Amy Gravely

Accuracy of teledermatology for pigmented neoplasms

BACKGROUND Accurate diagnosis and management of pigmented lesions is critical because of the morbidity and mortality associated with melanoma. OBJECTIVE We sought to compare accuracy of store-and-forward teledermatology for pigmented neoplasms with standard, in-person clinic dermatology. METHODS We conducted a repeated measures equivalence trial involving veterans with pigmented skin neoplasms. Each lesion was evaluated by a clinic dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and a management plan. The primary outcome was aggregated diagnostic accuracy (match of any chosen diagnosis with histopathology). We also compared the severity of inappropriately managed lesions and, for teledermatology, evaluated the incremental change in accuracy when polarized light dermatoscopy or contact immersion dermatoscopy images were viewed. RESULTS We enrolled 542 patients with pigmented lesions, most were male (96%) and Caucasian (97%). The aggregated diagnostic accuracy rates for teledermatology (macro images, polarized light dermatoscopy, and contact immersion dermatoscopy) were not equivalent (95% confidence interval for difference within +/-10%) and were inferior (95% confidence interval lower bound <10%) to clinic dermatology. In general, the addition of dermatoscopic images did not significantly change teledermatology diagnostic accuracy rates. In contrast to diagnostic accuracy, rates of appropriate management plans for teledermatology were superior and/or equivalent to clinic dermatology (all image types: all lesions, and benign lesions). However, for the subgroup of malignant lesions (n = 124), the rate of appropriate management was significantly worse for teledermatology than for clinic dermatology (all image types). Up to 7 of 36 index melanomas would have been mismanaged via teledermatology. LIMITATIONS Nondiverse study population and relatively small number of melanomas were limitations. CONCLUSIONS In general, the diagnostic accuracy of teledermatology was inferior whereas management was equivalent to clinic dermatology. However, for the important subgroup of malignant pigmented lesions, both diagnostic and management accuracy of teledermatology was generally inferior to clinic dermatology and up to 7 of 36 index melanomas would have been mismanaged via teledermatology. Teledermatology and teledermatoscopy should be used with caution for patients with suspected malignant pigmented lesions.

Validity of PTSD diagnoses in VA administrative data: Comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores

Little research has been done on the validity of posttraumatic stress disorder (PTSD) diagnoses that are found in Department of Veterans Affairs (VA) administrative data, even though they are often used in VA research. We compared PTSD diagnoses found in VA administrative data with PTSD Checklist (PCL) scores self-reported by 4,777 newly diagnosed participants in a national postal survey study. Using PCL scores of at least 50 as the gold standard, we compared positive predictive values (PPVs) for at least one versus at least two PTSD diagnoses (found within 4 months of the first) in VA administrative data overall and by subgroups of interest: age, sex, and clinic where first diagnosed. The overall PPV was 75% for at least one PTSD diagnosis and 82% for at least two PTSD diagnoses. Similarly, the PPV significantly increased for all subgroup analyses when at least two PTSD diagnoses were used. The increase in PPV was greatest for those first diagnosed in primary care and for those older than 65. To select a sample of veterans with more definitive PTSD from administrative data, researchers should select those veterans with at least two PTSD diagnoses as opposed to at least one.

Military to civilian questionnaire: A measure of postdeployment community reintegration difficulty among veterans using Department of Veterans Affairs medical care

The primary objective of this study was to describe the development, reliability, and construct validity of scores on the Military to Civilian Questionnaire (M2C-Q), a 16-item self-report measure of postdeployment community reintegration difficulty. We surveyed a national, stratified sample of 1,226 Iraq and Afghanistan veterans who used U.S. Department of Veterans Affairs (VA) medical care; 745 completed the M2C-Q and validated mental health screening measures. All analyses were based on weighted estimates. The internal consistency of the M2C-Q was .95 in this sample. Factor analyses indicated a single total score was the best-fitting model. Total scores were associated with measures theoretically related to reintegration difficulties including perception of overall difficulty readjusting back into civilian life (R(2) = .49), probable PTSD (d = 1.07), probable problem drug or alcohol use (d = 0.34), and overall mental health (r = -.83). Subgroup analyses revealed a similar pattern of findings in those who screened negative for PTSD. Nonwhite and unemployed veterans reported greater community reintegration difficulty (d = 0.20 and 0.45, respectively). Findings offer preliminary support for the reliability and construct validity of M2C-Q scores.

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial

Importance Limited evidence is available regarding long-term outcomes of opioids compared with nonopioid medications for chronic pain. Objective To compare opioid vs nonopioid medications over 12 months on pain-related function, pain intensity, and adverse effects. Design, Setting, and Participants Pragmatic, 12-month, randomized trial with masked outcome assessment. Patients were recruited from Veterans Affairs primary care clinics from June 2013 through December 2015; follow-up was completed December 2016. Eligible patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use. Of 265 patients enrolled, 25 withdrew prior to randomization and 240 were randomized. Interventions Both interventions (opioid and nonopioid medication therapy) followed a treat-to-target strategy aiming for improved pain and function. Each intervention had its own prescribing strategy that included multiple medication options in 3 steps. In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response. Main Outcomes and Measures The primary outcome was pain-related function (Brief Pain Inventory [BPI] interference scale) over 12 months and the main secondary outcome was pain intensity (BPI severity scale). For both BPI scales (range, 0-10; higher scores = worse function or pain intensity), a 1-point improvement was clinically important. The primary adverse outcome was medication-related symptoms (patient-reported checklist; range, 0-19). Results Among 240 randomized patients (mean age, 58.3 years; women, 32 [13.0%]), 234 (97.5%) completed the trial. Groups did not significantly differ on pain-related function over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95% CI, −0.5 to 0.7]). Pain intensity was significantly better in the nonopioid group over 12 months (overall P = .03); mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]). Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95% CI, 0.3 to 1.5]). Conclusions and Relevance Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain. Trial Registration clinicaltrials.gov Identifier: NCT01583985

Original articleAccuracy of teledermatology for nonpigmented neoplasms

BACKGROUND Studies of teledermatology utilizing the standard reference of histopathology are lacking. OBJECTIVE To compare accuracy of store-and-forward teledermatology for non-pigmented neoplasms with in-person dermatology. METHODS This study was a repeated-measures equivalence trial involving veterans with non-pigmented skin neoplasms. Each lesion was evaluated by an in-person dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and management plan. The primary outcome was aggregated diagnostic accuracy (percent correct matches of any chosen diagnosis with histopathology). Secondary outcomes included management plan accuracy (percent correct matches with expert panel management plan). Additional analyses included evaluation of the incremental effect of using polarized light dermatoscopy in addition to standard macro images, and evaluating benign and malignant lesion subgroups separately. RESULTS Most of the 728 participants were male (97.8%) and Caucasian (98.9%). The aggregated diagnostic accuracy (primary outcome) of teledermatology (macro images) was not equivalent (95% confidence interval [CI] for difference within +/-10%) and was inferior (95% CI lower bound <10%) to in-person dermatology for all lesions and the subgroups of benign and malignant lesions. However, management plan accuracy was equivalent. Teledermatology aggregated diagnostic accuracy using polarized light dermatoscopy was significantly better than for macro images alone (P = .0017). The addition of polarized light dermatoscopy showed the same pattern for malignant lesions, but not for benign lesions. Most interestingly, for malignant lesions, the addition of polarized light dermatoscopy yielded equivalent aggregated diagnostic accuracy rates. LIMITATIONS Non-diverse study population. CONCLUSIONS Using macro images, the diagnostic accuracy of teledermatology was inferior to in-person dermatology, but accuracy of management plans was equivalent. The addition of polarized light dermatoscopy yielded significantly better aggregated diagnostic accuracy, but management plan accuracy was not significantly improved. For the important subgroup of malignant lesions, the addition of polarized light dermatoscopy yielded equivalent diagnostic accuracy between teledermatologists and clinic dermatologists.

Reliability of store and forward teledermatology for skin neoplasms.

BACKGROUND Teledermatology may be less optimal for skin neoplasms than for rashes. OBJECTIVES We sought to determine agreement for skin neoplasms. METHODS This was a repeated measures study. Each lesion was examined by a clinic dermatologist and a teledermatologist; both generated a primary diagnosis, up to 2 differential diagnoses, and management. Macro images and polarized light dermoscopy images were obtained; for pigmented lesions only, contact immersion dermoscopy image was obtained. RESULTS There were 3021 lesions in 2152 patients. Of 1685 biopsied lesions, there were 410 basal cell carcinomas (24%), 240 squamous cell carcinomas (14%), and 41 melanomas (2.4%). Agreement was fair to substantial for primary diagnosis (45.7%-80.1%; kappa 0.32-0.62), substantial to almost perfect for aggregated diagnoses (primary plus differential; 78.6%-93.9%; kappa 0.77-0.90), and fair for management (66.7%-86.1%; kappa 0.28-0.41). Diagnostic agreement rates were higher for pigmented lesions (52.8%-93.9%; kappa 0.44-0.90) than nonpigmented lesions (47.7%-87.3%; kappa 0.32-0.86), whereas the reverse was found for management agreement (pigmented: 66.7%-79.8%, kappa 0.19-0.35 vs nonpigmented: 72.0%-86.1%, kappa 0.38-0.41). Agreement rates using macro images were similar to polarized light dermoscopy; contact immersion dermoscopy, however, significantly improved rates for pigmented lesions. LIMITATIONS We studied a homogeneous population. CONCLUSIONS Diagnostic agreement was moderate to almost perfect whereas management agreement was fair. Polarized light dermoscopy increased rates modestly whereas contact immersion dermoscopy significantly increased rates for pigmented lesions.

A national study of racial differences in pain screening rates in the VA health care system.

Objectives:To determine whether black patients are less likely to be screened for pain than white patients. Participants:A sample of 25,382 black and 220,122 non-Hispanic white Veterans Affairs (VA) patients was identified among the panel surveyed in the ambulatory care module of the 2007 Survey of Health Care Experiences of Patients. Design:This was a cross-sectional analysis of documentation of a pain score in the electronic medical record at the patient’s Survey of Health Care Experiences of Patients index visit. Hierarchical logistic regression analyses were used to examine the association between race and documentation of pain screening. Results:After accounting for site and whether the patient was a new or established primary care patient, black VA patients were significantly less likely than their white counterparts to be screened for pain, odds ratio: 0.79, P<0.0001, with estimated screening rates of 78% and 82% for black and white established primary care patients at a typical VA site, respectively. Further adjusting for demographics, medical and psychological comorbidity, prescription of pain medication, and health care utilization reduced the odds ratio to 0.86, P<0.0001). Additional analyses revealed that this reduction in odds ratio was primarily explained by higher rates of outpatient visits to the VA in the previous 2 years among black patients, which was associated with lower rates of screening at the index visit. Conclusions:Rates of screening were lower among black patients. The magnitude of this disparity was small and was explained, in part, by racial variation in prior health care utilization.

Timely Follow-Up of Positive Fecal Occult Blood Tests Strategies Associated with Improvement

BACKGROUND In light of previous research indicating that many patients fail to receive timely diagnostic follow-up of positive colorectal cancer (CRC) screening tests, the Veterans Health Administration (VA) initiated a national CRC diagnosis quality-improvement (QI) effort. PURPOSE This article documents the percent of patients receiving follow-up within 60 days of a positive CRC screening fecal occult blood test (FOBT) and identifies improvement strategies that predict timely follow-up. METHODS In 2007, VA facilities completed a survey in which they indicated the degree to which they had implemented a series of improvement strategies and described barriers to improvement. Three types of strategies were assessed: developing QI infrastructure, improving care delivery processes, and building gastroenterology capacity. Survey data were merged with a measure of 60-day positive-FOBT follow-up. Facility-level predictors of timely follow-up were identified and relationships among categories of improvement strategies were assessed. Data were analyzed in 2008. RESULTS The median facility-reported 60-day follow-up rate for positive screening FOBTs was 24.5%. Several strategies were associated with timeliness of follow-up. The relationship between the implementation of QI infrastructure strategies and timely follow-up was mediated by the implementation of process-change strategies. Although constraints on gastroenterology capacity were often sited as a key barrier, implementation of strategies to address this issue was unassociated with timely follow-up. CONCLUSIONS Developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up when this work is followed by process improvements. Increasing gastroenterology capacity may be more difficult than improving processes of care.

Organizational predictors of colonoscopy follow-up for positive fecal occult blood test results: an observational study

Background: This study assessed the contribution of organizational structures and processes identified from facility surveys to follow-up for positive fecal occult blood tests [FOBT-positive (FOBT+)]. Methods: We identified 74,104 patients with FOBT+ results from 98 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011, and followed them until September 30, 2011, for completion of colonoscopy. We identified patient characteristics from VHA administrative records, and organizational factors from facility surveys completed by primary care and gastroenterology chiefs. We estimated predictors of colonoscopy completion within 60 days and six months using hierarchical logistic regression models. Results: Thirty percent of patients with FOBT+ results received colonoscopy within 60 days and 49% within six months. Having gastroenterology or laboratory staff notify gastroenterology providers directly about FOBT+ cases was a significant predictor of 60-day [odds ratio (OR), 1.85; P = 0.01] and six-month follow-up (OR, 1.25; P = 0.008). Additional predictors of 60-day follow-up included adequacy of colonoscopy appointment availability (OR, 1.43; P = 0.01) and frequent individual feedback to primary care providers about FOBT+ referral timeliness (OR, 1.79; P = 0.04). Additional predictors of six-month follow-up included using guideline-concordant surveillance intervals for low-risk adenomas (OR, 1.57; P = 0.01) and using group appointments and combined verbal–written methods for colonoscopy preparation instruction (OR, 1.48; P = 0.0001). Conclusion: Directly notifying gastroenterology providers about FOBT+ results, using guideline-concordant adenoma surveillance intervals, and using colonoscopy preparations instruction methods that provide both verbal and written information may increase overall follow-up rates. Enhancing follow-up within 60 days may require increased colonoscopy capacity and feedback to primary care providers. Impact: These findings may inform organizational-level interventions to improve FOBT+ follow-up. Cancer Epidemiol Biomarkers Prev; 24(2); 422–34. ©2014 AACR.

Iraq and Afghanistan War Veterans with Reintegration Problems: Differences by Veterans Affairs Healthcare User Status

We studied 1,292 Iraq and Afghanistan War veterans who participated in a clinical trial of expressive writing to estimate the prevalence of perceived reintegration difficulty and compare Veterans Affairs (VA) healthcare users to nonusers in terms of demographic and clinical characteristics. About half of participants perceived reintegration difficulty. VA users and nonusers differed in age and military background. Levels of mental and physical problems were higher in VA users. In multivariate analysis, military service variables and probable traumatic brain injury independently predicted VA use. Findings demonstrate the importance of research comparing VA users to nonusers to understand veteran healthcare needs.