Andrew B. Lanto

Exposure to automated drug alerts over time: effects on clinicians' knowledge and perceptions.

Objective:We tested whether interval exposure to an automated drug alert system that included approximately 2000 drug–drug interaction alerts increased recognition of selected interacting drug pairs. We also examined other perceptions about computerized order entry. Research Design:We administered cross-sectional surveys in 2000 and 2002 that included more than 260 eligible clinicians in each time period. Subjects:We studied clinicians practicing in ambulatory settings within a Southern California Veterans Affairs Healthcare System and who responded to both surveys (97 respondents). Measures:We sought to measure (1) recognition of selected drug–drug and drug–condition interactions and (2) other benefits and barriers to using automated drug alerts. Results:Clinicians correctly categorized similar percentages of the 7 interacting drug–drug pairs at baseline and follow-up (53% vs. 54%, P = 0.51) but improved their overall recognition of the 3 contraindicated drug–drug pairs (51% vs. 60%, P = 0.01). No significant changes from baseline to follow-up were found for the 8 interacting drug–condition pairs (60% vs. 62%, P = 0.43) or the 4 contraindicated drug–condition pairs (52% vs. 56%, P = 0.24). More providers preferred using order entry at follow-up than baseline (63% vs. 45%, P < 0.001). Signal-to-noise ratio remained the biggest reported problem at follow-up and baseline (54 vs. 57%, P = 0.75). In 2002, clinicians reported seeing a median of 5 drug alerts per week (representing approximately 12.5% of prescriptions entered), with a median 5% reportedly leading to an action. Conclusions:Interval exposure to automated drug alerts had little to no effect on recognition of selected drug–drug interactions. The primary perceived barrier to effective utilization of drug alerts remained the same over time.

Prescription Sharing, Alcohol Use, and Street Drug Use to Manage Pain Among Veterans

CONTEXT Efforts to promote awareness and management of chronic pain have been accompanied by a troubling increase in prescription medication abuse. At the same time, some patients may misuse substances in an effort to manage chronic pain. OBJECTIVES This study examines self-reported substance misuse for pain management among veterans and identifies the contributing factors. METHODS We analyzed cross-sectional data from the Help Veterans Experience Less Pain study. RESULTS Of 343 veterans, 35.3% reported an aberrant pain management behavior (24% reported using alcohol, 11.7% reported using street drugs, and 16.3% reported sharing prescriptions to manage pain). Poorer mental health, younger age, substance use disorders (SUDs), number of nonpain symptoms, and greater pain severity and interference were associated with aberrant pain management behaviors. In multivariate analysis, SUDs (odds ratio [OR]: 3.9, 95% confidence interval [CI]: 2.3-6.7, P<0.000) and poorer mental health (OR: 2.3, 95% CI: 1.3-4.3, P=0.006) were associated with using alcohol or street drugs to manage pain; SUDs (OR: 2.4, 95% CI: 1.3-4.4, P=0.006) and pain interference (OR: 1.1, 95% CI: 1.0-1.2, P=0.047) were associated with prescription sharing; and SUDs (OR: 3.6, 95% CI: 2.2-6.1, P<0.000) and number of nonpain symptoms (OR: 6.5, 95% CI: 1.2-35.4, P=0.031) were associated with any aberrant pain management behavior. CONCLUSION Veterans with a history of SUDs, greater pain interference, more nonpain symptoms, and mental health concerns should be carefully managed to deter substance misuse for pain management.

Can a specialty society educate its members to think differently about clinical decisions? Results of a randomized trial.

OBJECTIVE: Measure the effect of specialty society-developed continuing medical education (CME) on clinical decision making.DESIGN: Randomized controlled trial.SETTING: National sample of neurologists.PARTICIPANTS: Of 492 neurologists randomly selected from an ongoing American Academy of Neurology CME program, 248 were randomized to receive a mailed CME course, and 244 did not receive it.INTERVENTION: A mailed educational course on movement disorders, developed by the specialty society, containing information on diseases and practice recommendations with illustrative case presentations.MEASUREMENTS AND MAIN RESULTS: We assessed adherence to 16 practice recommendations on disease detection, diagnostic test use, and treatments by mailed survey sent to all subjects 4.5 months after the intervention group received the course (73% response rate). The survey contained detailed clinical scenarios to measure self-reported clinical decision making and short open-ended questions to measure factual knowledge. More intervention participants (up to 2.6 times more) than control subjects reported clinical decision making adherent to 9 of the 16 recommendations (p<.05). For 4 of the other 7 recommendations, adherence exceeded 85% in both groups. Within the intervention group, neurologists who read the educational course were 2 to 6 times more likely to be adherent than neurologists who did not. The intervention group had better factual knowledge than control subjects in six of seven areas (p<.01).CONCLUSIONS: This educational course improved neurologists’ reported decision making. Specialty society-developed CME that utilizes a similar format may enhance the effectiveness of mailed CME information to improve physicians’ approach to clinical decisions.

The Utility of Adding Retrospective Medication Profiling to Computerized Provider Order Entry in an Ambulatory Care Population

BACKGROUND We assessed whether medication safety improved when a medication profiling program was added to a computerized provider order entry system. DESIGN Between June 2001 and January 2002 we profiled outpatients with potential prescribing errors using computerized retrospective drug utilization software. We focused primarily on drug interactions. Patients were randomly assigned either to Provider Feedback or to Usual Care. Subsequent adverse drug event (ADE) incidence and other outcomes, including ADE preventability and severity, occurring up to 1 year following the last profiling date were evaluated retrospectively by a pharmacist blinded to patient assignment. MEASUREMENTS Data were abstracted using a study-designed instrument. An ADE was defined by an Adverse Drug Reaction Probability scale score of 1 or more. Statistical analyses included negative binomial regression for comparing ADE incidence. RESULTS Of 913 patients in the analytic sample, 371 patients (41%) had one or more ADEs. Incidence, by individual, was not significantly different between Usual Care and Provider Feedback groups (37% vs. 45%; p = 0.06; Coefficient, 0.19; 95% CI: -0.008, 0.390). ADE severity was also similar. For example, 51% of ADEs in the Usual Care and 58% in the Provider Feedback groups involved symptoms that were not serious (95% CI for the difference, -15%, 2%). Finally, ADE preventability did not differ. For example, 16% in the Usual Care group and 17% in the Provider Feedback group had an associated warning (95% CI for the difference, -7 to 5%; p = 0.79). CONCLUSION Medications safety did not improve with the addition of a medication profiling program to an electronic prescribing system.

Delivery of clinical genetic consultative services in the Veterans Health Administration

Objective:To characterize the delivery of genetic consultative services for adults, we examined the prevalence and organizational determinants of genetic consult availability and the organization of these services in the Veterans Health Administration.Methods:We conducted a Web-based survey of Veterans Health Administration clinical leaders. We summarized facility characteristics using descriptive statistics. Multivariate logistic regression assessed associations between organizational characteristics and consult availability.Results:We received 353 survey responses from key informants representing 141 Veterans Affairs Medical Centers. Clinicians could obtain genetic consults at 110 (78%) Veterans Affairs Medical Centers. Cancer genetic and neurogenetic consults were most common. Academic affiliation (odds ratio = 3.0; 95% confidence interval: 1.1–8.6) and provider education about genetics (odds ratio = 2.9; 95% confidence interval: 1.1–7.8) were significantly associated with consult availability. The traditional model of multidisciplinary specialty clinics or coordinated services between geneticists and other providers was most prevalent, although variability in the organization of these services was described, with consults available on-site, at another Veterans Affairs Medical Center, via telegenetics, or at non–Veterans Health Administration facilities. The emerging model of nongeneticists integrating genetics into their practices was also reported, with considerable variability by specialty.Conclusion:Both traditional and emerging models for genetic consultation are available in the Veterans Health Administration; however, there is variability in service organization that could influence quality of care.Genet Med 16 8, 609–619.Genetics in Medicine (2014); 16 8, 609–619. doi:10.1038/gim.2013.202

Prevalence and correlates of smoking status among veterans affairs primary care patients with probable major depressive disorder.

In an attempt to guide planning and optimize outcomes for population-specific smoking cessation efforts, the present study examined smoking prevalence and the demographic, clinical and psychosocial characteristics associated with smoking among a sample of Veterans Affairs primary care patients with probable major depression. Survey data were collected between 2003 and 2004 from 761 patients with probable major depression who attended one of 10 geographically dispersed VA primary care clinics. Current smoking prevalence was 39.8%. Relative to nonsmokers with probable major depression, bivariate comparisons revealed that current smokers had higher depression severity, drank more heavily, and were more likely to have comorbid PTSD. Smokers with probable major depression were also more likely than nonsmokers with probable major depression to have missed a health care appointment and to have missed medication doses in the previous 5months. Smokers were more amenable than non-smokers to depression treatment and diagnosis, and they reported more frequent visits to a mental health specialist and less social support. Alcohol abuse and low levels of social support were significant concurrent predictors of smoking status in controlled multivariable logistic regression. In conclusion, smoking prevalence was high among primary care patients with probable major depression, and these smokers reported a range of psychiatric and psychosocial characteristics with potential to complicate systems-level smoking cessation interventions.

Potential safety gaps in order entry and automated drug alerts: a nationwide survey of VA physician self-reported practices with computerized order entry.

ObjectiveUnderstanding provider perceptions of and experiences with order entry and order checks (drug alerts) in an electronic prescribing system may help improve medication safety technology. DesignCross-sectional, national survey of Veterans Administration physicians practicing in various specialties. MeasurementThirty-five question instrument was divided into 4 content domains. Response options included dichotomous, numeric, multiple choices, and Likert-like scales. Statistical methods included logistic regression. ResultsThe adjusted response rate was 1543 of 3588 (43%). Almost all providers (90%) felt that the VA electronic prescribing system, including its order checks, improved prescribing safety to some degree. Most respondents (72%) reported that they always or almost always document outside medications in a clinic note, although only 44% always or almost always entered outside medications in the non-VA medication data field. Most physicians (88%) who encountered serious allergic or adverse drug reactions reported either notifying a pharmacist or entering the information in the allergies/adverse reactions field. Generalists and physicians with higher numbers of prescriptions were more likely to enter relevant data into the electronic medical record (or notify a pharmacist, in the case of adverse reactions). In addition, 48% of providers described critical drug-drug interaction alerts as very useful; medical specialists found these less useful, whereas surgical specialists found these more useful when compared with generalists. LimitationsSurvey was conducted within a single healthcare system. ConclusionComputerized provider order entry and related order checks are perceived to improve prescribing safety; however, provider entry of some relevant information into the appropriate electronic fields may not be optimal.

Stigma Predicts Treatment Preferences and Care Engagement Among Veterans Affairs Primary Care Patients with Depression

BackgroundWhereas stigma regarding mental health concerns exists, the evidence for stigma as a depression treatment barrier among patients in Veterans Affairs (VA) primary care (PC) is mixed.PurposeThis study tests whether stigma, defined as depression label avoidance, predicted patients’ preferences for depression treatment providers, patients’ prospective engagement in depression care, and care quality.MethodsWe conducted cross-sectional and prospective analyses of existing data from 761 VA PC patients with probable major depression.ResultsRelative to low-stigma patients, those with high stigma were less likely to prefer treatment from mental health specialists. In prospective controlled analyses, high stigma predicted lower likelihood of the following: taking medications for mood, treatment by mental health specialists, treatment for emotional concerns in PC, and appropriate depression care.ConclusionsHigh stigma is associated with lower preferences for care from mental health specialists and confers risk for minimal depression treatment engagement.

Relationships between mood and employment over time among depressed VA primary care patients

OBJECTIVE Associations between depression, productivity and work loss have been reported, yet few studies have examined relationships between longitudinal depression status and employment continuity. We assessed these relationships among Veterans of conventional working ages. METHODS We used longitudinal survey data from Veterans receiving primary care in 1 of 10 Veterans Health Administration primary care practices in five states. Our sample included 516 participants with nine-item Patient Health Questionnaire (PHQ-9) scores indicating probable major depression (PHQ-9≥10) at baseline and who completed either the 7-month follow-up survey or follow-up surveys at both 7 and 18 months postbaseline. We examined relationships between depression persistence and employment status using multinomial logistic regression models. RESULTS Although general employment rates remained stable (21%-23%), improved depression status was associated with an increased likelihood of becoming employed over 7 months among those who were both depressed and nonemployed at baseline. Improvements in depression status starting at 7 months and continuing through 18 months were associated with remaining employed over the 18-month period, relative to those who were depressed throughout the same time frame. CONCLUSIONS Given the pressing need to prevent socioeconomic deterioration in the increasing population of conventional working-aged Operation Enduring Freedom and Operation Iraqi Freedom Veterans, further attention to the depression/employment relationship is urgently needed.

Impact of the Northridge earthquake on the mental health of veterans: results from a panel study.

OBJECTIVE The 1994 earthquake that struck Northridge, California, led to the closure of the Veterans Health Administration Medical Center at Sepulveda. This article examines the earthquakes impact on the mental health of an existing cohort of veterans who had previously used the Sepulveda Veterans Health Administration Medical Center. METHODS From 1 to 3 months after the disaster, trained interviewers made repeated attempts to contact participants by telephone to administer a repeated measures follow-up design survey based on a survey that had been done preearthquake. Postearthquake data were obtained on 1144 of 1800 (64%) male veterans for whom there were previous data. We tested a predictive latent variable path model of the relations between sociodemographic characteristics, predisaster physical and emotional health measures, and postdisaster emotional health and perceived earthquake impact. RESULTS Perceived earthquake impact was predicted by predisaster emotional distress, functional limitations, and number of health conditions. Postdisaster emotional distress was predicted by preexisting emotional distress and earthquake impact. The regression coefficient from earthquake impact to postearthquake emotional distress was larger than that of the stability coefficient from preearthquake emotional distress. Postearthquake emotional distress also was affected indirectly by preearthquake emotional distress, health conditions, younger age, and lower socioeconomic status. CONCLUSIONS The postdisaster emotional health of veterans who experienced greater earthquake impact would have likely benefited from postdisaster intervention, regardless of their predisaster emotional health. Younger veterans and veterans with generally poor physical and emotional health were more vulnerable to greater postearthquake emotional distress. Veterans of lower socioeconomic status were disproportionately likely to experience more effects of the disaster because they had more predisaster emotional distress, more functional limitations, and a greater number of health conditions. Because many veterans use non-Department of Veterans Affairs (VA) health care providers for at least some of their health needs, future disaster planning for both VA and non-VA providers should incorporate interventions targeted at these groups.