Min Woong Sohn

Veterans' access to and use of medicare and veterans affairs health care

Objectives:We examined the impact of access to care characteristics on health care use patterns among those veterans dually eligible for Medicare and Veterans Affairs (VA) services. Methods:We used a retrospective, cross-sectional design to identify veterans who were eligible to use VA and Medicare health care in calendar year 1999. We analyzed national VA utilization and Medicare claims data. We used descriptive and multivariable generalized ordered logit analyses to examine how patient, geographic, and environmental factors affect the percent reliance on VA and Medicare inpatient and outpatient services. Results:Of the 1.47 million veterans in our study population with outpatient use, 18% were VA-only users, 36% were Medicare-only users, and 46% were both VA and Medicare users. Among veterans with inpatient use, 24% were VA only, 69% were Medicare only, and 6% were both VA and Medicare users. Multivariable analysis revealed that veterans who were black or had a higher VA priority were most likely to rely on the VA. Patient with higher risk scores were most likely to rely on a combination of VA and Medicare health care. Patients who lived farther from VA hospitals were less likely to rely on VA health care, particularly for inpatient care. Patients living in urban areas with more health care resources were less likely to rely on VA health care. Conclusions:VA health care provides an important safety net for vulnerable populations. Targeted approaches that carefully consider the simultaneous impacts of VA and Medicare policy changes on minority and high-risk populations are essential to ensure veterans have access to needed health care.

Charcot Arthropathy Risk Elevation in the Obese Diabetic Population

PURPOSE To examine the association of obesity, peripheral neuropathy, and other risk factors with the Charcot arthropathy incidence rate in a large diabetic population. METHODS The Department of Veterans Affairs inpatient and outpatient administrative datasets were used to identify persons with diabetes in 2003. Logistic regressions were used to model the likelihood of a person developing Charcot arthropathy as a function of individual characteristics, obesity, peripheral neuropathy, diabetic control, and comorbidities. RESULTS Of Veterans Affairs users with diabetes, 652 (0.12%) were newly diagnosed with Charcot arthropathy in 2003. Compared with persons without obesity or peripheral neuropathy, those with obesity alone were approximately 59% more likely, those with neuropathy alone were 14 times more likely, and those with both obesity and neuropathy were 21 times more likely to develop Charcot arthropathy. Ages 55 to 64 years, diabetes duration 6 years or more, hemoglobin-A1c 7% or more, renal failure, arthritis, and deficiency anemia also were associated with an increased incidence of Charcot arthropathy. CONCLUSION Obesity is significantly associated with an increased incidence of Charcot arthropathy independently of other risk factors. When obesity is combined with neuropathy, the Charcot arthropathy incidence rate increases multiplicatively. Prevention and detection of Charcot arthropathy should take the interaction between obesity and neuropathy into consideration.

Environmental tobacco smoke and asthma exacerbations and severity: the difference between measured and reported exposure

Objective To assess the impact of measured versus reported environmental tobacco smoke (ETS) exposure on asthma severity and exacerbations in an urban paediatric population. Design We analysed cross-sectional data from the Chicago Initiative to Raise Asthma Health Equity study that followed a cohort of 561 children aged 8–14 with physician-diagnosed asthma between 2003 and 2005. Participant sociodemographic data and asthma symptoms were gathered by parental survey; exposures to ETS were determined by salivary cotinine levels and parent report. Multivariable negative binomial and ordered logistic regressions were used to assess associations between ETS and asthma outcomes. Results Among 466 children included in our analysis, 58% had moderate or severe persistent asthma; 32% had >2 exacerbations requiring a hospitalisation or an emergency room visit or same day care in the previous year. Half of caregivers reported that at least one household member smoked. In multivariable analyses, salivary cotinine was significantly associated with frequently reported exacerbations in the previous year (adjusted incidence rate ratio=1.39, 95% CI 1.09 to 1.79), but not significantly associated with asthma severity. Reported household smoking was not significantly associated with either asthma severity or frequency of exacerbations. Conclusions Salivary cotinine was more predictive of asthma exacerbation frequency but caregiver- reported household smoking was not. Use of a nicotine biomarker may be important in both the clinical and research settings to accurately identify an important risk factor for asthma exacerbations.

Differences in empowerment and quality of life among parents of children with food allergy.

BACKGROUND Living with food allergy has been found to adversely affect quality of life. Previous studies of the psychosocial impact of food allergy on caregivers have focused on mothers. OBJECTIVE To describe differences in food allergy-related quality of life (FAQOL) and empowerment of mothers and fathers of a large cohort of children with food allergy. METHODS Eight hundred seventy-six families of children with food allergy were studied. Food allergy was defined by stringent criteria, including reaction history, skin prick testing, and specific IgE. Parental empowerment and FAQOL were assessed by the adapted Family Empowerment and FAQOL-Parental Burden scales. Parental scores were compared by Wilcoxon signed rank test. Multiple regression models examined the association of parental empowerment with FAQOL. RESULTS Mothers reported greater empowerment (P < .001) and lower FAQOL (P < .001) compared with fathers, regardless of allergen severity, type, or comorbidities. However, parental empowerment was not significantly associated with FAQOL for mothers or fathers. Although parents of children with peanut, cow milk, egg, and tree nut allergies were similarly empowered, milk and egg allergies were associated with lower FAQOL (P < .01). Parental concern in the QOL assessment was greatest for items involving fear of allergen exposure outside the home. CONCLUSION Parental empowerment and FAQOL vary significantly among mothers and fathers of children with food allergy. Greater effects on FAQOL were seen for milk and egg compared with other food allergies. Although parents of children with food allergy might be empowered to care for their child, they continue to experience impaired FAQOL owing to fears of allergen exposure beyond their control.

Significant J-shaped association between body mass index (BMI) and diabetic foot ulcers.

Disagreement exists regarding the relationship between body weight and foot ulceration risk among diabetic persons.

Adherence with postdischarge venous thromboembolism chemoprophylaxis recommendations after colorectal cancer surgery among elderly Medicare beneficiaries.

Objectives:To assess national adherence with extended venous thromboembolism (VTE) chemoprophylaxis guideline recommendations after colorectal cancer surgery. Background:Postoperative VTE remains a major cause of morbidity and mortality after abdominal cancer surgery. On the basis of the results from randomized controlled trials, since 2007, national guidelines have suggested that these patients be discharged on VTE chemoprophylaxis. Methods:Medicare beneficiaries undergoing open colorectal cancer resections in 2008–2009 were identified using the Medicare Provider Analysis and Review data and limited to those who were enrolled and used Part D for their postoperative prescriptions. Postdischarge use of low-molecular-weight-heparin and other anticoagulants was assessed. Results:A total of 5078 patients underwent open colorectal cancer surgery and met the inclusion criteria. Of these, 77% underwent colectomy and 23% underwent proctectomy. A prescription for an anticoagulant was filled immediately after discharge for 77 (1.5%) patients, and a low-molecular-weight-heparin for 60 (1.2%) patients. On multivariable analysis, patients were more likely to receive postdischarge VTE chemoprophylaxis if undergoing rectal cancer surgery [incidence rate ratio (IRR), 1.83; 95% confidence interval, 1.07–3.12; vs colon], if higher educational status (IRR, 2.20; 95% confidence interval, 1.23–3.95; vs low education), or if they had a higher Elixhauser comorbidity index (IRR, 1.13; 95% confidence interval, 1.01–1.25; vs lower index). Conclusions:Although VTE remains a major issue after abdominal cancer surgery, only 1.5% of Medicare beneficiaries undergoing colorectal cancer surgery received care consistent with established guidelines for postdischarge VTE chemoprophylaxis. Barriers to adherence must be elucidated to improve the quality of care for abdominal and pelvic cancer surgery patients.

Participant Retention in the Veterans Health Administration’s MOVE! Weight Management Program, 2010

Introduction Participant retention is a frequent concern in structured weight-management programs. Although research has explored participant characteristics influencing retention, little attention has been given to the influence of program characteristics. The objective of this study was to examine how program characteristics relate to participant retention in the Veterans Health Administration’s weight-management program, MOVE! Methods We conducted semistructured interviews with coordinators of 12 MOVE! programs located throughout the United States, 5 with high participant retention rates and 7 with low rates. We transcribed and descriptively coded interviews and compared responses from high- and low-retention programs. Results Characteristics related to retention were provider knowledge of and referral to the program, reputation of the program within the medical facility, the MOVE! meeting schedule, inclusion of physical activity in group meetings, and involvement of the MOVE! physician champion. MOVE! introductory sessions, frequency of group meetings, and meeting topics were not related to retention. Coordinators described efforts to improve retention, including participant contracts and team competitions. Coordinators at 5 high-retention facilities and 1 low-retention facility discussed efforts to improve retention. Conclusion Coordinators identified important program characteristics that could guide improvements to retention in group-based weight-management programs. Training for providers is needed to assist with referral decisions, and program planners should consider incorporating physical activity in group meetings.

Obesity Paradox in Amputation Risk Among Nonelderly Diabetic Men

The association between BMI and amputation risk is not currently well known. We used data for a cohort of diabetic patients treated in the US Department of Veterans Affairs Healthcare System in 2003. Men aged <65 years at the end of follow‐up were examined for their amputation risk and amputation‐free survival during the next 5 years (2004–2008). Compared to overweight individuals (BMI 25–29.9 kg/m2), the risks of amputation and treatment failure (amputation or death) were higher for patients with BMI <25 kg/m2 and were lower for those with BMI ≥30 kg/m2. Individuals with BMI ≥40 kg/m2 were only half as likely to experience any (hazard ratios (HR) = 0.49; 95% confidence interval (CI), 0.30–0.80) and major amputations (HR = 0.53; 95% CI, 0.39–0.73) during follow‐up as overweight individuals. While the amputation risk continued to decrease for higher BMI, amputation‐free survival showed a slight upturn at BMI >40 kg/m2. The association between obesity and amputation risk in our data shows a pattern consistent with “obesity paradox” observed in many health conditions. More research is needed to better understand pathophysiological mechanisms that may explain the paradoxical association between obesity and lower‐extremity amputation (LEA) risk.

Predialysis nephrology care and costs in elderly patients initiating dialysis

Background:Access to nephrology care before initiation of chronic dialysis is associated with improved outcomes after initiation. Less is known about the effect of predialysis nephrology care on healthcare costs and utilization. Methods:We conducted retrospective analyses of elderly patients who initiated dialysis between January 1, 2000 and December 31, 2001 and were eligible for services covered by the Department of Veterans Affairs. We used multivariable generalized linear models to compare healthcare costs for patients who received no predialysis nephrology care during the year before dialysis initiation with those who received low- (1–3 nephrology visits), moderate- (4–6 visits), and high-intensity (>6 visits) nephrology care during this time period. Results:There were 8022 patients meeting inclusion criteria: 37% received no predialysis nephrology care, while 24% received low, 16% moderate, and 23% high-intensity predialysis nephrology care. During the year after dialysis initiation, patients in these groups spent an average of 52, 40, 31, and 27 days in the hospital (P < 0.001), respectively, and accounted for an average of

Diagnostic accuracy of existing methods for identifying diabetic foot ulcers from inpatient and outpatient datasets

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