Mona Duggal

Gender Differences in Rates of Depression, PTSD, Pain, Obesity, and Military Sexual Trauma Among Connecticut War Veterans of Iraq and Afghanistan

PURPOSE The current wars in Iraq and Afghanistan have led to an increasing number of female veterans seeking medical and mental healthcare in the Department of Veterans Affairs (VA) healthcare system. To better understand gender differences in healthcare needs among recently returned veterans, we examined the prevalence of positive screenings for depression, posttraumatic stress disorder (PTSD), military sexual trauma (MST), obesity, and chronic pain among female and male veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) receiving care at the VA Connecticut Healthcare System. METHODS We performed a retrospective, cross-sectional data analysis of OEF/OIF veterans at VA Connecticut who received services in either Primary Care or the Womens Health Clinic between 2001 and 2006. RESULTS In this study, 1129 electronic medical records (1032 men, 197 women) were examined. Female veterans were more likely to screen positive for MST (14% vs. 1%, p < 0.001) and depression (48% vs. 39%, p = 0.01) and less likely to screen positive for PTSD (21% vs. 33%, p = 0.002). There was no significant gender difference in clinically significant pain scores. Men were more likely than women to have body mass index (BMI) >30 kg/m(2) (21% vs. 13%, p = 0.008). CONCLUSIONS These results suggest that important gender differences exist in the prevalence of positive screenings for MST, depression, obesity, and PTSD. As the VA continues to review and improve its services for women veterans, clinicians, researchers, and senior leaders should consider innovative ways to ensure that female veterans receive the health services they need within the VA system.

Comparison of the Effect on Long-Term Outcomes in Patients With Thoracic Aortic Aneurysms of Taking Versus Not Taking a Statin Drug

The potential of medical therapy to influence the courses and outcomes of patients with thoracic aortic aneurysms is not known. The aim of this study was to determine whether statin intake is associated with improved long-term outcomes in these patients. A total of 649 patients with thoracic aortic aneurysms were studied, of whom 147 were taking statins at their first presentation and 502 were not. After a median follow-up period of 3.6 years, 30 patients (20%) taking statins had died, compared with 167 patients (33%) not taking statins (hazard ratio 0.68, 95% confidence interval 0.46 to 1, p = 0.049); 87 patients (59%) taking statins reached the composite end point of death, rupture, dissection, or repair compared with 378 patients (75%) not taking statins (hazard ratio 0.72, 95% confidence interval 0.57 to 0.91, p = 0.006). After adjustments for co-morbidities, the association between statin therapy and the composite end point was driven mainly by a reduction in aneurysm repairs (hazard ratio 0.57 95% confidence interval 0.4 to 0.83, p = 0.003). On Kaplan-Meier analysis, the survival rate of patients taking statins was significantly better (p = 0.047). In conclusion, the intake of stains was associated with an improvement in long-term outcomes in this cohort of patients with thoracic aortic aneurysms. This was driven mainly by a reduction in aneurysm repairs.

Rural Residence Is Associated With Delayed Care Entry and Increased Mortality Among Veterans With Human Immunodeficiency Virus Infection

Context:Rural persons with human immunodeficiency virus (HIV) face many barriers to care, but little is known about rural-urban variation in HIV outcomes. Objective:To determine the association between rural residence and HIV outcomes. Design, Setting, and Patients:Retrospective cohort study of mortality among persons initiating HIV care in Veterans Administration (VA) during 1998–2006, with mortality follow-up through 2008. Rural residence was determined using Rural Urban Commuting Area codes. We identified 8489 persons initiating HIV care in VA with no evidence of combination antiretroviral therapy (cART) use at care entry, of whom 705 (8.3%) were rural. Outcome Measure:All-cause mortality. Results:At care entry, rural persons were less likely than urban persons to have drug use problems (10.6% vs. 19.5%, P < 0.001) or hepatitis C (34.3% vs. 41.2%, P = 0.001), but had more advanced HIV infection (median CD4: 186 vs. 246, P < 0.001). By 2 years after care entry, 5874 persons had initiated cART (528 rural [74.9%] and 5346 urban [68.7%], P = 0.001), and there were 1022 deaths (108 rural [15.3%] and 914 urban [11.7%], P = 0.004). The mortality hazard ratio for rural persons compared with urban was 1.34 (95% confidence interval: 1.05–1.69). The hazard ratio decreased to 1.18 (95% confidence interval: 0.93–1.50) after adjustment for HIV severity (CD4 and AIDS-defining illnesses) at care entry, and was 1.17 (95% confidence interval: 0.92–1.50) in a model adjusting for age, HIV severity at care entry, substance use, hepatitis B or C diagnoses, and cART initiation. Conclusions:Later entry into care drives increased mortality for rural compared with urban veterans with HIV. Future studies should explore the person, care system, and community-level determinants of late care entry for rural persons with HIV.

Comparison of outpatient health care utilization among returning women and men veterans from Afghanistan and Iraq

BackgroundThe number of women serving in the United States military increased during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), leading to a subsequent surge in new women Veterans seeking health care services from the Veterans Administration (VA). The objective of this study was to examine gender differences among OEF/OIF Veterans in utilization of VA outpatient health care services.MethodsOur retrospective cohort consisted of 1,620 OEF/OIF Veterans (240 women and 1380 men) who enrolled for outpatient healthcare at a single VA facility. We collected demographic data and information on military service and VA utilization from VA electronic medical records. To assess gender differences we used two models: use versus nonuse of services (logistic regression) and intensity of use among users (negative binomial regression).ResultsIn our sample, women were more likely to be younger, single, and non-white than men. Women were more likely to utilize outpatient care services (odds ratio [OR] = 1.47, 95% confidence interval [CI]:1.09, 1.98), but once care was initiated, frequency of visits over time (intensity) did not differ by gender (incident rate ratio [IRR] = 1.07; 95% CI: 0.90, 1.27).ConclusionRecently discharged OEF/OIF women Veterans were more likely to seek VA health care than men Veterans. But the intensity of use was similar between women and men VA care users. As more women use VA health care, prospective studies exploring gender differences in types of services utilized, health outcomes, and factors associated with satisfaction will be required.

Development and Performance of an Algorithm to Estimate the Child-Turcotte-Pugh Score From a National Electronic Healthcare Database.

BACKGROUND & METHODS The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. The CTP score is a composite of 5 subscores, 3 based on objective clinical laboratory values and 2 subjective variables quantifying the severity of ascites and hepatic encephalopathy. To date, no system to quantify CTP score from administrative databases has been validated. The Veterans Outcomes and Costs Associated with Liver Disease study is a multicenter collaborative study to evaluate the outcomes and costs of hepatocellular carcinoma in the U.S. Veterans Health Administration. We developed and validated an algorithm to calculate electronic CTP (eCTP) scores by using data from the Veterans Health Administration Corporate Data Warehouse. METHODS Multiple algorithms for determining each CTP subscore from International Classification of Diseases version 9, Common Procedural Terminology, pharmacy, and laboratory data were devised and tested in 2 patient cohorts. For each cohort, 6 site investigators (Boston, Bronx, Brooklyn, Philadelphia, Minneapolis, and West Haven VA Medical Centers) were provided cases from which to determine validity of diagnosis, laboratory data, and clinical assessment of ascites and encephalopathy. The optimal algorithm (designated eCTP) was then applied to 30,840 cirrhotic patients alive in the first quarter of 2008 for whom 5-year overall and transplant-free survival data were available. The ability of the eCTP score and other disease severity scores (Charlson-Deyo index, Veterans Aging Cohort Study index, Model for End-Stage Liver Disease score, and Cirrhosis Comorbidity) to predict survival was then assessed by Cox proportional hazards regression. RESULTS Spearman correlations for administrative and investigator validated laboratory data in the HCC and cirrhotic cohorts, respectively, were 0.85 and 0.92 for bilirubin, 0.92 and 0.87 for albumin, and 0.84 and 0.86 for international normalized ratio. In the HCC cohort, the overall eCTP score matched 96% of patients to within 1 point of the chart-validated CTP score (Spearman correlation, 0.81). In the cirrhosis cohort, 98% were matched to within 1 point of their actual CTP score (Spearman, 0.85). When applied to a cohort of 30,840 patients with cirrhosis, each unit change in eCTP was associated with 39% increase in the relative risk of death or transplantation. The Harrell C statistic for the eCTP (0.678) was numerically higher than those for other disease severity indices for predicting 5-year transplant-free survival. Adding other predictive models to the eCTP resulted in minimal differences in its predictive performance. CONCLUSION We developed and validated an algorithm to extrapolate an eCTP score from data in a large administrative database with excellent correlation to actual CTP score on chart review. When applied to an administrative database, this algorithm is a highly useful predictor of survival when compared with multiple other published liver disease severity indices.

Quality of HIV Care and Mortality Rates in HIV-Infected Patients

BACKGROUND The Patient Protection and Affordable Care Act encourages healthcare systems to track quality-of-care measures; little is known about their impact on mortality rates. The objective of this study was to assess associations between HIV quality of care and mortality rates. METHODS A longitudinal survival analysis of the Veterans Aging Cohort Study included 3038 human immunodeficiency virus (HIV)-infected patients enrolled between June 2002 and July 2008. The independent variable was receipt of ≥80% of 9 HIV quality indicators (QIs) abstracted from medical records in the 12 months after enrollment. Overall mortality rates through 2014 were assessed from the Veterans Health Administration, Medicare, and Social Security National Death Index records. We assessed associations between receiving ≥80% of HIV QIs and mortality rates using Kaplan-Meier survival analysis and adjusted Cox proportional hazards models. Results were stratified by unhealthy alcohol and illicit drug use. RESULTS The majority of participants were male (97.5%) and black (66.8%), with a mean (standard deviation) age of 49.0 (8.8) years. Overall, 25.9% reported past-year unhealthy alcohol use and 28.4% reported past-year illicit drug use. During 24 805 person-years of follow-up (mean [standard deviation], 8.2 [3.3] years), those who received ≥80% of QIs experienced lower age-adjusted mortality rates (adjusted hazard ratio, 0.75; 95% confidence interval, .65-.86). Adjustment for disease severity attenuated the association. CONCLUSIONS Receipt of ≥80% of select HIV QIs is associated with improved survival in a sample of predominantly male, black, HIV-infected patients but was insufficient to overcome adjustment for disease severity. Interventions to ensure high-quality care and address underlying chronic illness may improve survival in HIV-infected patients.

Use of statistical analysis in the biomedical informatics literature

Statistics is an essential aspect of biomedical informatics. To examine the use of statistics in informatics research, a literature review of recent articles in two high-impact factor biomedical informatics journals, the Journal of American Medical Informatics Association (JAMIA) and the International Journal of Medical Informatics was conducted. The use of statistical methods in each paper was examined. Articles of original investigations from 2000 to 2007 were reviewed. For each journal, the results by statistical methods were analyzed as: descriptive, elementary, multivariable, other regression, machine learning, and other statistics. For both journals, descriptive statistics were most often used. Elementary statistics such as t tests, chi(2), and Wilcoxon tests were much more frequent in JAMIA, while machine learning approaches such as decision trees and support vector machines were similar in occurrence across the journals. Also, the use of diagnostic statistics such as sensitivity, specificity, precision, and recall, was more frequent in JAMIA. These results highlight the use of statistics in informatics and the need for biomedical informatics scientists to have, as a minimum, proficiency in descriptive and elementary statistics.

Long-term follow-up of beryllium sensitized workers from a single employer

BackgroundUp to 12% of beryllium-exposed American workers would test positive on beryllium lymphocyte proliferation test (BeLPT) screening, but the implications of sensitization remain uncertain.MethodsSeventy two current and former employees of a beryllium manufacturer, including 22 with pathologic changes of chronic beryllium disease (CBD), and 50 without, with a confirmed positive test were followed-up for 7.4 +/-3.1 years.ResultsBeyond predicted effects of aging, flow rates and lung volumes changed little from baseline, while DLCO dropped 17.4% of predicted on average. Despite this group decline, only 8 subjects (11.1%) demonstrated physiologic or radiologic abnormalities typical of CBD. Other than baseline status, no clinical or laboratory feature distinguished those who clinically manifested CBD at follow-up from those who did not.ConclusionsThe clinical outlook remains favorable for beryllium-sensitized individuals over the first 5-12 years. However, declines in DLCO may presage further and more serious clinical manifestations in the future. These conclusions are tempered by the possibility of selection bias and other study limitations.

The need for validation of large administrative databases: Veterans Health Administration ICD-9CM coding of exudative age-related macular degeneration and ranibizumab usage

We performed a validation study by chart review of data for exudative age-related macular degeneration (eAMD) and, because of the Veterans Administration (VA) therapy policy, ranibizumab usage in the largest electronic medical record system in the USA. We reviewed 5,854 distinct patients who visited an ophthalmology clinic within VA Connecticut from January 2006–December 2008. We randomly selected 98 of 138 distinct eAMD patients and 265 of 5,588 non-eAMD patients who did not receive ranibizumab. International Classification of Diseases, Ninth Revision, Clinical Modification coding of eAMD had an excellent positive predictive value of 97.8% (95% confidence interval (CI), 93.5–99.4%). The national Decision Support System (DSS) had an excellent positive predictive value of 100% (95% CI, 79.9–100%) for ranibizumab. However, the negative predictive value of the DSS dispensed ranibizumab decreased to 67.5 (95% CI, 62.1–72.4) because of a change in the way local values were stored that led to errors. Therefore, validation of clinical information over time in large databases is necessary.

Sangoshthi : Empowering Community Health Workers through Peer Learning in Rural India

The Healthcare system of India provides outreach services to the rural population with a key focus on the maternal and child health through its flagship program of Community Health Workers (CHWs). The program since its launch has reached a scale of over 900000 health workers across the country and observed significant benefits on the health indicators. However, traditional face to face training mechanisms face persistent challenge in providing adequate training and capacity building opportunities to CHWs which leads to their sub-optimal knowledge and skill sets. In this paper, we propose Sangoshthi, a low-cost mobile based training and learning platform that fits well into the environment of low-Internet access. Sangoshthi leverages the architecture that combines Internet and IVR technology to host real time training sessions with the CHWs having access to basic phones only. We present our findings of a four week long field deployment with 40 CHWs using both qualitative and quantitative methods. Sangoshthi offers a lively environment of peer learning that was well received by the CHW community and resulted into their knowledge gains (16%) and increased confidence levels to handle the cases. Our study highlights the potential of complementary training platforms that can empower CHWs in-situ without the need of additional infrastructure.