Andrea M. Spehar

Health Outcomes Associated with Military Deployment: Mild Traumatic Brain Injury, Blast, Trauma, and Combat Associations in the Florida National Guard

OBJECTIVES To determine the association between specific military deployment experiences and immediate and longer-term physical and mental health effects, as well as examine the effects of multiple deployment-related traumatic brain injuries (TBIs) on health outcomes. DESIGN Online survey of cross-sectional cohort. Odds ratios were calculated to assess the association between deployment-related factors (ie, physical injuries, exposure to potentially traumatic deployment experiences, combat, blast exposure, and mild TBI) and current health status, controlling for potential confounders, demographics, and predeployment experiences. SETTING Nonclinical. PARTICIPANTS Members (N=3098) of the Florida National Guard (1443 deployed, 1655 not deployed). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Presence of current psychiatric diagnoses and health outcomes, including postconcussive and non-postconcussive symptoms. RESULTS Surveys were completed an average of 31.8 months (SD=24.4, range=0-95) after deployment. Strong, statistically significant associations were found between self-reported military deployment-related factors and current adverse health status. Deployment-related mild TBI was associated with depression, anxiety, posttraumatic stress disorder (PTSD), and postconcussive symptoms collectively and individually. Statistically significant increases in the frequency of depression, anxiety, PTSD, and a postconcussive symptom complex were seen comparing single to multiple TBIs. However, a predeployment TBI did not increase the likelihood of sustaining another TBI in a blast exposure. Associations between blast exposure and abdominal pain, pain on deep breathing, shortness of breath, hearing loss, and tinnitus suggested residual barotrauma. Combat exposures with and without physical injury were each associated not only with PTSD but also with numerous postconcussive and non-postconcussive symptoms. The experience of seeing others wounded or killed or experiencing the death of a buddy or leader was associated with indigestion and headaches but not with depression, anxiety, or PTSD. CONCLUSIONS Complex relationships exist between multiple deployment-related factors and numerous overlapping and co-occurring current adverse physical and psychological health outcomes. Various deployment-related experiences increased the risk for postdeployment adverse mental and physical health outcomes, individually and in combination. These findings suggest that an integrated physical and mental health care approach would be beneficial to postdeployment care.

Effect of concomitant use of benzodiazepines and other drugs on the risk of injury in a veterans population

AbstractBackground: Benzodiazepines comprise a class of drugs that when used as monotherapy are generally acknowledged to pose a risk for injury by increasing the likelihood of falls, fall-related injuries, adverse drug events and car accidents. Benzodiazepines may also be used concomitantly with other high risk medications that may further exacerbate the risk of injury. The aim of this study is to examine the occurrence of the concomitant use of benzodiazepines and other drugs and then quantify the indirect effect of these drug combinations on the likelihood of an injury-related healthcare episode. Methods: A multivariate model was specified that included outpatient prescription data and inpatient/outpatient medical utilisation records for 13 745 patients at a Veterans Administration hospital system over a 3-year period (1999–2001). We analysed 133 872 outpatient benzodiazepine prescriptions and >1.5 million non-benzodiazepine prescriptions for the study population. Micromedex software was used to identify combinations of benzodiazepines and other drugs that are likely to result in ‘major’ interactions. We then further restricted our focus to the use of these drug combinations within a 30-day period prior to an injury-related medical event. The adjusted odds ratio on a variable characterising concomitant use of a benzodiazepine and another drug within this period was used to quantify the relative risk of injury. The principal outcome was the estimated risk of an injury-related healthcare episode within a 30-day period when taking both a benzodiazepine and another drug with a ‘major’ severity rating as defined by Micromedex. The risk of injury was adjusted for comorbidities, hospital discharges, marital status, age, mean arterial pressure and body mass index, as well as the dose of benzodiazepine (converted to diazepam equivalents) and duration of benzodiazepine treatment. Results: Of the 1110 unique individuals who experienced an injury, 790 (71.2%) patients had used a benzodiazepine in combination with another drug. Furthermore, only 4.3% (320/7522) of the patients taking benzodiazepines who did not have concomitant drug use experienced an injury. The occurrence of this concomitant use increased the odds of an injury >2-fold in the model. Dose and duration of benzodiazepine use, as well as certain comorbidities, were also associated with an increased risk for injury, whereas being married reduced the risk. Conclusions: This is the first large-scale study to quantify the impact of concomitant use of benzodiazepines and other drugs on the risk of injury in a population of Veterans Administration patients. It demonstrates the utility of expanding the focus of inappropriate medication usage to include analyses that link potentially inappropriate drug use with healthcare utilisation for injuries.

National Veterans Health Administration Hospitalizations for Syncope Compared to Acute Myocardial Infarction, Fracture, or Pneumonia in Community‐Dwelling Elders: Outpatient Medication and Comorbidity Profiles

The authors used 2 national Veterans Health Administration databases to identify outpatient medications and all 30 Elixhauser comorbidities for 2579 unique patients, age 65+ years, hospitalized for syncope in fiscal year 2004. For comparison, we identified other elderly patients hospitalized with acute myocardial infarction (N = 4491), fracture (N = 2797), or pneumonia (N = 9473). The categories of medications included drugs that affect the cardiovascular, central nervous, or the muscular skeletal system. The most notable differences between syncope compared to acute myocardial infarction patients occurred in central nervous system drugs in anticonvulsants/barbiturates, antidepressants, antihistamine/antinauseants, antipsychotics, and cholinesterase inhibitors (P < .0018). Comparing syncope patients with fracture patients, the central nervous medication profile was similar, but the cardiovascular medication profile differed (P < .0018); their hypertension comorbidities also differed (60.45% vs 46.34%); (P < .0016). These findings indicate significant potential associations that warrant further study. Studies linking national outpatient medications to hospitalizations for specific conditions can foster the development of more proactive pharmacovigilance systems.

A medication surveillance system model to improve patient safety: A national veterans study of cyclooxygenase 2 inhibitors and risks of stroke or myocardial infarction

Background: The recent withdrawal of Vioxx (rofecoxib) from the market and emerging evidence that cyclooxygenase (COX) 2 inhibitors as a class of drugs may raise the risk of adverse cardiovascular events have highlighted the limitations of current postlicensing surveillance systems in the United States. We explored the use of linking national Veterans Health Administration (VHA) administrative datasets into a medication surveillance system to examine hospitalizations for stroke or myocardial infarction (MI) among COX-2 users compared with nonusers. Methods: We conducted a descriptive study of 719,058 inpatient hospitalizations within the VHA system over a 2-year period, 2002-2003. We analyzed the frequencies of strokes or MI among COX-2 users and nonusers, as well as mutually exclusive celecoxib or rofecoxib groups. We identified a total of 110,583 unique COX-2 users who had 708,617 COX-2 prescriptions. We then linked the COX-2 patients to acute hospital care for stroke or MI and analyzed frequencies by age strata. Results: Approximately 2% of COX-2 users (2246 individuals) had a stroke or MI, which represents 9.2% of all 24,452 hospitalized COX-2 patients. This is slightly higher than the 8.8% of all stroke or MI patients (63,548) accounted for in the total of 719,058 unique hospitalizations. However, adjustments for age produced mixed results in all analyses. Conclusions: Currently in the United States, medication safety programs are largely focused on monitoring and voluntary reporting of known risks and side effects of drugs as identified by the drug manufacturers, and medication administration process measure reporting. These approaches do not facilitate identification and analysis of a medications safety where the drug is an independent risk factor for an adverse health outcome that may not have been previously identified. This study demonstrates that a medication surveillance system based on large-scale national administrative datasets can be used to rapidly evaluate a reported medication risk or harm. More importantly, in the absence of a reported medication risk or harm, especially for outpatient medications, a medication surveillance system based on the emerging VHA model could be used to facilitate efficient, timely, and proactive postlicensing medication surveillance.

A Systems Science Approach to Understanding Polytrauma and Blast-Related Injury: Bayesian Network Model of Data From a Survey of the Florida National Guard.

We sought to further define the epidemiology of the complex, multiple injuries collectively known as polytrauma/blast-related injury (PT/BRI). Using a systems science approach, we performed Bayesian network modeling to find the most accurate representation of the complex system of PT/BRI and identify key variables for understanding the subsequent effects of blast exposure in a sample of Florida National Guard members (1,443 deployed to Operation Enduring Freedom/Operation Iraqi Freedom and 1,655 not deployed) who completed an online survey during the period from 2009 to 2010. We found that postdeployment symptoms reported as present at the time of the survey were largely independent of deployment per se. Blast exposure, not mild traumatic brain injury (TBI), acted as the primary military deployment–related driver of PT/BRI symptoms. Blast exposure was indirectly linked to mild TBI via other deployment-related traumas and was a significant risk for a high level of posttraumatic stress disorder (PTSD) arousal symptoms. PTSD arousal symptoms and tinnitus were directly dependent upon blast exposure, with both acting as bridge symptoms to other postdeployment mental health and physical symptoms, respectively. Neurobehavioral or postconcussion-like symptoms had no significant dependence relationship with mild TBI, but they were synergistic with blast exposure in influencing PTSD arousal symptoms. A replication of this analysis using a larger PT/BRI database is warranted.

Acquisition costs and use of Medicare Part D-excluded drugs in Veterans Health Administration long-stay nursing home residents: a national, descriptive, secondary data analysis.

AbstractBackground: Nursing home populations may consist of both short- and long-stay residents, who have different resource use profiles. Differentiating between these two populations is important in any analysis of drug costs and use. Objective: The aim of this analysis was to provide national annualized estimates of drug acquisition costs and use of drugs excluded under Medicare Part D for dually eligible long-stay nursing home residents in the US. Methods: This was a national, descriptive, secondary data analysis. The study population consisted of 6554 Veterans Health Administration (VHA) long-stay nursing home residents (n = 136 nursing homes), identified from the Minimum Data Set (MDS), who had an annual assessment during fiscal year (FY) 2005 linked with their 8 847 561 inpatient pharmacy claims. The study data generated were descriptive statistics of the annual drug acquisition costs and use of medications excluded under Medicare Part D. VHA therapeutic drug classes were obtained from FY 2005 national pharmacy claims linked at the individual resident level. Results: The excluded drugs accounted for 3 036 306 of the more than 8.8 million inpatient pharmacy claims, totalling

The Veterans Health Administration’s traumatic brain injury clinical reminder screen and evaluation: Practice patterns

US3 406 756 or

A Multivariate Fall Risk Assessment Model for VHA Nursing Homes Using the Minimum Data Set

US526 per resident (99% CI 490, 562). Non-opioid analgesics were received by 73.3% of the residents, totalling

Drugs and falls in community-dwelling older people: a national veterans study.

US352 608 or

Benzodiazepines and injury: a risk adjusted model

US73 per resident; 25.3% received antitussives, decongestants, or cold and cough medications, totalling