Christopher L. Bryson

The prevalence of cirrhosis and hepatocellular carcinoma in patients with human immunodeficiency virus infection

Cirrhosis is a leading cause of death among patients infected with human immunodeficiency virus (HIV). We sought to determine risk factors for and time trends in the prevalence of cirrhosis, decompensated cirrhosis, and hepatocellular carcinoma (HCC) among patients diagnosed with HIV who received care in the Veterans Affairs (VA) health care system nationally between 1996 and 2009 (n = 24,040 in 2009). Among patients coinfected with HIV and hepatitis C virus (HCV), there was a dramatic increase in the prevalence of cirrhosis (3.5%‐13.2%), decompensated cirrhosis (1.9%‐5.8%), and HCC (0.07%‐1.6%). Little increase was observed among patients without HCV coinfection in the prevalence of cirrhosis (1.7%‐2.2%), decompensated cirrhosis (1.1%‐1.2%), and HCC (0.03%‐0.13%). In 2009, HCV infection was present in the majority of patients with HIV who had cirrhosis (66%), decompensated cirrhosis (62%), and HCC (80%). Independent risk factors for cirrhosis included HCV infection (adjusted odds ratio [AOR], 5.82; 95% confidence interval [CI], 5.0‐6.7), hepatitis B virus (HBV) infection (AOR, 2.40; 95% CI, 2.0‐2.9), age (AOR, 1.03; 95% CI, 1.02‐1.04), Hispanic ethnicity (AOR, 1.76; 95% CI, 1.4‐2.2), diabetes (AOR, 1.79; 95% CI, 1.6‐2.1), and alcohol abuse (AOR, 1.78; 95% CI, 1.5‐2.1), whereas black race (AOR, 0.56; 95% CI, 0.48‐0.64) and successful eradication of HCV (AOR, 0.61; 95% CI, 0.4‐0.9) were protective. Independent risk factors for HCC included HCV infection (AOR, 10.0; 95% CI, 6.1‐16.4), HBV infection (AOR, 2.82; 95% CI, 1.7‐4.7), age (AOR, 1.05; 95% CI, 1.03‐1.08), and low CD4+ cell count (AOR, 2.36; 95% CI, 1.3‐4.2). Among 5999 HIV/HCV‐coinfected patients, 994 (18%) had ever received HCV antiviral treatment, of whom 165 (17%) achieved sustained virologic response. Conclusion: The prevalence of cirrhosis and HCC has increased dramatically among HIV‐infected patients driven primarily by the HCV epidemic. Potentially modifiable risk factors include HCV infection, HBV infection, diabetes, alcohol abuse, and low CD4+ cell count. (HEPATOLOGY 2013)

Iron deficiency and gastrointestinal malignancy: a population-based cohort study

PURPOSEnWe investigated whether iron deficiency, with or without anemia, is associated with an increased likelihood of gastrointestinal malignancy.nnnSUBJECTS AND METHODSnData were obtained from the first National Health and Nutrition Examination Survey and Epidemiologic Followup Study, a nationally representative, prospective cohort study that measured hemoglobin levels and iron saturation and recorded follow-up diagnoses. We included persons 25 to 74 years of age with no previous gastrointestinal malignancy. Anemia was defined as a hemoglobin value below the fifth percentile for each age group and sex. Iron deficiency was defined as an iron saturation below 15%.nnnRESULTSnEighteen (0.2%) gastrointestinal malignancies were identified among the 9024 participants during the first 2 years of follow-up. None of the 442 premenopausal women with iron deficiency (92 with anemia and 350 without anemia) were diagnosed with gastrointestinal malignancy. Among men and postmenopausal women, the proportion diagnosed with gastrointestinal malignancy was 31 times greater (95% confidence interval [CI]: 9 to 107) in those with iron deficiency anemia (3/51 [6%]) and five times greater (95% CI: 1 to 21) in those with iron deficiency without anemia (2/223 [1%]), compared with those with normal hemoglobin levels and iron saturation (11/5733 [0.2%]).nnnCONCLUSIONSnGastrointestinal malignancy is uncommon in iron-deficient premenopausal women with or without anemia. Among men and postmenopausal women, gastrointestinal malignancy is significantly more common in those with iron deficiency than in persons with normal serum iron saturation and hemoglobin levels.

The Effects of Smoking Cessation on the Risk of Chronic Obstructive Pulmonary Disease Exacerbations

BACKGROUNDSmoking cessation has been demonstrated to reduce the rate of loss of lung function and mortality among patients with mild to moderate chronic obstructive pulmonary disease (COPD). There is a paucity of evidence about the effects of smoking cessation on the risk of COPD exacerbations.OBJECTIVEWe sought to examine whether smoking status and the duration of abstinence from tobacco smoke is associated with a decreased risk of COPD exacerbations.DESIGNWe assessed current smoking status and duration of smoking abstinence by self-report. Our primary outcome was either an inpatient or outpatient COPD exacerbation. We used Cox regression to estimate the risk of COPD exacerbation associated with smoking status and duration of smoking cessation.PARTICIPANTSWe performed a cohort study of 23,971 veterans who were current and past smokers and had been seen in one of seven Department of Veterans Affairs (VA) primary care clinics throughout the US.MEASUREMENTS AND MAIN RESULTSIn comparison to current smokers, ex-smokers had a significantly reduced risk of COPD exacerbation after adjusting for age, comorbidity, markers of COPD severity and socio-economic status (adjusted HR 0.78, 95% CI 0.75–0.87). The magnitude of the reduced risk was dependent on the duration of smoking abstinence (adjusted HR: quitu2009<1xa0year, 1.04; 95% CI 0.87–1.26; 1–5xa0years 0.93, 95% CI 0.79–1.08; 5–10xa0years 0.84, 95% CI 0.70–1.00; ≥10xa0years 0.65, 95% CI 0.58–0.74; linear trendu2009<0.001).CONCLUSIONSSmoking cessation is associated with a reduced risk of COPD exacerbations, and the described reduction is dependent upon the duration of abstinence.

A Randomized Trial to Improve Communication About End-of-Life Care Among Patients With COPD

OBJECTIVEnPatients with COPD consistently express a desire to discuss end-of-life care with clinicians, but these discussions rarely occur. We assessed whether an intervention using patient-specific feedback about preferences for discussing end-of-life care would improve the occurrence and quality of communication between patients with COPD and their clinicians.nnnMETHODSnWe performed a cluster-randomized trial of clinicians and patients from the outpatient clinics at the Veterans Affairs Puget Sound Health Care System. Using self-reported questionnaires, we assessed patients preferences for communication, life-sustaining therapy, and experiences at the end of life. The intervention clinicians and patients received a one-page patient-specific feedback form, based on questionnaire responses, to stimulate conversations. The control group completed questionnaires but did not receive feedback. Patient-reported occurrence and quality of end-of-life communication (QOC) were assessed within 2 weeks of a targeted visit. Intention-to-treat regression analyses were performed with generalized estimating equations to account for clustering of patients within clinicians.nnnRESULTSnNinety-two clinicians contributed 376 patients. Patients in the intervention arm reported nearly a threefold higher rate of discussions about end-of-life care (unadjusted, 30% vs 11%; P < .001). Baseline end-of-life communication was poor (intervention group QOC score, 23.3; 95% CI, 19.9-26.8; control QOC score, 19.2; 95% CI, 15.9-22.4). Patients in the intervention arm reported higher-quality end-of-life communication that was statistically significant, although the overall improvement was small (Cohen effect size, 0.21).nnnCONCLUSIONSnA one-page patient-specific feedback form about preferences for end-of-life care and communication improved the occurrence and quality of communication from patients perspectives.nnnTRIAL REGISTRYnClinicalTrials.gov; No.: NCT00106080; URL: www.clinicaltrials.gov.

Predicting risk of hospitalization or death among patients receiving primary care in the Veterans Health Administration.

Background:Statistical models that identify patients at elevated risk of death or hospitalization have focused on population subsets, such as those with a specific clinical condition or hospitalized patients. Most models have limitations for clinical use. Our objective was to develop models that identified high-risk primary care patients. Methods:Using the Primary Care Management Module in the Veterans Health Administration (VHA)’s Corporate Data Warehouse, we identified all patients who were enrolled and assigned to a VHA primary care provider on October 1, 2010. The outcome variable was the occurrence of hospitalization or death during the subsequent 90 days and 1 year. We extracted predictors from 6 categories: sociodemographics, medical conditions, vital signs, prior year use of health services, medications, and laboratory tests and then constructed multinomial logistic regression models to predict outcomes for over 4.6 million patients. Results:In the predicted 95th risk percentiles, observed 90-day event rates were 19.6%, 6.2%, and 22.6%, respectively, for hospitalization, death, and either hospitalization or death, compared with population averages of 2.7%, 0.7%, and 3.4%, respectively; 1-year event rates were 42.3%, 19.4%, and 51.3%, respectively, compared with population averages of 8.2%, 2.6%, and 10.8%, respectively. The C-statistics for 90-day outcomes were 0.83, 0.86, and 0.81, respectively, for hospitalization, death, and either hospitalization or death and were 0.81, 0.85, and 0.79, respectively, for 1-year outcomes. Conclusions:Prediction models using electronic clinical data accurately identified patients with elevated risk for hospitalization or death. This information can enhance the coordination of care for patients with complex clinical conditions.

Initial validation of a self-report measure of the extent of and reasons for medication nonadherence

BackgroundSelf-report measures of medication nonadherence confound the extent of and reasons for medication nonadherence. Each construct is assessed with a different type of psychometric model, which dictates how to establish reliability and validity. Objectives:To evaluate the psychometric properties of a self-report measure of medication nonadherence that assesses separately the extent of nonadherence and reasons for nonadherence. Research Design:Cross-sectional survey involving the new measure and comparison measures to establish convergent, discriminant, and predictive validity. The new measure was readministered 2–21 days later. Subjects:A total of 202 veterans with treated hypertension were recruited from the Durham Veterans Affairs Medical Center. Measures:A new self-report measure assessed the extent of nonadherence and reasons for nonadherence. Comparison measures included self-reported medication self-efficacy, beliefs about medications, impression management, conscientiousness, habit strength, and an existing nonadherence measure. Results:Three items assessing the extent of nonadherence produced reliable scores for this sample, &agr;=0.84 (95% confidence interval, 0.80–0.87). Correlations with comparison measures provided evidence of convergent and discriminant validity. Correlations with systolic (r=0.27, P<0.0001) and diastolic (r=0.27, P<0.0001) blood pressure provided evidence of predictive validity. Reasons for nonadherence were assessed with 21 independent items. Intraclass correlations were 0.58 for the extent score and ranged from 0.07 to 0.64 for the reasons. Conclusions:The dual conceptualization of medication nonadherence allowed a stronger evaluation of the reliability and validity than was previously possible with measures that confounded these 2 constructs. Measurement of self-reported nonadherence consistent with psychometric principles will enable reliable, valid evaluation of interventions to reduce nonadherence.

The Incidence and Timing of Noncardiac Surgery after Cardiac Stent Implantation

BACKGROUNDnIn November 2007, national guidelines were released recommending delay of elective noncardiac surgery after cardiac revascularization with drug eluting stents (DES) for 12 months compared with 6 weeks after implantation of bare metal stents (BMS).nnnSTUDY DESIGNnTo determine the incidence of noncardiac surgery within 24 months after stent placement, national VA data on cardiac stent implantation were merged with data from the VA National Surgery Office and Medicare. Using chi-square tests and log-rank analyses, we measured the incidence of noncardiac surgery after BMS and DES in relation to guideline release and surgical characteristics.nnnRESULTSnFrom 2000 to 2010, 126,773 stent procedures were followed by 25,977 (20.5%) noncardiac operations within 24 months. Overall, 11.8% of the BMS surgery cohort had early surgery (less than 6 weeks) compared with 46.7% of the DES surgery cohort, which had early surgery (less than 12 months). The incidence of surgery differed significantly by stent type (BMS 24.1% vs DES 17.5%, p < 0.001) and in relation to guideline release (pre- 24.6% vs postguideline 13.1%, p < 0.001). Higher complexity operations (work relative value units) were more likely to occur in the early period for both BMS (p < 0.0001) and DES (p < 0.003). After guideline release, the incidence of surgery within 12 months decreased from 16.7% to 10.0% (p < 0.0001).nnnCONCLUSIONSnWe found evidence that guidelines recommending delaying surgery appear to be effective in decreasing the incidence of early surgery; however, early surgery is still a frequent occurrence. Additional research is needed to better define the risk of cardiac and bleeding complications in patients undergoing subsequent noncardiac surgery, as well as the optimal time for surgery and method of antiplatelet management.

Adoption of Transradial Percutaneous Coronary Intervention and Outcomes According to Center Radial Volume in the Veterans Affairs Healthcare System Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program

Background—Studies examining the association between radial approach and post–percutaneous coronary intervention (PCI) bleeding and mortality have reached conflicting conclusions. There are no current data about the use and outcomes of transradial PCI (r-PCI) in the Veterans Affairs system. Methods and Results—Consecutive veterans (n=24u2009143 patients) undergoing PCI in the Veterans Affairs between 2007 and 2010 were examined. On the basis of propensity to undergo r-PCI, 3 cohorts matched with veterans undergoing transfemoral access were constructed among sites performing ≥1 r-PCI, ≥50 r-PCI (high volume), and <50 r-PCI (low volume). Cox proportional hazard models were used to determine the association between PCI access site, blood transfusion, and mortality. The prevalence of r-PCI increased over time (2007=2.1%; 2010=8.8%). Overall, there was no difference in procedure success between matched groups (r-PCI 97.3% versus transfemoral PCI 96.6%; P=0.182), or in the risk of postprocedure transfusion or mortality. Among matched patients treated at high r-PCI volume sites, radial access was associated with a decreased risk of post-PCI blood transfusion (hazard ratio, 0.4; 95% confidence interval, 0.3–0.7; P<0.001), and no significant difference in the risk of mortality (hazard ratio, 0.7; 95% confidence interval, 0.4–1.3; P=0.279). Conclusions—Within the Veterans Affairs, the use of r-PCI increased over time. r-PCI may be associated with a significant decreased risk of post-PCI blood transfusion among higher volume r-PCI sites. These data demonstrate that potential benefits of r-PCI in terms of reduced post-PCI blood transfusions may be more pronounced at sites that routinely use radial access.

AUDIT-C Alcohol Screening Results and Postoperative Inpatient Health Care Use.

BACKGROUNDnAlcohol screening scores ≥5 on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) up to a year before surgery have been associated with postoperative complications, but the association with postoperative health care use is unknown. This study evaluated whether AUDIT-C scores in the year before surgery were associated with postoperative hospital length of stay, total ICU days, return to the operating room, and hospital readmission.nnnSTUDY DESIGNnThis cohort study included male Veterans Affairs patients who completed the AUDIT-C on mailed surveys (October 2003 through September 2006) and were hospitalized for nonemergent noncardiac major operations in the following year. Postoperative health care use was evaluated across 4 AUDIT-C risk groups (scores 0, 1 to 4, 5 to 8, and 9 to 12) using linear or logistic regression models adjusted for sociodemographics, smoking status, surgical category, relative value unit, and time from AUDIT-C to surgery. Patients with AUDIT-C scores indicating low-risk drinking (scores 1 to 4) were the referent group.nnnRESULTSnAdjusted analyses revealed that among eligible surgical patients (n = 5,171), those with the highest AUDIT-C scores (ie, 9 to 12) had longer postoperative hospital length of stay (5.8 [95% CI, 5.0-6.7] vs 5.0 [95% CI, 4.7-5.3] days), more ICU days (4.5 [95% CI, 3.2-5.8] vs 2.8 [95% CI, 2.6-3.1] days), and increased probability of return to the operating room (10% [95% CI, 6-13%] vs 5% [95% CI, 4-6%]) in the 30 days after surgery, but not increased hospital readmission within 30 days postdischarge, relative to the low-risk group.nnnCONCLUSIONSnAUDIT-C screening results could be used to identify patients at risk for increased postoperative health care use who might benefit from preoperative alcohol interventions.

Collaborative Care Intervention for Stable Ischemic Heart Disease

BACKGROUNDnAccumulating evidence suggests that collaborative models of care enhance communication among primary care providers, improving quality of care and outcomes for patients with chronic conditions. We sought to determine whether a multifaceted intervention that used a collaborative care model and was directed through primary care providers would improve symptoms of angina, self-perceived health, and concordance with practice guidelines for managing chronic stable angina.nnnMETHODSnWe conducted a prospective trial, cluster randomized by provider, involving patients with symptomatic ischemic heart disease recruited from primary care clinics at 4 academically affiliated Department of Veterans Affairs health care systems. Primary end points were changes over 12 months in symptoms on the Seattle Angina Questionnaire, self-perceived health, and concordance with practice guidelines.nnnRESULTSnIn total, 183 primary care providers and 703 patients participated in the study. Providers accepted and implemented 91.6% of 701 recommendations made by collaborative care teams. Almost half were related to medications, including adjustments to β-blockers, long-acting nitrates, and statins. The intervention did not significantly improve symptoms of angina or self-perceived health, although end points favored collaborative care for 10 of 13 prespecified measures. While concordance with practice guidelines improved 4.5% more among patients receiving collaborative care than among those receiving usual care (P < .01), this was mainly because of increased use of diagnostic testing rather than increased use of recommended medications.nnnCONCLUSIONnA collaborative care intervention was well accepted by primary care providers and modestly improved receipt of guideline-concordant care but not symptoms or self-perceived health in patients with stable angina.