Maria Ribeiro

Unintended Consequences of Health Information Technology: Evidence From Veterans Affairs Colorectal Cancer Oncology Watch Intervention

PURPOSE We evaluated the Colorectal Cancer (CRC) Oncology Watch intervention, a clinical reminder implemented in Veterans Integrated Service Network 7 (including eight hospitals) to improve CRC screening rates in 2008. PATIENTS AND METHODS Veterans Affairs (VA) administrative data were used to construct four cross-sectional groups of veterans at average risk, age 50 to 64 years; one group was created for each of the following years: 2006, 2007, 2009, and 2010. We applied hospital fixed effects for estimation, using a difference-in-differences model in which the eight hospitals served as the intervention sites, and the other 121 hospitals served as controls, with 2006 to 2007 as the preintervention period and 2009 to 2010 as the postintervention period. RESULTS The sample included 4,352,082 veteran-years in the 4 years. The adherence rates were 37.6%, 31.6%, 34.4%, and 33.2% in the intervention sites in 2006, 2007, 2009, and 2010, respectively, and the corresponding rates in the controls were 31.0%, 30.3%, 32.3%, and 30.9%. Regression analysis showed that among those eligible for screening, the intervention was associated with a 2.2-percentage point decrease in likelihood of adherence (P < .001). Additional analyses showed that the intervention was associated with a 5.6-percentage point decrease in likelihood of screening colonoscopy among the adherent, but with increased total colonoscopies (all indicators) of 3.6 per 100 veterans age 50 to 64 years. CONCLUSION The intervention had little impact on CRC screening rates for the studied population. This absence of favorable impact may have been caused by an unintentional shift of limited VA colonoscopy capacity from average-risk screening to higher-risk screening and to CRC surveillance, or by physician fatigue resulting from the large number of clinical reminders implemented in the VA.

Bone density in haemophilia: a single institutional cross-sectional study.

Haemophilia has been associated with low bone mineral density (BMD). However, prior clinical studies of this population have neither clearly elucidated risk factors for development of low BMD nor identified who may warrant screening for osteoporosis. The aim of the study was to evaluate the relationship between BMD and haemophilic arthropathy and other demographic and clinical variables. We undertook a cross‐sectional study of BMD in adult men with haemophilia. Measures of predictor variables were collected by radiographic studies, physical examination, patient questionnaires and review of medical records. Among 88 enrolled subjects, the median age was 41 years (IQR: 20); median femoral neck BMD (n = 87) was 0.90 g cm−2 (IQR: 0.24); and median radiographic joint score was 7.5 (IQR: 18). Among subjects <50 years (n = 62), after controlling for BMI, alcohol, HIV and White race, BMD decreased as radiographic joint score increased (est. β = −0.006 mg cm−2; 95% CI −0.009, −0.003; partial R2 = 0.23). Among subjects ≥50 years (n = 26), 38% had osteoporosis (T score less than or equal to −2.5) and there was no association between BMD and arthropathy. Risk factors for low BMD in men with haemophilia <50 years include haemophilic arthropathy, low or normal BMI and HIV. Men with haemophilia over age 50 years should have routine screening for detection of osteoporosis.

Long‐term use of valproic acid in US veterans is associated with a reduced risk of smoking‐related cases of head and neck cancer

Epigenetic events play a major role in the carcinogenesis of tobacco‐related cancers. The authors conducted a retrospective cohort study to evaluate the effects of exposure to the anticonvulsant agent valproic acid (VPA), a histone deacetylase inhibitor, on the risk of developing cancers of the lung, head and neck, prostate, bladder, and colon.

CHFR protein expression predicts outcomes to taxane-based first line therapy in metastatic NSCLC

Purpose: Currently, there is no clinically validated test for the prediction of response to tubulin-targeting agents in non–small cell lung cancer (NSCLC). Here, we investigated the significance of nuclear expression of the mitotic checkpoint gene checkpoint with forkhead and ringfinger domains (CHFR) as predictor of response and overall survival with taxane-based first-line chemotherapy in advanced stage NSCLC. Methods: We studied a cohort of 41 patients (median age 63 years) with advanced NSCLC treated at the Atlanta VAMC between 1999 and 2010. CHFR expression by immunohistochemistry (score 0–4) was correlated with clinical outcome using chi-square test and Cox proportional models. A cutoff score of “3” was determined by receiver operator characteristics analysis for “low” CHFR expression. Results were validated in an additional 20 patients who received taxane-based chemotherapy at Emory University Hospital and the Atlanta VAMC. Results: High expression (score = 4) of CHFR is strongly associated with adverse outcomes: the risk for progressive disease after first-line chemotherapy with carboplatin–paclitaxel was 52% in patients with CHFR-high versus only 19% in those with CHFR-low tumors (P = 0.033). Median overall survival was strongly correlated with CHFR expression status (CHFR low: 9.9 months; CHFR high: 6.2 months; P = 0.002). After multivariate adjustment, reduced CHFR expression remained a powerful predictor of improved overall survival (HR = 0.24; 95% CI, 0.1–0.58%; P = 0.002). In the validation set, low CHFR expression was associated with higher likelihood of clinical benefit (P = 0.03) and improved overall survival (P = 0.038). Conclusions: CHFR expression is a novel predictive marker of response and overall survival in NSCLC patients treated with taxane-containing chemotherapy. Clin Cancer Res; 19(6); 1603–11. ©2013 AACR.

Physical activity and functional abilities in adult males with haemophilia: a cross-sectional survey from a single US haemophilia treatment centre.

Physical activity and functional ability are important determinants of quality of life and these metrics are affected by both haemophilia and ageing. Outside haemophilic arthropathy, risk factors leading to reduced physical activity and function in people with haemophilia (PWH) are under‐explored. The purpose of this analysis was to determine risk factors for reduced physical activity and functional limitations in PWH. A secondary analysis was conducted on data indexing physical activity and functioning of 88 PWH using data originally collected as part of a cross‐sectional study at a single large haemophilia treatment centre. The Framingham Physical Activities Index (PAI), the Hemophilia Activities List (HAL) and the Timed Up‐and‐Go Test (TUG) were the outcome measures. The World Federation of Haemophilia (WFH) orthopaedic joint score was used as a measure of arthropathy. Multiple linear regression analysis was used to assess the relationship between the outcome measures and covariates. Worsening WFH joint score was independently associated with all three outcome measures (P < 0.05). Increasing age was associated with reduced PAI and increased TUG time (P < 0.05). The HAL summary score was decreased in patients with chronic liver disease (P = 0.006). The adjusted R2 for each model was ≤0.35. This study provides evidence for the relationship between arthropathy and reduced physical functioning/activity, but also highlights that much of the variation in physical functioning/activity is not explained by haemophilia‐related characteristics.

Distress in patients with bleeding disorders: a single institutional cross-sectional study.

Distress may affect a patients ability to cope with and manage disease.

Physician trust and depression influence adherence to factor replacement: a single‐centre cross‐sectional study

Poor adherence to factor replacement therapy among patients with haemophilia can lead to joint bleeding and eventual disability.

Long-term use of valproic acid in United States Veterans associates with reduced risk of smoking related head-and neck cancer

Epigenetic events play a major role in the carcinogenesis of tobacco‐related cancers. The authors conducted a retrospective cohort study to evaluate the effects of exposure to the anticonvulsant agent valproic acid (VPA), a histone deacetylase inhibitor, on the risk of developing cancers of the lung, head and neck, prostate, bladder, and colon.

Abstract C75: Correlation of nephrectomy status and race with overall survival in patients with metastatic renal cell carcinoma

Introduction: In most settings median overall survival (OS) is longer for non-Hispanic whites when compared to non-Hispanic blacks with metastatic renal cell carcinoma (mRCC). However, the clinical outcome has been equally poor for both groups in patients who do not undergo nephrectomy. The primary objectives of this study were to explore the reasons why patients with mRCC do not undergo nephrectomy and to evaluate the impact of nephrectomy status and race on OS. Methods: After obtaining approval from the Institutional Review Board of Emory University and the Atlanta Research and Education Foundation, a retrospective chart review was conducted at the Atlanta VA Medical Center in conjunction with a longitudinal biomarker study of patients with mRCC. Patients who were treated with targeted therapy between 2005 and 2015 were eligible for inclusion. Nephrectomy status was assessed and the reasons for not undergoing nephrectomy were documented. Descriptive statistics were employed along with Kaplan-Meier survival analysis. Results: Forty four of the 46 patients from the biomarker study were included in the analysis of nephrectomy status (31 non-Hispanic whites and 13 non-Hispanic blacks; 2 Hispanics were not included). Of the non-Hispanic patients, 39 had unilateral disease and 5 had bilateral disease for a total of 49 primary tumors. Nephrectomy rates with respect to the number of primary tumors were 59% for non-Hispanic whites (n=20 of 34) and 53% for non-Hispanic blacks (n=8 of 15) for an overall rate of 57% (n=28 of 49). There was no significant difference in OS by race with a median of 29.5 months (2.42 years) for non-Hispanic blacks (95% C.I. 7.4 – 56.9 months) and 35.6 months (2.92 years) for non-Hispanic whites (95% C.I. 19.4 – 61.4 months) with a log-rank p-value of 0.88. Metastasis was present at the time of nephrectomy in 14 cases while the remaining 15 cases were the result of recurrence after nephrectomy with curative intent. Of the 21 primary tumors that were not resected in 19 non-Hispanic patients, metastases were present in most instances at the time decisions were made regarding nephrectomy (n=17 of 21; 81%). There were relative or absolute contraindications to nephrectomy for 12 of the primary tumors that were not resected (57%). These included unresectable tumors and patients with poor performance status, chronic kidney disease or other significant medical comorbidities. For the 9 remaining unresected primary tumors, no contraindications to surgery were identified, yet some patients declined of their own volition, others were not referred or re-referred to urology and some did not keep their follow up appointments with urology. Also, some surgeons did not recommend nephrectomy. As such, no predominant reason for absence of nephrectomy was identified for the group as a whole or by race. However, in the absence of nephrectomy, the median OS was only 15.5 months (1.27 years) with a 95% C.I. of 8.5 to 29.5 months, versus 45.2 months (3.71 years) for patients who had undergone nephrectomy with a 95% C.I. of 30.3 to 100.9 months and a log-rank p-value of 0.0002. Summary: No racial disparity in OS was observed in this retrospective study of a small number of patients at a single institution. However, absence of nephrectomy may be a significant confounding factor since it is a strong predictor of short survival irrespective of race. Larger studies are required. Of note, a nephrectomy was much less likely to have been performed in patients who had metastatic disease at the time of diagnosis. Though no predominant reason for absence of nephrectomy was found, key factors were identified such as unresectability, poor performance status, significant medical comorbidities, the failure to schedule or keep appointments with surgical staff, and patient choice to forego nephrectomy. Citation Format: Dale Kesley Robertson, Yuan Liu, Chao Zhang, Theresa Gillespie, John Petros, Muta Issa, Maria Ribeiro, Wayne B. Harris. Correlation of nephrectomy status and race with overall survival in patients with metastatic renal cell carcinoma. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C75.

Long-term use of valproic acid in US veterans is associated with a reduced risk of smoking-related cases of head and neck cancer: Reduced HNC Risk After VPA Use

Epigenetic events play a major role in the carcinogenesis of tobacco‐related cancers. The authors conducted a retrospective cohort study to evaluate the effects of exposure to the anticonvulsant agent valproic acid (VPA), a histone deacetylase inhibitor, on the risk of developing cancers of the lung, head and neck, prostate, bladder, and colon.