Margaret D. Voelker

Is there a Persian Gulf War syndrome? Evidence from a large population-based survey of veterans and nondeployed controls.

PURPOSE Concerns have been raised about whether veterans of the Gulf War have a medical illness of uncertain etiology. We surveyed veterans to look for evidence of an illness that was unique to those deployed to the Persian Gulf and was not seen in comparable military controls. SUBJECTS AND METHODS A population-based sample of veterans (n = 1,896 from 889 units) deployed to the Persian Gulf and other Gulf War-era controls (n = 1799 from 893 units) who did not serve in the Gulf were surveyed in 1995-1996. Seventy-six percent of eligible subjects, including 91% of located subjects, answered questions about commonly reported and potentially important symptoms. We used factor analysis, a statistical technique that can identify patterns of related responses, on a random subset of the deployed veterans to identify latent patterns of symptoms. The results from this derivation sample were compared with those obtained from a separate validation sample of deployed veterans, as well as the nondeployed controls, to determine whether the results were replicable and unique. RESULTS One half (50%) of the deployed veterans and 14% of the nondeployed controls reported health problems that they attributed to military service during 1990-1991. Compared with the nondeployed controls, the deployed veterans had significantly greater prevalences of 123 of 137 (90%) symptoms; none was significantly lower. Factor analysis identified three replicable symptom factors (or patterns) in the deployed veterans (convergent correlations > or =0.85). However, these patterns were also highly replicable in the nondeployed controls (convergent correlations of 0.95 to 0.98). The three factors also accounted for similar proportions of the common variance among the deployed veterans (35%) and nondeployed controls (30%). CONCLUSIONS The increased prevalence of nearly every symptom assessed from all bodily organ systems among the Gulf War veterans is difficult to explain pathophysiologically as a single condition. Identification of the same patterns of symptoms among the deployed veterans and nondeployed controls suggests that the health complaints of Gulf War veterans are similar to those of the general military population and are not consistent with the existence of a unique Gulf War syndrome.

Evaluation of the Iowa Medicaid pharmaceutical case management program.

OBJECTIVE To test the effect of pharmaceutical case management (PCM) on medication safety and health care utilization. DESIGN Prospective cohort design with 9-month follow-up period (enrollment from October 1, 2000, through July 1, 2001, with follow-up through July 1, 2002). SETTING Iowa Medicaid program. PARTICIPANTS 2,211 noninstitutionalized, continuously eligible Iowa Medicaid patients taking four or more chronic medications including at least one agent commonly used in at least 1 of 12 specific diseases who were cared for by pharmacists in 117 pharmacies. INTERVENTIONS Reimbursement for PCM services (initial patient assessment, written recommendations to physician, follow-up assessments and communication of progress and new problems to physician). MAIN OUTCOME MEASURES Use of high-risk medications, Medication Appropriateness Index (MAI) score, health care utilization. RESULTS Pharmacists in 114 pharmacies had eligible patients during at least one quarter during the study period; 28 pharmacies were classified as high intensity based on the number of PCM patients they managed. A total of 524 of the eligible patients received 1,599 PCM services; 90% of claims were filed by pharmacists, and the remainder by physicians. Nearly one half (46.1%) of medications and 92.1% of patients had at least one medication problem before PCM. By closeout, the percentage of medications with problems decreased in 8 of 10 MAI domains for those who received PCM. Compared with baseline, mean MAI score improved significantly from 9.4 to 8.3 among PCM recipients (P < .001). Percentage of PCM recipients using high-risk medications decreased significantly compared with PCM eligibles who did not receive the service. In the 28 pharmacies that adopted the new service most intensely, patients had a significant decrease in high-risk medication use, compared with patients of low-intensity pharmacies (P < .001). No difference was observed between PCM recipients and PCM eligibles who did not receive PCM in health care utilization or charges, even after including reimbursements for PCM. CONCLUSION Medication safety problems were prevalent in this high-risk population. The PCM program improved medication safety during a 9-month follow-up period.

The impact of Parkinson's disease on health status, health expenditures, and productivity. Estimates from the National Medical Expenditure Survey.

SummaryParkinson’s disease (PD) is a common disorder that leads to severe disability, despite pharmacological and surgical interventions. As PD progresses, patients and their families experience substantial health and economic burdens. Little research has been conducted into the economic consequences of PD or the impairment of health dimensions, such as social function and mental health, that may accompany the deterioration in economic resources and physical function.may accompany the deterioration in economic resources and physical function. In the current study, the US National Medical Expenditure Survey (NMES) was examined as a source of population-based information about health-resource use, medical expenditures and health status. 43 patients with PD were identified, and each was matched with 3 individuals without PD to estimate the costs attributable to PD.Data from the NMES demonstrate the serious health and economic burdens of PD. The patients with PD were clearly shown to have decreased health status, increased health expenditures and lost productivity relative to controls. However, these estimates of the magnitude of disease burden must be used with caution. The small sample size appears to have inadequately represented patients in the earliest and the most advanced stages of PD. There was also considerable variability in case-control groups, resulting in wide confidence intervals for the estimates.

The Usefulness of the Functional Status Questionnaire and Medical Outcomes Study Short Form in Parkinson's Disease Research

Parkinsons disease (PD) has no cure and is a progressive neurological disorder with treatment aimed at the maintenance of function and limitation of the symptoms. No extensive studies of the diseases impact on health-related quality of life (HRQoL) have been conducted. The purpose of this study was to assess the potential usefulness of the Medical Outcomes Study Short Form (SP-36) and the Functional Status Questionnaire (FSQ) in Parkinsons disease research. This cross-sectional study of 193 PD patients who visited two hospital-based neurology clinics used self-administered in-clinic and take-home questionnaires to ascertain the demographic and environmental characteristics of the subjects and to gain health profile measures from the SF-36 and the FSQ. The two health profiles provide important HRQoL information supplementary to the traditional signs and symptoms evaluated by the Unified Parkinsons Disease Rating Scale (UPDRS). Many of the HRQoL measures discriminate progressive stages of disease in this study group and distinguish those with complications of therapy from subjects without complications.

Gulf War veterans with anxiety: Prevalence, comorbidity, and risk factors

Background: Veterans of the first Gulf War have higher rates of medical and psychiatric symptoms than nondeployed military personnel. Methods: To assess the prevalence of and risk factors for current anxiety disorders in Gulf War veterans, we administered a structured telephone interview to a population-based sample of 4886 military personnel from Iowa at enlistment. Participants were randomly drawn from Gulf War regular military, Gulf War National Guard/Reserve, non-Gulf War regular military, and non-Gulf War National Guard/Reserve. Medical and psychiatric conditions were assessed through standardized interviews and questionnaires in 3695 subjects (76% participation). Risk factors were assessed using multivariate logistic regression models. Results: Veterans of the first Gulf War reported a markedly higher prevalence of current anxiety disorders than nondeployed military personnel (5.9% vs. 2.8%; odds ratio = 2.1; 95% confidence interval = 1.3–3.1), and their anxiety disorders are associated with co-occurring psychiatric disorders. Posttraumatic stress disorder, panic disorder, and generalized anxiety disorder were each present at rates nearly twice expected. In our multivariate model, predeployment psychiatric treatment and predeployment diagnoses (posttraumatic stress disorder, depression, or anxiety) were independently associated with current anxiety disorder. Participation in Gulf War combat was independently associated with current posttraumatic stress disorder, panic disorder, and generalized anxiety disorder. Conclusions: Current anxiety disorders are relatively frequent in a military population and are more common among Gulf War veterans than nondeployed military personnel. Predeployment psychiatric difficulties are robustly associated with the development of anxiety. Healthcare providers and policymakers need to consider panic disorder and generalized anxiety disorder, in addition to posttraumatic stress disorder, to ensure their proper assessment, treatment, and prevention in veteran populations.

Population-based assessment of hospitalizations for neutropenia from chemotherapy in older adults with non-Hodgkin's lymphoma (United States).

ObjectiveTo study neutropenia hospitalization (NH) incidence and risk factors in a population-based sample of older adults with non-Hodgkin’s lymphoma (NHL) and evaluate the validity of inferences from Surveillance, Epidemiology and End Results (SEER)-Medicare linked databases.MethodsNHL cases receiving first-course chemotherapy were identified from Iowa SEER-Medicare. Survival methods evaluated NH risk factors. Medical record and Medicare claims data on chemotherapy and NH were compared.ResultsOf 761 subjects, 165 (21.7%, 95% CI: 18.8, 24.6) were hospitalized for neutropenia. Of those hospitalized, 41% were hospitalized in cycle 1 and 22% in cycle 2. Significant multivariable risk factors for NH were diffuse large cell histology, renal disease, Charlson comorbidity index, and anthracycline chemotherapy but not patient age. Medicare and medical records agreed on month of chemotherapy initiation 95% of the time and chemotherapy type 95% of the time. ICD-9 code 288.0 sensitivity for NH was 80%.ConclusionsNeutropenia hospitalizations were common in the first 2 chemotherapy cycles, especially among older adults with comorbidity. Findings conflict with a prior medical records study in which age was a risk factor for NH and dose intensity a negative confounder. Valid inferences about age effects on chemotherapy toxicity require more clinical detail than is available in administrative data.

Risk Factors for Adverse Drug Events in Older Adults with Mobility Limitations in the Community Setting

OBJECTIVES: To investigate risk factors for self‐reported adverse drug events (ADEs) in a cohort of annually surveyed Iowa Medicare beneficiaries with mobility limitations.

Diffuse large B-cell lymphoma in the elderly: diffusion of treatment with rituximab and survival advances with and without anthracyclines

Anthracycline-based chemotherapy (ABC) is the most effective therapy for diffuse large B-cell lymphoma (DLBCL). The addition of rituximab to ABC in controlled trials has demonstrated superior survival, yet ABC is inconsistently utilized in elderly patients, and little is known about the penetrance or impact of rituximab with other treatments. We analyzed the treatment and survival patterns of 7559 patients with DLBCL over age 66 diagnosed from 1992 to 2002 using a linked Surveillance, Epidemiology and End Results (SEER)–Medicare database. Rituximab use was first detected in 1999 and by 2002 was incorporated in 79% of ABC-treated patients and 71% of patients treated with non-anthracycline chemotherapy, but only 12% of patients not receiving cytotoxic chemotherapy. ABC rates remained constant across time as did rates of no therapy, which were highest among the very old. Rituximab-associated survival improvements were seen among elderly treated with or without anthracyclines. Patients treated with rituximab but not anthracyclines had comparable survival to those treated with anthracycline but not rituximab.

Quality of life and health-services utilization in a population-based sample of military personnel reporting multiple chemical sensitivities.

We sought to assess quality of life and health-services utilization variables in persons with symptoms suggestive of multiple chemical sensitivity/idiopathic environmental intolerance (MCS/IEI) among military personnel. We conducted a cross-sectional telephone survey of a population-based sample of Persian Gulf War (PGW) veterans from Iowa and a comparison group of PGW-era military personnel. A complex sample survey design was used, selecting subjects from four domains: PGW active duly, PGW National Guard/Reserve, non-PGW active duty, and non-PGW National Guard/Reserve. Each domain was substratified by age, gender, race, rank, and military branch. The criteria for MCS/IEI were developed by expert consensus and from the medical literature. In the total sample, 169 subjects (4.6%) of the 3695 who participated (76% of those eligible) met our criteria for MCS/IEI. Persons who met the criteria for MCS/IEI more often reported the following than did other subjects: more than 12 days in bed due to disability, Veterans Affairs disability status, Veterans Affairs disability compensation, medical disability, and unemployment. MCS/IEI cases also had higher outpatient rates of physician visits, emergency department visits, and inpatient hospital stays. Subjects who met the criteria for MCS/IEI more often reported impaired functioning on each Medical Outcomes Study 36-Item Short Form subscale, compared with those who did not meet the criteria. We concluded that although the diagnosis of MCS/IEI remains controversial, the persons who met our criteria for the disorder are functionally impaired.

Effect of clinical characteristics on neutropenia-related inpatient costs among newly diagnosed non-Hodgkin's lymphoma cases during first-course chemotherapy.

Study Objective. To estimate the costs of hospitalization for neutropenia among chemotherapy‐treated patients with newly diagnosed non‐Hodgkins lymphoma and to assess baseline patient factors associated with these costs.