Bei-Hung Chang

Agreement Between Administrative Data and Patients’ Self-Reports of Race/Ethnicity

OBJECTIVES We examined agreement of administrative data with self-reported race/ethnicity and identified correlates of agreement. METHODS We used Veterans Affairs administrative data and VA 1999 Large Health survey race/ethnicity data. RESULTS Relatively low rates of agreement (approximately 60%) between data sources were largely the result of administrative data from patients whose race/ethnicity was unknown, with least agreement for Native American, Asian, and Pacific Islander patients. After exclusion of patients with missing race/ethnicity, agreement improved except for Native Americans. Agreement did not increase substantially after inclusion of data from individuals indicating multiple race/ethnicities. Patients for whom there was better agreement between data sources tended to be less educated, non-solitary living, younger, and White; to have sufficient food; and to use more inpatient Department of Veterans Affairs (VA) care. CONCLUSIONS Better reporting of race/ethnicity data will improve agreement between data sources. Previous studies using VA administrative data may have underestimated racial disparities.

Relaxation Response Induces Temporal Transcriptome Changes in Energy Metabolism, Insulin Secretion and Inflammatory Pathways

The relaxation response (RR) is the counterpart of the stress response. Millennia-old practices evoking the RR include meditation, yoga and repetitive prayer. Although RR elicitation is an effective therapeutic intervention that counteracts the adverse clinical effects of stress in disorders including hypertension, anxiety, insomnia and aging, the underlying molecular mechanisms that explain these clinical benefits remain undetermined. To assess rapid time-dependent (temporal) genomic changes during one session of RR practice among healthy practitioners with years of RR practice and also in novices before and after 8 weeks of RR training, we measured the transcriptome in peripheral blood prior to, immediately after, and 15 minutes after listening to an RR-eliciting or a health education CD. Both short-term and long-term practitioners evoked significant temporal gene expression changes with greater significance in the latter as compared to novices. RR practice enhanced expression of genes associated with energy metabolism, mitochondrial function, insulin secretion and telomere maintenance, and reduced expression of genes linked to inflammatory response and stress-related pathways. Interactive network analyses of RR-affected pathways identified mitochondrial ATP synthase and insulin (INS) as top upregulated critical molecules (focus hubs) and NF-κB pathway genes as top downregulated focus hubs. Our results for the first time indicate that RR elicitation, particularly after long-term practice, may evoke its downstream health benefits by improving mitochondrial energy production and utilization and thus promoting mitochondrial resiliency through upregulation of ATPase and insulin function. Mitochondrial resiliency might also be promoted by RR-induced downregulation of NF-κB-associated upstream and downstream targets that mitigates stress.

Potentially inappropriate prescribing in elderly veterans: Are we using the wrong drug, wrong dose, or wrong duration?

Objectives: To identify the extent of inappropriate prescribing using criteria for proper use developed by the Agency for Healthcare Research and Quality (AHRQ) and dose‐limitation criteria defined by Beers, as well as to describe duration of use and patient characteristics associated with inappropriate prescribing for older people.

STRESS MANAGEMENT VERSUS LIFESTYLE MODIFICATION ON SYSTOLIC HYPERTENSION AND MEDICATION ELIMINATION: A RANDOMIZED TRIAL

Isolated systolic hypertension is common in the elderly, but decreasing systolic blood pressure (SBP) without lowering diastolic blood pressure (DBP) remains a therapeutic challenge. Although stress management training, in particular eliciting the relaxation response, reduces essential hypertension its efficacy in treating isolated systolic hypertension has not been evaluated. We conducted a double-blind, randomized trial comparing 8 weeks of stress management, specifically relaxation response training (61 patients), versus lifestyle modification (control, 61 patients). Inclusion criteria were >or=55 years, SBP 140-159 mm Hg, DBP <90 mm Hg, and at least two antihypertensive medications. The primary outcome measure was change in SBP after 8 weeks. Patients who achieved SBP <140 mm Hg and >or=5 mm Hg reduction in SBP were eligible for 8 additional weeks of training with supervised medication elimination. SBP decreased 9.4 (standard deviation [SD] 11.4) and 8.8 (SD 13.0) mm Hg in relaxation response and control groups, respectively (both ps <0.0001) without group difference (p=0.75). DBP decreased 1.5 (SD 6.2) and 2.4 (SD 6.9) mm Hg (p=0.05 and 0.01, respectively) without group difference (p=0.48). Forty-four (44) in the relaxation response group and 36 in the control group were eligible for supervised antihypertensive medication elimination. After controlling for differences in characteristics at the start of medication elimination, patients in the relaxation response group were more likely to successfully eliminate an antihypertensive medication (odds ratio 4.3, 95% confidence interval 1.2-15.9, p=0.03). Although both groups had similar reductions in SBP, significantly more participants in the relaxation response group eliminated an antihypertensive medication while maintaining adequate blood pressure control.

Racial differences in health-related beliefs, attitudes, and experiences of VA cardiac patients: Scale development and application

Objectives. To determine whether there are racial differences in patients’ health-related attitudes, beliefs, and experiences regarding invasive cardiac procedures, and to develop psychometrically and conceptually valid scales and single items to assess these dimensions. Methods. A survey was designed and administered to 854 white and black patients with ischemic heart disease at five VA medical centers. Patients were queried about the domains proposed to be important to treatment decision making by the Health Decision Model: sociodemographic characteristics, social interactions, health care experiences, patient preferences for care, knowledge about diseases and potential treatments, and health beliefs. Using multitrait analysis, the psychometric properties of scales assessing these domains were examined. It was then assessed whether there were racial differences in scale or individual item scores using &khgr;2 and t test analyses. Results. The analyses yielded eight psychometrically valid scales: disease severity, patient evaluation of physician’s interpersonal style, patient evaluations of VA care, satisfaction with treatment decision making, perceived urgency of catheterization, vulnerability to catheterization, bodily impact of catheterization, and attitudes toward religion. There were only racial differences on mean scores for the latter scale. Individual item analyses indicated that black patients were less likely to have been encouraged by friends or family to have cardiac catheterization, and had less personal or familial experiences with this or other surgical procedures. In contrast to expectations, white patients were more likely to be skeptical of medical care. Conclusions. The multiple dimensions of white and black patients’ health-related attitudes, beliefs, and experiences were examined, and few differences were found. These results suggest that racial differences in patients’ attitudes, beliefs, and experiences are not a likely source of racial disparities in cardiac care. Future research will examine the association of beliefs, attitudes and experiences with actual use of invasive cardiac procedures.

A relaxation response randomized trial on patients with chronic heart failure.

PURPOSE Patients with various medical conditions benefit from eliciting the relaxation response (RR), using a variety of techniques, but few studies have focused on chronic heart failure (CHF). We evaluated the efficacy of an RR intervention program on the quality of life (QOL) and exercise capacity of CHF patients by conducting a single-blind, 3-arm, randomized, controlled trial. METHODS Between April 2000 and June 2002, we enrolled 95 patients with moderate severity CHF from the Veterans Affairs Boston Healthcare System. Patients in the study intervention group attended a weekly RR group for 15 weeks and were requested to practice the techniques at home twice a day. A 15-week cardiac education (EDU) program was used as an alternative intervention, and usual care (UC) was the control group. The QOL questionnaires and a bicycle test were administered at baseline and after intervention or 15 to 19 weeks. RESULTS Eighty-three (87%) of the 95 enrolled patients completed both baseline and post-intervention QOL measures (31 RR, 24 EDU, and 28 UC). No dropout bias was observed. The RR group had significantly better QOL change scores in peace-spiritual scales than did the UC group (P = .02), adjusting for baseline scores, time between assessments, age, education, diet, and medication, whereas no significant difference was observed between the EDU and UC groups. A similar trend was observed in emotional QOL (RR and UC group comparison, P = .07). No statistically significant intervention effect on physical QOL or exercise capacity was observed. CONCLUSIONS A short RR intervention can improve some aspects of QOL in CHF patients.

Religion and mental health among women veterans with sexual assault experience

Objective: Religion has been shown to have a positive impact on well-being and to play an important role in coping with stressful life events. However, the buffering effect of religiosity on mental health, after a particularly stressful life event such as sexual assault, has not been studied. In this study we examined the buffering effect of religion on mental health and depression for women who report experiencing sexual assault while in the military. Method: The sample includes a nationally representative sample of 3,543 women veterans who use VA ambulatory care. Two dimensions of religiosity were used: organizational (frequency of religious service attendance) and subjective (the extent religious beliefs are a source of strength/comfort). Mental health was measured by the mental component summary (MCS) from the SF36 and depressive symptoms were measured by the Center for Epidemiologic Studies-Depression (CES-D) scale. Results: Women veterans who reported experiencing sexual assault while in the military had lower mental health scores and higher levels of depression. Linear regression analysis indicated that these negative impacts diminished with increased frequency of religious service attendance, supporting the buffering effect of organizational religiosity on mental health and depression. Although the buffering effect of subjective religiosity was not evident, subjective religiosity was shown to be positively associated with better mental health in both groups of women with and without sexual assault experience in the military. Conclusions: Frequent religious service attendance buffers the negative impacts of sexual assault on mental health and depression of women veterans. The potential of integrating religiosity in designing interventions is discussed.

A model for integrating a mind/body approach to cardiac rehabilitation: outcomes and correlators.

PURPOSE Although cardiac rehabilitation programs have been shown to decrease cardiovascular risk, morbidity, and mortality, few programs have integrated a balanced mind/body approach in which patients are taught the relaxation response and utilize cognitive behavior skills for stress management, along with diet and exercise. We examined the medical and psychological outcomes of patients treated in such a cardiac rehabilitation program in a general hospital setting. METHODS From 1997 to 2005, outcomes were measured in 637 patients with coronary artery disease at baseline and after a 3-month program. Components of the intervention included smoking cessation, moderate aerobic exercise, nutrition counseling, relaxation response training, and cognitive/behavioral skills. RESULTS Men and women improved significantly with respect to medical outcomes (blood pressure, lipids, weight, exercise conditioning, frequency of symptoms of chest pain and shortness of breath) and psychological outcomes (general severity index, depression, anxiety, and hostility) (P < .0001). Patients considered “at higher risk” for cardiac events due to high baseline measures improved their measures to a less than “at higher risk” level. Data indicate that specific components of the intervention, that is, increased relaxation response practice and exercise, significantly contributed to these improvements (P < .05). Furthermore, age and gender differences, particularly for psychological measures, were found; younger patients and female patients had greater improvements than older patients and male patients. CONCLUSIONS This study provides preliminary data for a subsequent randomized control trial to test mind/body-based interventions to determine the most effective outcomes at an affordable cost.

The relationship between sexual assault, religiosity, and mental health among male veterans.

Objectives: We examine the association between sexual assault, religion and mental health among male veterans. Methods: We used longitudinal data collected from 2,427 male veterans who received VA outpatient care. Sexual assault was self-reported in the questionnaire. Two dimensions of religiosity were used: organizational (frequency of religious service attendance) and subjective religiosity (the extent that religious beliefs are a source of strength or comfort). Mental health was measured by the mental component summary from the Veterans SF-36 and depression was measured by the Center for Epidemiologic Studies-Depression scale. A regression model that uses the generalized estimating equation approach for longitudinal repeated data analysis was used. Results: Based on the baseline data, 96 (4%) patients reported ever experiencing sexual assault. These patients have significantly lower levels of mental health status and higher levels of depression (p < .001). The regression results show that this decrement in mental health and increment in depression associated with sexual assault are in lesser degrees for patients who attended religious service more frequently compared to those who never did (p < .05). Similarly, there is a smaller magnitude of increment in depression associated with sexual assault for those who have a higher level of subjective religiosity (p < .05). Conclusions: Although the prevalence of self reported sexual assault is low among male veterans, those who reported sexual assault experiences had lower levels of mental health status and higher levels of depression. Further, religion attenuates this association which highlights the important role religion might have in coping with this stressful life event.

Risk adjustment for measuring health outcomes: an application in VA long-term care.

An empirically derived risk adjustment model is useful in distinguishing among facilities in their quality of care. We used Veterans Affairs (VA) administrative databases to develop and validate a risk adjustment model to predict decline in functional status, an important outcome measure in long-term care, among patients residing in VA long-term care facilities. This model was used to compare facilities on adjusted and unadjusted rates of decline. Predictors of decline included age, time between assessments, baseline functional status, terminal illness, pressure ulcers, pulmonary disease, cancer, arthritis, congestive heart failure, substance-related disorders, and various neurologic disorders. The model performed well in the development and validation databases (c statistics, 0.70 and 0.68, respectively). Risk-adjusted rates and rankings of facilities differed from unadjusted ratings. We conclude that judgments of facility performance depend on whether risk-adjusted or unadjusted decline rates are used. Valid risk adjustment models are therefore necessary when comparing facilities on outcomes.