CI, 15-21%) against cardiorespiratory-associated hospitalization; and 14% (95% CI, 6-22%) against influenza/pneumonia-associated hospitalization. The findings by season were similar., Interpretation: Our analysis of VHA clinical data collected from approximately 1.7 million Veterans 65 years and older during five seasons demonstrates that high-dose influenza vaccine is more effective than standard-dose influenza vaccines in preventing influenza- or pneumonia-associated hospitalizations, cardiorespiratory hospitalizations, and all-cause hospitalizations., (Published by Elsevier Ltd.)

Importance: Reducing wrong-site surgery is fundamental to safe, high-quality care. This is a follow-up study examining 8 years of reported surgical adverse events and root causes in the nation's largest integrated health care system., Objectives: To provide a follow-up description of incorrect surgical procedures reported from 2010 to 2017 from US Veterans Health Administration (VHA) medical centers, compared with the previous studies of 2001 to 2006 and 2006 to 2009, and to recommend actions for future prevention of such events., Design, Setting, and Participants: This quality improvement study describes patient safety adverse events and close calls reported from 86 VHA medical centers from the approximately 130 VHA facilities with a surgical program. The surgical procedures and programs vary in size and complexity from small rural centers to large, complex urban facilities. Procedures occurring between January 1, 2010, and December 31, 2017, were included. Data analysis took place in 2018., Main Outcomes and Measures: The categories of incorrect procedure types were wrong patient, side, site (including wrong-level spine), procedure, or implant. Events included those in or out of the operating room, adverse events or close calls, surgical specialty, and harm. These results were compared with the previous studies of VHA-reported wrong-site surgery (2001-2006 and 2006-2009)., Results: Our review produced 483 reports (277 adverse events and 206 close calls). The rate of in-operating room (in-OR) reported adverse events with harm has continued to trend downward from 1.74 to 0.47 reported adverse events with harm per 100 000 procedures between 2000 and 2017 based on 6 591 986 in-OR procedures. When in-OR events were examined by discipline as a rate, dentistry had 1.54, neurosurgery had 1.53, and ophthalmology had 1.06 reported in-OR adverse events per 10 000 cases. The overall VHA in-OR rate for adverse events during 2010 to 2017 was 0.53 per 10 000 procedures based on 3 234 514 in-OR procedures. The most common root cause for adverse events was related to issues in performing a comprehensive time-out (28.4%). In these cases, the time-out either was conducted incorrectly or was incomplete in some way., Conclusions and Relevance: Over the period studied, the VHA identified a decrease in the rate of reported adverse events in the OR associated with harm and continued reporting of adverse event close calls. Organizational efforts continue to examine root cause analysis reports, promulgate lessons learned, and enhance policy to promote a culture and behavior that minimizes events and is transparent in reporting occurrences.

This article reports on improved processes and outcomes from a virtual breakthrough series quality improvement collaborative to reduce preventable falls and fall-related injuries in 23 State Veterans Homes. Participating teams implemented 24 interventions (process changes); the most common was the postfall huddle. Teams reduced falls and fall-related injuries. This project highlights the importance of leadership support, interdisciplinary team involvement, and collaboration as essential components of fall prevention work.

Objective: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have consistently shown efficacy for posttraumatic stress disorder (PTSD) in meta-analyses of randomized controlled trials. However, no study has compared the effectiveness of these agents in routine clinical practice. We conducted a retrospective comparative effectiveness study of these 5 medications using electronic medical record data., Methods: We identified 2,931 Department of Veterans Affairs outpatients initiating treatment for PTSD between fiscal years 2004 and 2013 who received 1 of the 5 medications at an adequate dose and duration, combined with baseline and endpoint PTSD Checklist (PCL) measurements. Patients were identified based on clinical diagnoses of PTSD (DSM-IV criteria). We weighted participants in order to balance pretreatment characteristics. We compared continuous changes on total PCL score, symptom cluster scores, and sleep items, as well as categorical changes including reliable improvement and loss of PTSD diagnosis, using weighted regression analyses. We conducted exploratory analysis to determine whether any patient characteristics or service use variables predicted loss of PTSD diagnosis., Results: Patients improved by a mean of 5-6 points on the PCL over approximately 6 months of treatment. While half of patients had a reliable improvement of 5 points or more on the PCL, less than a fifth achieved loss of PTSD diagnosis. There were no differences between medications. The only significant (P < .001) predictor of loss of PTSD diagnosis was concurrent treatment with evidence-based psychotherapy., Conclusions: Available evidence-based medications for PTSD are equally effective in clinical practice. Although effective, our data suggest that patients choosing medication treatment for PTSD should consider concurrent treatment with evidence-based psychotherapy in order to maximize their chances of meaningful improvement., (© Copyright 2018 Physicians Postgraduate Press, Inc.)

Purpose: The aim of this article was to describe and compare treatment patterns, health care resource utilization (HRU), and health care costs before and after transition in veterans with schizophrenia who were transitioned from paliperidone palmitate given once monthly (PP1M) to paliperidone palmitate given every 3 months (PP3M) according to prescribing-information guidelines., Methods: This retrospective, longitudinal study was conducted using electronic health records data from the Veterans Health Administration (VHA). Veterans were eligible for inclusion if they were aged 18years or older, had ≥1 dispensation of PP3M, were enrolled with VHA benefits for ≥24 months prior to transition to PP3M, had ≥1 schizophrenia diagnosis, were transitioned to PP3M according to prescribing-information guidelines (operationalized as no gap in PP1M treatment of >45days during the 4 months prior to PP3M transition, with the same dosage in the last 2 PP1M dispensations), and had appropriate dose conversion. Treatment patterns, HRU, and costs 6 months pre and post PP3M transition were described and compared using the McNemar test and the Wilcoxon signed rank test., Findings: Of the 277 veterans identified, the majority were men (92.8%); the median age was 56.5years. Among 197 veterans who had at least 6 months of follow-up pre and post PP3M transition, oral antipsychotic use was significantly decreased (from 49.7% to 43.1%; P = 0.0326). Additionally, the mean number of days spent in an inpatient setting (41.4vs 21.6; P = 0.0164), the mean number of outpatient visits per patient (31.0vs 25.6; P < 0.0001), and the mean total health care costs ($27,745vs $23,772; P = 0.0050) were significantly decreased., Implications: After transitioning to PP3M treatment, veterans had significantly reduced use of oral antipsychotics, HRU, and costs. Although generalizability may be limited due to the veteran population and to those who transitioned according to PP3M prescribing guidelines, future studies in other patient populations may be used to extend these conclusions., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: We examined whether a high-dose inactivated influenza vaccine was more efficacious in preventing hospitalizations than a standard-dose vaccine in the Veterans Health Administration (VHA) senior population., Methods: This study estimated the relative vaccine effectiveness (rVE) of high dose versus standard dose using a retrospective cohort of VHA patients 65 years of age or older in the 2015-2016 influenza season. To adjust for measured confounders, we matched each high-dose recipient with up to 4 standard-dose recipients vaccinated at the same location within a 2-week period and having 2 or more pre-existing medical comorbidities. We used the previous event rate ratio method (PERR), a type of difference-in-differences analysis, to adjust for unmeasured confounders., Results: We evaluated 104965 standard-dose and 125776 high-dose recipients; matching decreased the population to 49091 standard-dose and 24682 high-dose recipients. The matched, PERR-adjusted rVE was 25% (95% confidence interval [CI], 2%-43%) against influenza- or pneumonia-associated hospitalization, 7% (95% CI, -2% to 14%) against all-cause hospitalization, 14% (95% CI, -8% to 32%) against influenza- or pneumonia-associated outpatient visit, 5% (95% CI, 2%-8%) against all-cause outpatient visit, and 38% (95% CI, -5% to 65%) against laboratory-confirmed influenza., Conclusions: In protecting senior VHA patients against influenza- or pneumonia-associated hospitalization, a high-dose influenza vaccine is more effective than a standard-dose vaccine.

The Veterans Health Administration implemented The Daily Plan (TDP) to improve patient safety. We compared length of stay and readmission between intervention and control units. Length of stay decreased for both groups. Readmission rates increased for controls (21.3%-25.0%, P = .02) and barely changed for TDP units (21.7%-22.5%, P = .37). Although there were no efficiency improvements, TDP's ultimate goal was safety. Not all patient safety actions improve efficiency; nonetheless, their value continues.

The Veterans Health Administration implemented a Virtual Breakthrough Series to prevent pressure ulcers. The pressure ulcer rate decreased from 1.2 to 0.9 per 1000 bed days of care (P = .017). The most common interventions were education (N = 26; 68%), improved documentation (N = 23; 61%), and the use of equipment and supplies (N = 21; 55%). In summary, this project helped improve pressure ulcer rates in the Veterans Health Administration and presents a promising model for implementing a virtual model for improvement.

Purpose: Almost half of all patients diagnosed with schizophrenia have a history of substance abuse (SA). However, data on treatment of schizophrenia with paliperidone palmitate (PP) among patients with comorbid SA are limited. The objective of this study was to compare all-cause and SA-related health care resource utilization and costs in veterans with schizophrenia and co-occurring SA who were treated with PP versus oral atypical antipsychotics (OAAs)., Methods: Veterans Health Administration electronic health record data were used to conduct a retrospective longitudinal study in veterans with schizophrenia who initiated PP or OAA between January 1, 2010 and June 30, 2016, had ≥12 months of enrollment before treatment initiation (baseline), were diagnosed with SA, and had ≥1 Global Assessment of Functioning score during baseline. Differences in baseline characteristics were adjusted for using inverse probability of treatment weighting. Adjusted cost differences and incidence rate ratios (IRR) for the association between PP versus OAA and all-cause and SA-related health care costs and health care resource utilization in the 12 months after treatment initiation were estimated with corresponding 95% CIs using weighted linear and Poisson regression models, respectively., Findings: Of 6872 veterans in the study, 1684 (25%) and 5188 (75%) were treated with PP and OAA, respectively. After adjustment, PP was associated with fewer all-cause inpatient (IRR = 0.88; 95% CI, 0.85 to 0.90), mental health-related inpatient (IRR = 0.88; 95% CI, 0.85 to 0.91), and long-term care stays (IRR = 0.53; 95% CI, 0.44 to 0.64), but more frequent mental health intensive case management visits (IRR = 1.51; 95% CI, 1.49 to 1.53) compared with OAA (all P < 0.001). Similarly, PP was associated with significantly lower rates of SA-related inpatient stays (IRR = 0.80; 95% CI, 0.77 to 0.83), mental health stays (IRR = 0.85; 95% CI, 0.82 to 0.88), long-term care stays (IRR = 0.22; 95% CI, 0.15 to 0.32), and outpatient visits (IRR = 0.78; 95% CI, 0.77 to 0.79) than OAA (all P < 0.001). Relative to OAA, patients treated with PP also had lower mean annual all-cause (cost difference = -$10,473; 95% CI, -$17,827 to -$3491) and SA-related (cost difference = -$8457; 95% CI, -$12,710 to -$3638) medical costs (all P < 0.001)., Implications: PP was associated with significant total medical cost savings resulting from fewer hospitalizations and lower rates of SA-related health care resource utilization compared with OAA in patients with schizophrenia and comorbid SA. Thus, PP appears to be a valuable treatment option for patients in this subpopulation., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Background Few randomised controlled trials (RCTs) have shown decreases in suicide. Aims To identify interventions for preventing suicide. Method We searched EMBASE and Medline from inception until 31 December 2015. We included RCTs comparing prevention strategies with control. We pooled odds ratios (ORs) for suicide using the Peto method. Results Among 8647 citations, 72 RCTs and 6 pooled analyses met inclusion criteria. Three RCTs ( n = 2028) found that the World Health Organization (WHO) brief intervention and contact (BIC) was associated with significantly lower odds of suicide (OR = 0.20, 95% CI 0.09-0.42). Six RCTs ( n = 1040) of cognitive-behavioural therapy (CBT) for suicide prevention and six RCTs of lithium ( n = 619) yielded non-significant findings (OR = 0.34, 95% CI 0.12-1.03 and OR = 0.23, 95% CI 0.05-1.02, respectively). Conclusions The WHO BIC is a promising suicide prevention strategy. No other intervention showed a statistically significant effect in reducing suicide., Competing Interests: Declaration of interestNone., (© The Royal College of Psychiatrists 2017.)

Objective: The Mental Health Environment of Care Checklist (MHEOCC) has been reported to be effective in decreasing suicide on inpatient mental health units. The authors sought to examine whether the effect of the MHEOCC was sustained., Methods: Root cause analysis reports from all Department of Veterans Affairs (VA) hospitals were reviewed to obtain a count of suicides occurring on mental health units from 2000 to 2015. The number of mental health admissions and bed-days of care were obtained for the same period., Results: The rate of suicide prior to the implementation of the MHEOCC was 4.2 per 100,000 admissions or 2.72 per million bed-days of care. The rate after implementation was .74 per 100,000 admissions or .69 per million bed-days of care. There was no loss of effect in the seven years after implementation., Conclusions: The MHEOCC was associated with a sustained reduction in suicides occurring on inpatient mental health units.

Seasonal influenza epidemics have a substantial public health and economic burden in the United States (US). On average, over 200,000 people are hospitalized and an estimated 23,000 people die from respiratory and circulatory complications associated with seasonal influenza virus infections each year. Annual direct medical costs and indirect productivity costs across the US have been found to average respectively at $10.4 billion and $16.3 billion. The objective of this study was to estimate the economic impact of severe influenza-induced illness on the US Veterans Affairs population. The five-year study period included 2010 through 2014. Influenza-attributed outcomes were estimated with a statistical regression model using observed emergency department (ED) visits, hospitalizations, and deaths from the Veterans Health Administration of the Department of Veterans Affairs (VA) electronic medical records and respiratory viral surveillance data from the Centers for Disease Control and Prevention (CDC). Data from VA's Managerial Cost Accounting system were used to estimate the costs of the emergency department and hospital visits. Data from the Bureau of Labor Statistics were used to estimate the costs of lost productivity; data on age at death, life expectancy and economic valuations for a statistical life year were used to estimate the costs of a premature death. An estimated 10,674 (95% CI 8,661-12,687) VA ED visits, 2,538 (95% CI 2,112-2,964) VA hospitalizations, 5,522 (95% CI 4,834-6,210) all-cause deaths, and 3,793 (95% CI 3,375-4,211) underlying respiratory or circulatory deaths (inside and outside VA) among adult Veterans were attributable to influenza each year from 2010 through 2014. The annual value of lost productivity amounted to $27 (95% CI $24-31) million and the annual costs for ED visits were $6.2 (95% CI $5.1-7.4) million. Ninety-six percent of VA hospitalizations resulted in either death or a discharge to home, with annual costs totaling $36 (95% CI $30-43) million. The remaining 4% of hospitalizations were followed by extended care at rehabilitation and skilled nursing facilities with annual costs totaling $5.5 (95% CI $4.4-6.8) million. The annual monetary value of quality-adjusted life years (QALYs) lost amounted to $1.1 (95% CI $1.0-1.2) billion. In total, the estimated annual economic burden was $1.2 (95% CI $1.0-1.3) billion, indicating the substantial burden of seasonal influenza epidemics on the US Veterans Affairs population. Premature death was found to be the largest driver of these costs, followed by hospitalization., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: AC and JL are employees of Sanofi Pasteur. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials. AC has performed duties as a peer reviewer for PLOS ONE, this does not alter AC’s adherence to PLOS ONE Editorial policies and criteria.

Rationale, Aims and Objectives: Patient safety culture may have a significant influence on safety processes and outcomes. Therefore, it is important to have valid tools to measure patient safety culture in order to identify potential levers for cultural change that could improve patient safety. The 65-item Department of Veterans Affairs Patient Safety Culture Survey (VA PSCS) consists of 14 dimensions and is administered biannually to VA employees. Test-retest reliability of the VA PSCS has not been established., Methods: We conducted repeated administrations of the VA PSCS among 28 VA employees. We measured intraclass correlation coefficients for each item and dimension., Results: Test-retest intraclass correlation coefficient values were 0.7 or greater for 13 out of 14 dimensions of the VA PSCS. Employees had difficulty reliably reporting how others feel about patient safety., Conclusions: In general, the VA PSCS survey showed adequate test-retest reliability. Items asking what others think or feel showed lower reliability. Further work is needed to better understand the relationship between safety culture, safety processes and safety outcomes., (Published 2016. This article is a U.S. Government work and is in the public domain in the USA.)

Background: In 2014 the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help VHA facilities prevent hospital-acquired conditions: catheter-associated urinary tract infection (CAUTI) and hospital-acquired pressure ulcers (HAPUs)., Methods: During the prework phase, participating facilities assembled a multidisciplinary team, assessed their current system for CAUTI or HAPU prevention, and examined baseline data to set improvement aims. The action phase consisted of educational conference calls, coaching, and monthly team reports. Learning was conducted via phone, web-based options, and e-mail. The CAUTI bundle focused on four key principles: (1) avoidance of indwelling urinary catheters, (2) proper insertion technique, (3) proper catheter maintenance, and (4) timely removal of the indwelling catheter. The HAPU bundle focused on assessment and inspection, pressure-relieving surfaces, turning and repositioning, incontinence management, and nutrition/hydration assessment and intervention., Results: For the 18 participating units, the mean aggregated CAUTI rate decreased from 2.37 during the prework phase to 1.06 per 1,000 catheter-days during the action (implementation) phase (p < 0.001); the rate did not change for CAUTI nonparticipating sites. HAPU data were available only for 21 of the 31 participating units, whose mean aggregated HAPU rate decreased from 1.80 to 0.99 from prework to continuous improvement (p < 0.001). Staff education and documentation improvement were the most frequently implemented changes., Conclusion: This project helped improve CAUTI and HAPU rates in the VHA and presents a promising model for implementing a virtual model for improvement., (Copyright 2016 The Joint Commission.)

Background: The Veterans Health Administration (VHA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help prevent falls and fall-related injuries. This project enabled teams to expand program infrastructure, redesign improvement strategies, and enhance program evaluation., Methods: A VBTS collaborative involves prework, action, and continuous improvement. Actions included educational calls, monthly reports, coaching, and feedback. Evaluation included assessment of interventions, team capacity and infrastructure changes, and rates of falls and fall-related major injuries., Results: Fifty-nine teams completed the project. The majority submitted monthly reports. The average number of interventions per team was 6.66 (range, 1-12; mode = 6). The most frequently implemented changes were staff education; post-fall huddles; data tracking; and classifying falls, handoff communication, and intentional rounding. On a program questionnaire aggregated average summary scores improved from 136.54 (baseline) to 58.26 (follow-up; range, 0-189; p < 0.0001). The mean aggregated fall-related major injury rate for participants decreased from 6.8 to 4.8 per 100,000 bed-days of care (p = 0.02), or 5 major injuries avoided per month. No statistically significant changes occurred for nonparticipants. The mean aggregated fall rate did not change significantly from baseline to follow-up for participants (p = 0.42) or nonparticipants (p = 0.21)., Conclusion: Teams submitted reports and implemented changes resulting in decreased major injuries related to falls for participating units. Teams also made changes in their fall prevention programs such as classifying how they analyze falls and implementing injury reduction strategies. The approaches used show promise for reducing fall-related harm for inpatients, as well as assisting teams in implementing changes., (Copyright 2016 The Joint Commission.)

Objective: To compare health care resource utilization and costs in veterans with schizophrenia treated with paliperidone palmitate (PP) versus oral atypical antipsychotics (OAAs)., Methods: A retrospective longitudinal study was conducted using electronic health record data from the Veterans Health Administration. Veterans with schizophrenia (identified using ICD-9-CM 295.x) initiating PP or OAAs between January 2010 and October 2014, with ≥ 12 months of benefits enrollment prior to treatment initiation and ≥ 6 months of enrollment after treatment initiation, and with ≥ 1 Global Assessment of Functioning measurement at baseline were included. Inverse probability of treatment weighted regression models were used to estimate incidence rate ratios (IRRs) and cost differences (CDs) for the impact of PP versus OAAs on health care resource utilization and costs., Results: Among 10,290 eligible veterans, 2,285 and 8,005 were initiated on PP and OAAs, respectively. After adjustment, PP was associated with less frequent all-cause inpatient hospitalizations (IRR = 0.89, P < .001) and more frequent mental health intensive case management visits (IRR = 1.81, P < .001) compared to OAAs. PP treatment was associated with higher likelihood of increased income (odds ratio [OR] = 1.20, P = .027) and lower likelihood of homelessness (OR = 0.82, P < .001). While mean annual pharmacy and outpatient costs were higher among PP users (CD = $3,417 pharmacy, $2,527 outpatient, P < .001), mean annual inpatient costs were lower (CD = -$14,456, P < .001), resulting in average annual total health care (medical and pharmacy) cost savings associated with PP (CD = -$8,511, P = .012) relative to OAAs., Conclusions: PP treatment was associated with significantly lower total health care costs attributable to reduced inpatient admissions compared to OAAs. Higher mental health intensive case management participation among PP users may have contributed to the differences observed., (© Copyright 2016 Physicians Postgraduate Press, Inc.)

Suicidal ideation may be associated with all-cause mortality. Available research shows that treatment of depression reduces the risk of all-cause mortality in patients with suicidal ideation. However, this finding has not been replicated in a clinical population, where patients have various mental health conditions. We examined the association between suicidal ideation and all-cause mortality in a clinical cohort. We stratified patients presenting to a mental health clinic from January 2005 through December 2007 based upon their degree of suicidal ideation and obtained vital status information through June 2015. We compared groups using survival analysis, adjusting for patient characteristics and treatment receipt. Among 1,869 patients who completed the initial assessment, there were 363 deaths. Patients with the highest levels of suicidal ideation died at increased rates. Cause-of-death data in the year following the initial assessment indicates that the difference in mortality is not likely attributable to suicide. Accounting for patient characteristics and treatment, which included medical care and mental health care, did not meaningfully diminish the relationship between suicidal ideation and all-cause mortality. Additional research is needed to determine specific treatment elements that may moderate the relationship between suicidal ideation and all-cause mortality., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Background: Many administrative data sources are available to study the epidemiology of infectious diseases, including Clostridium difficile infection (CDI), but few publications have compared CDI event rates across databases using similar methodology. We used comparable methods with multiple administrative databases to compare the incidence of CDI in older and younger persons in the United States., Methods: We performed a retrospective study using three longitudinal data sources (Medicare, OptumInsight LabRx, and Healthcare Cost and Utilization Project State Inpatient Database (SID)), and two hospital encounter-level data sources (Nationwide Inpatient Sample (NIS) and Premier Perspective database) to identify CDI in adults aged 18 and older with calculation of CDI incidence rates/100,000 person-years of observation (pyo) and CDI categorization (onset and association)., Results: The incidence of CDI ranged from 66/100,000 in persons under 65 years (LabRx), 383/100,000 in elderly persons (SID), and 677/100,000 in elderly persons (Medicare). Ninety percent of CDI episodes in the LabRx population were characterized as community-onset compared to 41 % in the Medicare population. The majority of CDI episodes in the Medicare and LabRx databases were identified based on only a CDI diagnosis, whereas almost ¾ of encounters coded for CDI in the Premier hospital data were confirmed with a positive test result plus treatment with metronidazole or oral vancomycin. Using only the Medicare inpatient data to calculate encounter-level CDI events resulted in 553 CDI events/100,000 persons, virtually the same as the encounter proportion calculated using the NIS (544/100,000 persons)., Conclusions: We found that the incidence of CDI was 35 % higher in the Medicare data and fewer episodes were attributed to hospital acquisition when all medical claims were used to identify CDI, compared to only inpatient data lacking information on diagnosis and treatment in the outpatient setting. The incidence of CDI was 10-fold lower and the proportion of community-onset CDI was much higher in the privately insured younger LabRx population compared to the elderly Medicare population. The methods we developed to identify incident CDI can be used by other investigators to study the incidence of other infectious diseases and adverse events using large generalizable administrative datasets.

Background: Population attributable risk percent (PAR%) is an epidemiological tool that provides an estimate of the percent reduction in total disease burden if that disease could be entirely eliminated among a subpopulation. As such, PAR% is used to efficiently target prevention interventions. Due to significant limitations in current Clostridium difficile Infection (CDI) prevention practices and the development of new approaches to prevent CDI, such as vaccination, we determined the PAR% for CDI in various subpopulations in the Medicare 5% random sample., Methods: This was a retrospective cohort study using the 2009 Medicare 5% random sample. Comorbidities, infections, and healthcare exposures during the 12 months prior to CDI were identified. CDI incidence and PAR% were calculated for each condition/exposure. Easy to identify subpopulations that could be targeted from prevention interventions were identified based on PAR%., Findings: There were 1,465,927 Medicare beneficiaries with 9,401 CDI cases for an incidence of 677/100,000 persons. Subpopulations representing less than 15% of the entire population and with a PAR% ≥ 30% were identified. These included deficiency anemia (PAR% = 37.9%), congestive heart failure (PAR% = 30.2%), fluid and electrolyte disorders (PAR% = 29.6%), urinary tract infections (PAR% = 40.5%), pneumonia (PAR% = 35.2%), emergent hospitalization (PAR% = 48.5%) and invasive procedures (PAR% = 38.9%). Stratification by age and hospital exposures indicates hospital exposures are more strongly associated with CDI than age., Significance: Small and identifiable subpopulations that account for relatively large proportions of CDI cases in the elderly were identified. These data can be used to target specific subpopulations for CDI prevention interventions.

Objective: To report on the prevalence and incidence of Clostridium difficile infection (CDI) from 2009 to 2013 among Veterans Healthcare Administration patients, Design: A retrospective descriptive analysis of data extracted from a large electronic medical record (EMR) database, Setting: Data were acquired from VHA healthcare records from 2009 to 2013 that included outpatient clinical visits, long-term care, and hospitalized care as well as pharmacy and laboratory information., Results: In 2009, there were 10,207 CDI episodes, and in 2013, there were 12,143 CDI episodes, an increase of 19.0%. The overall CDI rate increased by 8.4% from 193 episodes per 100,000 patient years in 2009 to 209 episodes per 100,000 patient years in 2013. Of the CDI episodes identified in 2009, 58% were identified during a hospitalization, and 42% were identified in an outpatient setting. In 2013, 44% of the CDI episodes were identified in an outpatient setting., Conclusion: This is one of the largest studies that has utilized timely EMR data to describe the current CDI epidemiology at the VHA. Despite an aging population with greater burden of comorbidity than the general US population, our data show that VHA CDI rates stabilized between 2011 and 2013 following increases likely attributable to the introduction of the more sensitive nucleic acid amplification tests (NAATs). The findings in this report will help establish an accurate benchmark against which both current and future VA CDI prevention initiatives can be measured.

Objective: Patient decision aids have been used in many clinical situations to improve the patient centeredness of care. A patient decision aid for patients with posttraumatic stress disorder (PTSD) has not been developed or tested. The authors evaluated the effects of a patient decision aid on the patient centeredness of PTSD treatment., Methods: The study was a randomized trial of a patient decision aid for PTSD versus treatment as usual (control group). The participants were 132 male and female veterans who presented to a single U.S. Department of Veterans Affairs hospital with a new diagnosis of PTSD. Patient centeredness was assessed by knowledge of PTSD and its treatment, level of decisional uncertainty, and ability to state a preferred treatment option. Secondary outcomes included treatments received and PTSD symptoms in the six months after study entry., Results: Compared with the control group (N=65), participants who reviewed the patient decision aid (N=63) had higher scores for PTSD knowledge (p=.002) and less conflict about their choice of treatment (p=.003). In addition, participants who reviewed the patient decision aid were more likely to select and receive an evidence-based treatment for PTSD (p=.04) and had superior PTSD outcomes (p=.004) compared with the control group., Conclusions: Use of a patient decision aid was associated with improvements in patient-centered PTSD treatment. The patient decision aid was also associated with greater use of evidence-based treatments and improvement of PTSD symptoms. This study suggests that clinics should consider using a patient decision aid for patients with PTSD.

We developed linguistics-driven prediction models to estimate the risk of suicide. These models were generated from unstructured clinical notes taken from a national sample of U.S. Veterans Administration (VA) medical records. We created three matched cohorts: veterans who committed suicide, veterans who used mental health services and did not commit suicide, and veterans who did not use mental health services and did not commit suicide during the observation period (n = 70 in each group). From the clinical notes, we generated datasets of single keywords and multi-word phrases, and constructed prediction models using a machine-learning algorithm based on a genetic programming framework. The resulting inference accuracy was consistently 65% or more. Our data therefore suggests that computerized text analytics can be applied to unstructured medical records to estimate the risk of suicide. The resulting system could allow clinicians to potentially screen seemingly healthy patients at the primary care level, and to continuously evaluate the suicide risk among psychiatric patients.

To improve methods of estimating use of evidence-based psychotherapy for posttraumatic stress disorder in the Veteran's health administration, we evaluated administrative data and note text for patients newly enrolling in six VHA outpatient PTSD clinics in New England during the 2010 fiscal year (n = 1,924). Using natural language processing, we developed machine learning algorithms that mimic human raters in classifying note text. We met our targets for algorithm performance as measured by precision, recall, and F-measure. We found that 6.3 % of our study population received at least one session of evidence-based psychotherapy during the initial 6 months of treatment. Evidence-based psychotherapies appear to be infrequently utilized in VHA outpatient PTSD clinics in New England. Our method could support efforts to improve use of these treatments.

Objective: Posttraumatic stress disorder (PTSD) is an important mental health issue in terms of the number of people affected and the morbidity and functional impairment associated with the disorder. The purpose of this study was to examine the efficacy of all treatments for PTSD., Data Sources: PubMed, MEDLINE, PILOTS, and PsycINFO databases were searched for randomized controlled clinical trials of any treatment for PTSD in adults published between January 1, 1980, and April 1, 2012, and written in the English language. The following search terms were used: post-traumatic stress disorders, posttraumatic stress disorder, PTSD, combat disorders, and stress disorders, post-traumatic., Study Selection: Articles selected were those in which all subjects were adults with a diagnosis of PTSD based on DSM criteria and a valid PTSD symptom measure was reported. Other study characteristics were systematically collected. The sample consisted of 137 treatment comparisons drawn from 112 studies., Results: Effective psychotherapies included cognitive therapy, exposure therapy, and eye movement desensitization and reprocessing (g = 1.63, 1.08, and 1.01, respectively). Effective pharmacotherapies included paroxetine, sertraline, fluoxetine, risperidone, topiramate, and venlafaxine (g = 0.74, 0.41, 0.43, 0.41, 1.20, and 0.48, respectively). For both psychotherapy and medication, studies with more women had larger effects and studies with more veterans had smaller effects. Psychotherapy studies with wait-list controls had larger effects than studies with active control comparisons., Conclusions: Our findings suggest that patients and providers have a variety of options for choosing an effective treatment for PTSD. Substantial differences in study design and study participant characteristics make identification of a single best treatment difficult. Not all medications or psychotherapies are effective., (© Copyright 2013 Physicians Postgraduate Press, Inc.)

Context: Suicide is one of the leading causes of death in the United States. While suicides occurring during psychiatric hospitalization represent a very small proportion of the total number of suicides, these events are highly preventable owing to the controlled nature of the environment. Many methods have been proposed, but no interventions have been tested., Objective: To evaluate the effect of identification and abatement of hazards on inpatient suicides in the Veterans Health Administration (VHA)., Design, Setting, and Patients: The effect of implementation of a checklist (the Mental Health Environment of Care Checklist) and abatement process designed to remove suicide hazards from inpatient mental health units in all VHA hospitals was examined by measuring change in the rate of suicides before and after the intervention., Intervention: Implementation of the Mental Health Environment of Care Checklist., Main Outcome Measure: The number of completed suicides on inpatient mental health units in VHA hospitals., Results: Implementation of the Mental Health Environment of Care Checklist was associated with a reduction in the rate of completed inpatient suicide in VHA hospitals nationally. This reduction remained present when controlling for number of admissions (2.64 per 100 000 admissions before to 0.87 per 100 000 admissions after implementation; P < .001) and bed days of care (2.08 per 1 million bed days before to 0.79 per 1 million bed days after implementation; P < .001)., Conclusions: Use of the Mental Health Environment of Care Checklist was associated with a substantial reduction in the inpatient suicide rate occurring on VHA mental health units. Use of the checklist in non-VHA hospitals may be warranted.

Background: Posttraumatic stress disorder (PTSD) is a commonly occurring and often debilitating psychiatric condition. There currently is not definitive information regarding the efficacy of repetitive transcranial magnetic stimulation (rTMS) for PTSD., Objective: This study seeks to examine the efficacy of rTMS for PTSD., Methods: Twenty subjects with PTSD were randomly assigned to receive either 10 rTMS sessions delivered at 1 Hz to the right dorsolateral prefrontal cortex (DLPRC) or 10 sham rTMS sessions to the same area. A blinded rater assessed PTSD, depressive, anxiety, and neurocognitive symptoms before treatment, after the treatment series, and during a 2-month follow-up period., Results: Trancranial magnetic stimulation delivered at 1 Hz to the right DLPRC resulted in statistically and clinically significant improvements in core PTSD symptoms and depressive symptoms compared with sham treatments. The effectiveness showed some degradation during the 2 months after treatments were stopped., Conclusions: This blinded sham controlled trial supports the efficacy of 10 sessions of right DLPRC rTMS delivered at 1 Hz for the treatment of PTSD symptoms., (Published by Elsevier Inc.)

Objective: Measurement-based care has been endorsed but not embraced in mental health settings. There is currently little guidance regarding the best methods to implement measurement-based care., Methods: A survey of mental health providers was conducted before (N=15) and after (N=17) the implementation of a patient self-report symptom measurement system., Results: At baseline, respondents rarely used the patient self-assessment information (mean±SD=1.8±1.8); they reported the patient data to be marginally useful (4.1±1.9), and only slightly recommended the use of patient assessments (4.3±2.0). Possible scores ranged from 1 to 7, with higher scores indicating more positivity. At follow-up, respondents almost always used the information in the assessments (6.3±1.7), found the patient report data very useful (6.4±.8), and highly recommended continued use of patient surveys in the integrated clinic (6.6±.5)., Conclusions: Providers' lack of enthusiasm about integration of routine data collection and reporting of patient symptoms may be overcome by simply exposing providers to this process.

Objective: To determine whether there is an association between the Veterans Health Administration Medical Team Training (MTT) program and surgical morbidity., Design, Setting, and Participants: A retrospective health services study was conducted with a contemporaneous control group. Outcome data were obtained from the Veterans Health Administration Surgical Quality Improvement Program. The analysis included aggregated measures representing 119,383 sampled procedures from 74 Veterans Health Administration facilities that provide care to veterans., Main Outcome Measures: The primary outcome measure was the rate of change in annual surgical morbidity rate 1 year after facilities enrolled in the MTT program as compared with 1 year before and compared with the non-MTT program sites., Results: Facilities in the MTT program (n = 42) had a significant decrease of 17% in observed annual surgical morbidity rate (rate ratio, 0.83; 95% CI, 0.79-0.88; P = .01). Facilities not trained (n = 32) had an insignificant decrease of 6% in observed morbidity (rate ratio, 0.94; 95% CI, 0.86-1.05; P = .11). After adjusting for surgical risk, we found a decrease of 15% in morbidity rate for facilities in the MTT program and a decrease of 10% for those not yet in the program. The risk-adjusted annual surgical morbidity rate declined in both groups, and the decline was 20% steeper in the MTT program group (P = .001) after propensity-score matching. The steeper decline in annual surgical morbidity rates was also observed in specific morbidity outcomes, such as surgical infection., Conclusion: The Veterans Health Administration MTT program is associated with decreased surgical morbidity.

Objective: To describe incorrect surgical procedures reported from mid-2006 to 2009 from Veterans Health Administration medical centers and build on previously reported events from 2001 to mid-2006., Design: Retrospective database review., Setting: Veterans Health Administration medical centers., Interventions: The Veterans Health Administration implemented Medical Team Training and continues to support their directive for ensuring correct surgery to improve surgical patient safety., Main Outcome Measures: The categories were incorrect procedure types (wrong patient, side, site, procedure, or implant), major or minor surgery, in or out of the operating room (OR), adverse event or close call, specialty, and harm., Results: Our review produced 237 reports (101 adverse events, 136 close calls) and found decreased harm compared with the previous report. The rate of reported adverse events decreased from 3.21 to 2.4 per month (P = .02). Reported close calls increased from 1.97 to 3.24 per month (P ≤ .001). Adverse events were evenly split between OR (50) and non-OR (51). When in-OR events were examined as a rate, Neurosurgery had 1.56 and Ophthalmology had 1.06 reported adverse events per 10 000 cases. The most common root cause for adverse events was a lack of standardization of clinical processes (18%)., Conclusions: The rate of reported adverse events and harm decreased, while reported close calls increased. Despite improvements, we aim to achieve further gains. Current plans and actions include sharing lessons learned from root cause analyses, policy changes based on root cause analysis review, and additional focused Medical Team Training as needed.

Background: In 2000, the Department of Veterans Affairs (VA) instituted a performance measure to improve the quality of depression care. The measure evaluated adequacy of follow-up for depressed patients but was removed from clinic directors' performance plans in fiscal year (FY) 2009 because it had not been empirically validated. The VA depression performance measure was compared with an empirically validated model for assessing adherence to important depression treatment processes., Methods: VA medical centers (VAMCs) whose performance on the VA depression measure was in the top or bottom quartile nationally for all four quarters in FY2008 were selected for inclusion. A blinded interviewer attempted to contact clinical directors of both primary care and mental health at each VAMC and conducted telephone interviews using a protocol designed to employ the 3-Component Model (3CM) fidelity measure, which assesses domains of evidence-based depression care., Results: There were 9 sites in the "high-performing" group and 10 sites in the "low-performing" group. At least one interview was completed at 8 of the 9 sites in the high-performing group and 9 of the 10 sites in the low-performing group. There was a significant difference in the percentage of patients meeting the VA depression performance measure between the high- and low-performing groups (47.5% versus 14.7%; chi2 = 837.5, p < .001). The adapted version of the 3CM fidelity scale detected a significant difference in process of depression care between the high- and low-performing sites (82.3 versus 71.4; z = 2.4, p = .018)., Conclusions: The highest-performing sites on the VA depression performance measure adhered to important care processes more often than did the lowest-performing sites.

This study compares a sample of PTSD-positive, female survivors of interpersonal assault (n = 162) to a sample of similarly traumatized male counterparts (n = 45) on a number of variables, including PTSD-symptom severity, depressive symptoms, anger, guilt, and health-related concerns. Results indicate that male and female interpersonal assault survivors presented similarly with respect to PTSD and depressive symptomatology and reported comparable levels of guilt and that women reported significantly more health-related complaints than men did. With respect to the experience of anger, men report significant elevations on the state anger subscale of the State-Trait Anger Expression Inventory compared to women.

The authors examined the relationship between changes in symptoms of posttraumatic stress disorder (PTSD) and functioning as measured by the Medical Outcomes Study Short Form-36 (SF-36) among 167 veterans in a primary care clinic. Those who reported at least moderate baseline symptoms were categorized as better, unchanged, or worse at reassessment. The SF-36 was used to examine concordance between change in functioning and symptoms. Veterans with reliable changes in symptoms of PTSD showed corresponding statistically significant changes in functioning across health domains. Moreover, these changes in functioning were clinically significant on several SF-36 subscales and on one summary scale., (Copyright © 2011 International Society for Traumatic Stress Studies.)

A seven-valent pneumococcal conjugate vaccine (PCV7) introduced in the United States in 2000 has been shown to reduce invasive pneumococcal disease (IPD) in both vaccinated children and adults through induction of herd immunity. We assessed the impact of infant immunization on pneumococcal pneumonia hospitalizations and mortality in all age groups using Health Care Utilization Project State Inpatient Databases (SID) for 1996 to 2006 from 10 states; SID contain 100% samples of ICD9-coded hospitalization data for the selected states. Compared to a 1996-1997 through 1998-1999 baseline, by the 2005-2006 season, both IPD and pneumococcal pneumonia hospitalizations and deaths had decreased substantially in all age groups, including a 47% (95% confidence interval [CI], 38 to 54%) reduction in nonbacteremic pneumococcal pneumonia (ICD9 code 481 with no codes indicating IPD) in infants <2 years old and a 54% reduction (CI, 53 to 56%) in adults ≥65 years of age. A model developed to calculate the total burden of pneumococcal pneumonia prevented by infant PCV7 vaccination in the United States from 2000 to 2006 estimated a reduction of 788,838 (CI, 695,406 to 875,476) hospitalizations for pneumococcal pneumonia. Ninety percent of the reduction in model-attributed pneumococcal pneumonia hospitalizations occurred through herd immunity among adults 18 years old and older; similar proportions were found in pneumococcal disease mortality prevented by the vaccine. In the first seasons after PCV introduction, when there were substantial state differences in coverage among <5-year-olds, states with greater coverage had significantly fewer influenza-associated pneumonia hospitalizations among children, suggesting that PCV7 use also reduces influenza-attributable pneumonia hospitalizations., (Copyright © 2011 Simonsen et al.)

Context: There is insufficient information about the effectiveness of medical team training on surgical outcomes. The Veterans Health Administration (VHA) implemented a formalized medical team training program for operating room personnel on a national level., Objective: To determine whether an association existed between the VHA Medical Team Training program and surgical outcomes., Design, Setting, and Participants: A retrospective health services study with a contemporaneous control group was conducted. Outcome data were obtained from the VHA Surgical Quality Improvement Program (VASQIP) and from structured interviews in fiscal years 2006 to 2008. The analysis included 182,409 sampled procedures from 108 VHA facilities that provided care to veterans. The VHA's nationwide training program required briefings and debriefings in the operating room and included checklists as an integral part of this process. The training included 2 months of preparation, a 1-day conference, and 1 year of quarterly coaching interviews, Main Outcome Measure: The rate of change in the mortality rate 1 year after facilities enrolled in the training program compared with the year before and with nontraining sites., Results: The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.76-0.91; P = .01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR, 0.93; 95% CI, 0.80-1.06; P = .59). The risk-adjusted mortality rates at baseline were 17 per 1000 procedures per year for the trained facilities and 15 per 1000 procedures per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 procedures per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in the risk-adjusted surgical mortality rate was about 50% greater in the training group (RR,1.49; 95% CI, 1.10-2.07; P = .01) than in the nontraining group. A dose-response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program, a reduction of 0.5 deaths per 1000 procedures occurred (95% CI, 0.2-1.0; P = .001)., Conclusion: Participation in the VHA Medical Team Training program was associated with lower surgical mortality.

Background: Morbid obesity is associated with serious health and social consequences, high medical costs and is increasing in the USA, particularly among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long-term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, insurance categories, socioeconomic, and comorbidity levels., Methods: We examined 159,116 records representing 774,000 patients with morbid obesity from the 2006 Nationwide Inpatient Sample. We determined the likelihood, expressed in odds ratios, of bariatric surgery associated with each patient characteristic using survey-weighted univariate logistic regression. We also performed multivariate logistic regression, assuming all patient factors were independent., Results: After adjusting for patient-level characteristics, the most rural residents were 23% less likely to receive bariatric surgery than urban residents. Other demographic features associated with significantly lower odds ratios for bariatric surgery included minority status, male gender, lower income, older age, non-private insurance status, and higher comorbidity. Rural-dwelling patients who are non-white, male, poorer, older, sicker, and non-privately insured almost never received bariatric surgery (OR = 0.0089)., Conclusions: Though obesity is more prevalent among middle-aged, rural, economically disadvantaged, and racial/ethnic minority populations, these patients are unlikely to access bariatric surgery. Because obesity is a leading cause of preventable morbidity and mortality in the USA, effective treatments should be made available to all patients who might benefit. Current Medicare/Medicaid policies that reimburse only high volume centers may effectively deny rural residents who rely on these insurance programs for bariatric surgery.

Objective: The present study investigated the influence of race on posttraumatic stress disorder (PTSD) treatment among 94 African American and 214 Caucasian female victims of interpersonal violence participating in 2 studies of cognitive-behavioral treatment for PTSD that were conducted sequentially and continuously., Method: In each study, participants were randomized into 1 of 3 conditions. The first study compared cognitive processing therapy with prolonged exposure and a delayed treatment condition. In the second study, cognitive processing therapy was compared with its constituent components: cognitive therapy only and written accounts. Participants were assessed with the Clinician Administered PTSD Scale and the Structured Clinical Interview for DSM-IV, as well as through self-report measures of PTSD., Results: Analyses revealed that African Americans were significantly less likely to complete treatment compared with Caucasians (45% vs. 73%, respectively, p < .001) and that the differences held even after controlling for education and income. Despite racial differences in treatment completion status, analyses with the intent-to-treat sample indicated no racial differences in outcomes on PTSD measures., Conclusions: The lack of difference in treatment outcomes despite racial differences in dropout may be explained by greater symptom improvement of African Americans who dropped out compared with Caucasians who dropped out. Implications of these findings and practical approaches to addressing sociocultural barriers to care are explored., ((PsycINFO Database Record (c) 2010 APA, all rights reserved).)

To evaluate the tolerability and liver safety profiles of the systemic antifungal agents commonly used for the treatment of invasive fungal infection, we conducted a systematic review and meta-analysis of randomized controlled trials published before 31 August 2009. Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. We used the beta-binomial model to account for variation across studies and the maximum likelihood method to estimate the pooled risks. We identified 39 studies with more than 8,000 enrolled patients for planned comparisons. The incidence rates of treatment discontinuation due to adverse reactions and liver injury associated with antifungal therapy ranged widely. The pooled risks of treatment discontinuation due to adverse reactions were above 10% for amphotericin B formulations and itraconazole, whereas they were 2.5% to 3.8% for fluconazole, caspofungin, and micafungin. We found that 1.5% of the patients stopped itraconazole treatment due to hepatotoxicity. Furthermore, 19.7% of voriconazole users and 17.4% of itraconazole users had elevated serum liver enzyme levels, although they did not require treatment discontinuation, whereas 2.0% or 9.3% of fluconazole and echinocandin users had elevated serum liver enzyme levels but did not require treatment discontinuation. The results were similar when we stratified the data by empirical or definitive antifungal therapy. Possible explanations for antifungal agent-related hepatotoxicity were confounded by antifungal prescription to patients with a high risk of liver injury, the increased chance of detection of hepatotoxicity due to prolonged treatment, or the pharmacological entity.

Objective: Women working in traditionally male-dominated environments are at higher risk for alcohol use disorders (AUDs). The male-dominated U.S. military has additional risk factors associated with problem drinking, including isolation from family and exposure to life-threatening stressors. In the 1980s, the military conformed to all U.S. states' 21-year minimum legal drinking age (MLDA), and established prevention and intervention policies for abusive drinking., Methods: Using a serial cross-sectional design, we explored trends in annual alcohol treatment rates among female veterans versus civilians. From the Department of Health's Treatment Episode Data Set, we extracted AUD admissions from years 1992-2003 for female veterans and civilians in four age categories. Using age-specific population figures, we calculated annual AUD treatment rates and odds ratios for female veterans versus civilians. We used time-series analyses to examine trends in annual AUD treatment for female veterans and civilians across the years examined., Results: In 1992, odds ratios of alcohol treatment episodes for female veterans compared to civilians ranged from 1.9 for 25-29-year-olds to 4.2 for 40-44-year-olds (all p < 0.01). Female veterans' annual alcohol treatment rates dropped substantially from 1992 to 2003, while rates for female civilians ages 25-34 dropped marginally and those for civilians ages 35-44 increased. Time-series analysis showed a statistically significant drop in rates for veterans from 1992 to 2003 and a significant difference between veterans' and civilians' rates, but demonstrated that female civilian annual treatment rates remained static from 1992 to 2003., Conclusions: Prior to the military's efforts to reduce underage and problem drinking, female veterans' alcohol treatment rates exceeded those of same-age civilians. However, with increasing exposure to an environment that discourages abusive drinking, female veterans' annual rates of alcohol treatment fell to below those for same-age civilians.

Background: Racial and ethnic minorities generally receive fewer medical interventions than whites, but racial and ethnic patterns in Medicare expenditures and interventions may be quite different at life's end., Methods: Based on a random, stratified sample of Medicare decedents (N = 158 780) in 2001, we used regression to relate differences in age, sex, cause of death, total morbidity burden, geography, life-sustaining interventions (eg, ventilators), and hospice to racial and ethnic differences in Medicare expenditures in the last 6 months of life., Results: In the final 6 months of life, costs for whites average $20,166; blacks, $26,704 (32% more); and Hispanics, $31,702 (57% more). Similar differences exist within sexes, age groups, all causes of death, all sites of death, and within similar geographic areas. Differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic status, and hospice use account for 53% and 63% of the higher costs for blacks and Hispanics, respectively. While whites use hospice most frequently (whites, 26%; blacks, 20%; and Hispanics, 23%), racial and ethnic differences in end-of-life expenditures are affected only minimally. However, fully 85% of the observed higher costs for nonwhites are accounted for after additionally modeling their greater end-of-life use of the intensive care unit and various intensive procedures (such as, gastrostomies, used by 10.5% of blacks, 9.1% of Hispanics, and 4.1% of whites)., Conclusions: At life's end, black and Hispanic decedents have substantially higher costs than whites. More than half of these cost differences are related to geographic, sociodemographic, and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest.

Background: To evaluate the risk/benefit profiles of gefitinib in comparison with platinum-based doublets chemotherapy as a first-line treatment for chemonaïve patients with advanced non-small-cell lung cancer in East Asia., Methods: We searched MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov to identify randomized and non-randomized phase II or III clinical trials of gefitinib or chemotherapy treatment in East Asian patients published before 4/30/2007. Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. Treatment arms with gefitinib 250mg/day and platinum-based doublets chemotherapy irrespective of dosage and schedule were combined to calculate the pooled estimates for efficacy and safety outcomes of interest., Results: We identified 7 gefitinib and 41 platinum-based doublets chemotherapy trials with nearly 3000 enrolled patients for planned comparison. The pooled response rate (95% confidence interval) to gefitinib for unselected chemonaïve population was 31% (23-38%), not substantially different from 34% (31-38%) reported by platinum-based doublets chemotherapy trials. Patients with certain characteristics were more likely to benefit from gefitinib treatment, with pooled response rates as high as 75% (60-90%) for patients with epidermal growth factor receptor (EGFR) exon 18-21 mutations; 56% (38-74%) for never smokers; 55% (41-69%) for female; and 43% (30-57%) for adenocarcinoma or bronchioalveolar carcinoma. Severe hematological adverse events related to gefitinib treatment were not observed in any of the included trials. However, the risks of severe liver and lung injury related to gefitinib treatment were both approximately 6%, significantly higher than 1% and 0.2% reported by platinum-based doublets chemotherapy trials., Conclusion: Our data suggest that one third of chemonaïve NSCLC patients in East Asia would respond to oral gefitinib monotherapy while 6% would develop severe liver and lung injury. Although patients with EGFR gene mutations, female gender, non-smokers, or adenocarcinoma were more likely to respond to gefitinib, further study with valid comparison groups are needed to identify the optimal treatment strategy in these subpopulations.

The purpose of this experiment was to conduct a dismantling study of cognitive processing therapy in which the full protocol was compared with its constituent components--cognitive therapy only (CPT-C) and written accounts (WA)--for the treatment of posttraumatic stress disorder (PTSD) and comorbid symptoms. The intent-to-treat (ITT) sample included 150 adult women with PTSD who were randomized into 1 of the 3 conditions. Each condition consisted of 2 hr of therapy per week for 6 weeks; blind assessments were conducted before treatment, 2 weeks following the last session, and 6 months following treatment. Measures of PTSD and depression were collected weekly to examine the course of recovery during treatment as well as before and after treatment. Secondary measures assessed anxiety, anger, shame, guilt, and dysfunctional cognitions. Independent ratings of adherence and competence were also conducted. Analyses with the ITT sample and with study completers indicate that patients in all 3 treatments improved substantially on PTSD and depression, the primary measures, and improved on other indices of adjustment. However, there were significant group differences in symptom reduction during the course of treatment whereby the CPT-C condition reported greater improvement in PTSD than the WA condition., (PsycINFO Database Record (c) 2008 APA, all rights reserved.)

Purpose: We estimated the absolute risks of treatment termination and incidence of adverse liver outcomes among all commonly used oral antifungal treatments for superficial dermatophytosis and onychomycosis., Methods: MEDLINE, EMBASE, and Cochrane Library were searched to identify randomized and nonrandomized controlled trials, case series, and cohort studies published before December 31, 2005. Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. Treatment arms with the same regimen in terms of drug, type (continuous or intermittent), and dosage were combined to estimate the risk of an outcome of interest., Results: We identified 122 studies with approximately 20,000 enrolled patients for planned comparison. The pooled risks (95% confidence intervals) of treatment discontinuation resulting from adverse reactions for continuous therapy were 3.44% (95% confidence interval [CI], 2.28%-4.61%) for terbinafine 250 mg/day; 1.96% (95% CI, 0.35%-3.57%) for itraconazole 100 mg/day; 4.21% (95% CI, 2.33%-6.09%) for itraconazole 200 mg/day; and 1.51% (95% CI, 0%-4.01%) for fluconazole 50 mg/day. For intermittent therapy, the pooled risks were as follows: pulse terbinafine: 2.09% (95% CI, 0%-4.42%); pulse itraconazole: 2.58% (95% CI, 1.15%-4.01%); intermittent fluconazole 150 mg/week: 1.98% (95% CI, 0.05%-3.92%); and intermittent fluconazole 300 to 450 mg/week: 5.76% (95% CI, 2.42%-9.10%). The risk of liver injury requiring termination of treatment ranged from 0.11% (continuous itraconazole 100 mg/day) to 1.22% (continuous fluconazole 50 mg/day). The risk of having asymptomatic elevation of serum transaminase but not requiring treatment discontinuation was less than 2.0% for all treatment regimens evaluated., Conclusion: Oral antifungal therapy against superficial dermatophytosis and onychomycosis, including intermittent and continuous terbinafine, itraconazole, and fluconazole, was associated with a low incidence of adverse events in an immunocompetent population.

Objectives: This study examined the effect of anxiety on mortality and nonfatal myocardial infarction (MI) in patients with coronary artery disease (CAD)., Background: Inconsistent data exist regarding the impact of anxiety on the prognosis of patients with CAD., Methods: The authors conducted a prospective cohort study at an outpatient cardiology clinic of 516 patients with CAD (mean age 68 years at entry, 82% male) by administering the Kellner Symptom Questionnaire annually. The primary outcome was the composite of nonfatal MI or all-cause mortality., Results: During an average follow-up of 3.4 years, we documented 44 nonfatal MIs and 19 deaths. A high cumulative anxiety score was associated with an increased risk of nonfatal MI or death. Comparing the highest to lowest tertile of anxiety score, the age-adjusted hazard ratio was 1.97 (95% confidence interval 1.03 to 3.78, p = 0.04). In a multivariate Cox model after adjusting for age, gender, education, marital status, smoking, hypertension, diabetes mellitus, previous MI, body mass index, and total cholesterol, each unit increase in the cumulative mean anxiety score was associated with increased risk of nonfatal MI or total mortality; the hazard ratio was 1.06 (95% confidence interval 1.01 to 1.12, p = 0.02)., Conclusions: A high level of anxiety maintained after CAD diagnosis constitutes a strong risk of MI or death among patients with CAD.

Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population., (Copyright 2006 APA, all rights reserved.)

The objective of this study was to assess long-term clinical outcomes and their correlates in medically managed outpatients with stable angina pectoris, healed myocardial infarction (MI), or documented asymptomatic coronary artery disease (CAD). Management strategy emphasized maximally tolerated medical therapy and modification of coronary risk factors. Referral to invasive coronary interventions followed stricter criteria than standard published guidelines. Primary study outcomes were all-cause mortality or nonfatal myocardial infarction. Secondary study outcomes included cardiac death, unstable angina, or coronary revascularization. A total of 693 men and women with proved CAD (mean age 67 years at entry, 85% men, 41% with history of MI) were enrolled. The annual incidence of nonfatal MI, cardiac mortality, and total mortality was 2.2%, 0.8%, and 1.4%, respectively, during an average follow-up of 4.6 years. Coronary revascularization was performed in 24% of subjects; unstable or progressive anginal symptoms were the most common reasons for revascularization. In patients with documented stable CAD, a management strategy based on intensive medical therapy and modification of established coronary risk factors was associated with excellent long-term outcomes. Thus, coronary interventions can be safely delayed until clinical instability ensues, without increased risk of MI or death. This treatment approach represents a viable alternative to invasive strategies.

Atrial fibrillation (AF) is prevalent in the elderly, in patients with hypertension, and in patients with coronary artery disease (CAD). We hypothesized that statin therapy might be effective in preventing AF in patients with CAD and examined this hypothesis in a sample of patients with chronic stable CAD without AF, followed prospectively at a large outpatient cardiology practice. The association between statin use and the risk of developing AF was examined univariately and then with adjustment for potential confounding factors. Four hundred forty-nine men and women between the ages of 40 and 87 years were followed for an average of 5 years. Fifty-two patients (12%) developed AF during follow-up. Statin therapy was used by 59% of the patients during the study period and was associated with a significantly reduced risk of developing AF (crude odds ratio, 0.48, 95% confidence interval 0.28 to 0.83). This association remained significant after adjustment for potential confounders, including age, hypertension, left ventricular systolic function, occurrence of heart failure or acute ischemic events, and baseline cholesterol and changes in cholesterol levels (adjusted odds ratio 0.37, 95% confidence interval 0.18 to 0.76). Use of statins in patients with chronic stable CAD appears to be protective against AF. The underlying mechanism for this effect is unknown but appears to be independent of the reduction in serum cholesterol levels.

Brain natriuretic peptide (BNP) levels were measured in 72 outpatients with chronic atrial fibrillation (AF) and in 49 control patients without AF. BNP levels were significantly higher in patients with AF (median value 131 pg/ml) than without AF (median value 49 pg/ml; p <0.001), and remained significantly higher after controlling for demographic and clinical variables.