Sean Nugent

Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population

ObjectivesPrevious studies have shown that a single question may identify individuals with inadequate health literacy. We evaluated and compared the performance of 3 health literacy screening questions for detecting patients with inadequate or marginal health literacy in a large VA population.MethodsWe conducted in-person interviews among a random sample of patients from 4 VA medical centers that included 3 health literacy screening questions and 2 validated health literacy measures. Patients were classified as having inadequate, marginal, or adequate health literacy based on the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). We evaluated the ability of each of 3 questions to detect: 1) inadequate and the combination of “inadequate or marginal” health literacy based on the S-TOFHLA and 2) inadequate and the combination of “inadequate or marginal” health literacy based on the REALM.Measurements and Main ResultsOf 4,384 patients, 1,796 (41%) completed interviews. The prevalences of inadequate health literacy were 6.8% and 4.2%, based on the S-TOHFLA and REALM, respectively. Comparable prevalences for marginal health literacy were 7.4% and 17%, respectively. For detecting inadequate health literacy, “How confident are you filling out medical forms by yourself?” had the largest area under the Receiver Operating Characteristic Curve (AUROC) of 0.74 (95% CI: 0.69–0.79) and 0.84 (95% CI: 0.79–0.89) based on the S-TOFHLA and REALM, respectively. AUROCs were lower for detecting “inadequate or marginal” health literacy than for detecting inadequate health literacy for each of the 3 questions.ConclusionA single question may be useful for detecting patients with inadequate health literacy in a VA population.

The Magnitude of Acute Serum Creatinine Increase After Cardiac Surgery and the Risk of Chronic Kidney Disease, Progression of Kidney Disease, and Death

BACKGROUND Long-term outcomes after acute kidney injury remain poorly defined. We determined the association between the magnitude of creatinine increase after cardiac surgery and the risk of incident chronic kidney disease (CKD), CKD progression, and death. METHODS We identified 29,388 individuals who underwent cardiac surgery at Veterans Affairs hospitals between November 1999 and September 2005. The magnitude of creatinine increase was defined by the percent change from baseline to peak creatinine levels after cardiac surgery and categorized as none (≤0%) or as class I, (1%-24%), II (25%-49%), III (50%-99%), or IV (≥100%). Cox proportional hazard models were used to examine the association between the magnitude of creatinine increase and outcomes. RESULTS The relative hazards for outcomes increased monotonically with greater increases in creatinine levels compared with no change in creatinine levels. The relative hazards for adverse outcomes were significantly higher immediately after the creatinine increase and attenuated over time. Three months after surgery, creatinine increase classes I, II, III, and IV were associated with a greater risk of incident CKD (hazard ratios [HRs] 2.1, 4.0, 5.8, and 6.6, respectively; all P<.01), progression of CKD stage (HRs 2.5, 3.8, 4.4, and 8.0; all P<.01), and long-term mortality (HRs 1.4, 1.9, 2.8, and 5.0; all P<.01). At 5 years, the associations were lower in magnitude: incident CKD (HRs 1.4, 1.9, 2.3, and 2.3; all P<.01), CKD progression (HRs 1.5, 1.7, 1.7, and 2.4; all P<.01), and mortality (HRs 1.0, 1.2, 1.4, and 1.8; all P<.01, except class I). CONCLUSION The magnitude of creatinine increase after cardiac surgery is associated in a graded manner with an increased risk of incident CKD, CKD progression, and mortality.

Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior

In the context of a school-based prevention of conduct disorder program, 7,231 first- through fourth-grade children were screened for cross-setting disruptive behavior. Frequencies of DSM-III-R psychiatric disorders and patterns of comorbidity were assessed. We also examined the association of psychiatric diagnosis with child and parent characteristics to determine differential risk based on diagnostic subgroups. Attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) were the most frequent diagnoses. Mood and anxiety disorders were infrequent as single diagnoses. Patterns of comorbidity demonstrated that both externalizing and internalizing disorders commonly cooccurred with ADHD. More severe degrees of psychopathology and psychosocial risk accrued to the subgroup of youths with ADHD plus a comorbid externalizing disorder.

Psychiatric diagnoses among Iraq and Afghanistan war veterans screened for deployment-related traumatic brain injury†

The authors examined psychiatric diagnoses in administrative records for 13,201 United States military veterans who were screened for traumatic brain injury (TBI) in Department of Veterans Affairs facilities. Over 80% of the veterans with positive TBI screens had psychiatric diagnoses. Compared to veterans with negative TBI screens, those with positive screens, but without confirmed TBI status, were three times more likely to have a posttraumatic stress disorder (PTSD) diagnosis and were two times more likely to have depression and substance-related diagnoses. Among veterans with positive TBI screens, those with clinically confirmed TBI status were more likely than those without confirmed TBI status to have diagnoses for PTSD, anxiety, and adjustment disorders. These findings have implications for health care delivery and provider education.

Impact of Age and Comorbidity on Colorectal Cancer Screening Among Older Veterans

Context Guidelines increasingly state that screening for cancer should be targeted to people who will live long enough to benefit from it. Content The investigators studied receipt of colorectal cancer screening in 27068 screen-eligible VA patients 70 years or older. Only 47% of patients with no comorbidity (5-year mortality rate, 19%) were screened, whereas 41% with severe comorbidity (5-year mortality rate, 55%) were screened. Rates were somewhat lower for older men but varied only slightly by life expectancy. Caution Some tests may have been done for diagnosis rather than screening. Implication In this population of elderly men, screening did not target healthier patients. The Editors Colorectal cancer screening guidelines recommend screening older adults who have substantial life expectancies according to age and comorbid conditions (1). For example, the U.S. Preventive Services Task Force recommends routine screening until age 75 years, whereas the Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society (25) recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbid conditions that would preclude treatment. Targeting screening to healthy persons who are likely to live at least 5 years is recommended because randomized trials of fecal occult blood testing (FOBT) suggest that a difference in colorectal cancer mortality between screened and unscreened persons does not become noticeable until at least 5 years after screening (68). Therefore, persons with a life expectancy of 5 years or less are not likely to benefit from screening but remain at risk for harms that may occur immediately, such as complications from procedures and the treatment of clinically unimportant disease (9, 10). However, it remains unclear whether screening is being targeted to healthy older persons with substantial life expectancies and avoided in older persons with significant comorbidity, for whom the risks of screening outweigh the benefits. Previous studies of associations among age, comorbidity, and receipt of cancer screening have found that age is a stronger determinant of screening than comorbidity. For example, whereas advancing age is consistently associated with lower screening rates, worsening comorbidity has had little effect on the use of screening mammography, Papanicolaou smears, or prostate-specific antigen screening (1113). Previous studies of the relationship between colorectal cancer screening and comorbidity have been limited by small sample size, short follow-up times, and focus on FOBT rather than all types of colorectal cancer screening tests (14, 15). In addition, previous Veterans Affairs (VA) studies have not measured colorectal cancer screening performed outside the VA health care system by means of Medicare (1517). Having a better understanding of how comorbidity and age affect overall screening use is particularly important for colorectal cancer screening because the tests and follow-up procedures are often more invasive than those for other types of cancer and may result in substantial harms, such as major bleeding events, colon perforation, or strokeespecially in elderly persons with limited life expectancies (9, 18, 19). To characterize the use of colorectal cancer screening across a prognostic spectrum of advancing age and comorbidity, we examined VA data and Medicare claims for patients 70 years of age or older who were seen at 4 geographically diverse VA facilities. Specifically, we determined 2-year screening incidence and 5-year mortality rate for subgroups of older patients without significant comorbidity for whom guidelines recommend screening, as well as for subgroups of older patients with severe comorbidity for whom most guidelines agree that the risks of screening outweigh the benefits. Methods Data Sources and Patients We identified a cohort of screen-eligible patients on 1 January 2001 and followed them for 2 years for the performance of colorectal cancer screening. We obtained data for this cohort study from National VA Data Systems, clinical data extracted from the electronic record system (Veterans Health Information Systems and Technology Architectures) of 4 VA medical centers (Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California), and Medicare claims. National VA data included the National Patient Care Database (which captures all inpatient and outpatient claims within the VA), Fee Basis Files (which capture claims for non-VA services paid for by the VA), and the Vital Status File (which captures mortality data for veterans) (20). Clinical data extracted from the 4 VA centers included text entered by clinicians in response to computerized clinical reminders about colorectal cancer screening (21). We used linked Medicare claims from the VA Information Resource Center to capture services provided to our cohort outside the VA by Medicare (22). On the basis of these data sources, we identified a cohort of 60933 patients 70 years of age or older who had at least 1 outpatient visit within the VA health care system or Medicare between 1 January 2000 and 31 December 2000 (the period during which we measured comorbidity) and at least 1 outpatient visit at 1 of the 4 VA centers between 1 January 2001 and 31 December 2002 (the period during which we measured the performance of colorectal cancer screening) (Figure 1). We selected the 4 VA centers for geographic diversity. We excluded 11817 (19%) patients who were enrolled in Medicare managed care at any point from 1 January 2000 to 31 December 2002, because they lacked Medicare claims. In addition, patients had to be eligible for screening to be included in our cohort. Therefore, we used VA and Medicare inpatient and outpatient claims from the 8-year period before the start of 2001 (dating back to 1 October 1992 for VA claims and 1 January 1999 for Medicare claims) to exclude 11200 (18%) patients with a history of colorectal cancer, colitis, colorectal polyps, colectomy, or colostomy and 8153 (13%) patients who had any history of a colonoscopy or had had a sigmoidoscopy or barium enema within 5 years and were therefore not due for screening at the start of 2001. We also used claims from the 6 months before their index test to exclude 2695 (4%) of patients who had signs or symptoms that would justify the performance of a test for nonscreening purposes (Figure 1). This left a final screen-eligible cohort of 27068 patients on 1 January 2001. Figure 1. Study flow diagram. Eligibility criteria included having been seen in an outpatient clinic at 1 of 4 Veterans Affairs (VA) centers between 1 January 2001 and 31 December 2002, which indicated that the VA was at least partially responsible for medical care, but data on colorectal cancer screening were gathered during the entire 2-year screening interval from both national VA and Medicare claims. Additional eligibility criteria included having at least 1 outpatient visit between 1 January and 31 December 2000 to define comorbidity as of 1 January 2001. *Defined by searching VA and Medicare inpatient and outpatient claims before 1 January 2001, dating as far back as 1 October 1992 for VA claims and 1 January 1999 for Medicare claims. Data Collection and Measurement Outcome Variables We assessed receipt of colorectal cancer screening between 1 January 2001 and 31 December 2002 for our cohort across the VA health care system and Medicare, because many elderly veterans use more than 1 VA center and most are enrolled in Medicare (23). We identified colorectal cancer screening in National VA Data Systems and linked Medicare payment data (hospital outpatient and physician/supplier files) by using International Classification of Disease, Ninth Revision (ICD-9), codes; Current Procedural Terminology (CPT) codes; and Level II Healthcare Common Procedure Coding System (HCPCS) codes for FOBT (CPT codes 82270, 82273, and 82274 and HCPCS code G0107), colonoscopy (ICD-9 codes 45.22, 45.23, 45.25, 45.41, 45.42, and 45.43; CPT codes 44388 to 44394, 45355, and 45378 to 45385; and HCPCS codes G0105, G0121), sigmoidoscopy (ICD-9 codes 45.24, 48.22 to 48.24, 48.26, 48.35, and 48.36; CPT codes 45300, 45303, 45305, 45308, 45309, 45315, 45320, 45330 to 45334, and 45337 to 45339; and HCPCS code G0104), or barium enema (ICD-9 code 87.64; CPT codes 74270 and 74280; and HCPCS codes G0106, G0120, and G0122) (2427). We assigned patients to 1 of the 4 screening procedures on the basis of their first test during 2001 through 2002. We chose a 2-year screening period to allow sufficient time for screening tests to be scheduled and performed; this is also the screening interval used in randomized trials of FOBT (6, 7). We obtained vital status through 31 December 2005 from the VA Vital Status File to determine 5-year mortality rates. The VA Vital Status File is similar to the National Death Index in terms of accuracy and completeness (28). We used 5-year mortality rates descriptively to identify conditions associated with having a life expectancy less than 5 years (5-year mortality rate >50%). Predictor Variables We assigned patients to 1 of 3 categories on the basis of their age on 1 January 2001: 70 to 74 years, 75 to 79 years, or 80 years or older. We defined the burden of comorbidity by using the Deyo adaptation of the Charlson Comorbidity Index (2931), a summary measure of 19 chronic disease diagnoses from administrative data that are selected and weighted according to their association with mortality. We calculated CharlsonDeyo scores from VA and Medicare inpatient and outpatient claims during the 12 months before the start of 2001 (3234). We categorized patients as having no significant comorbidity if they had a CharlsonDeyo score of 0, average comorbidity if they had a CharlsonDeyo score of 1 to 3, and severe comorbidity if they had a CharlsonDeyo score of 4 or greater. We chose th

Randomized trial examining the effect of two prostate cancer screening educational interventions on patient knowledge, preferences, and behaviors

AbstractOBJECTIVE: To assess the effect of video and pamphlet interventions on patient prostate cancer (CaP) screening knowledge, decision-making participation, preferences, and behaviors. DESIGN: Randomized, controlled trial. SETTING: Four midwestern Veterans Affairs medical facilities. PATIENTS/PARTICIPANTS: One thousand, one hundred fifty-two male veterans age 50 and older with primary care appointments at participating facilities were randomized and 893 completed follow-up. INTERVENTIONS: Patients were randomized to mailed pamphlet, mailed video, or usual care/control. MEASUREMENTS AND MAIN RESULTS: Outcomes assessed by phone survey 2 weeks postintervention included a 10-item knowledge index; correct responses to questions on CaP natural history, treatment efficacy, the prostate-specific antigen (PSA)’s predictive value, and expert disagreement about the PSA; whether screening was discussed with provider; screening preferences; and PSA testing rates.Mean knowledge index scores were higher for video (7.44; P=.001) and pamphlet (7.26; P=.03) subjects versus controls (6.90). Video and pamphlet subjects reported significantly higher percentages of correct responses relative to controls to questions on CaP natural history (63%, 63%, and 54%, respectively); treatment efficacy (19%, 20%, and 5%), and expert disagreement (28%, 19%, and 8%), but not PSA accuracy (28%, 22%, and 22%). Pamphlet subjects were more likely than controls to discuss screening with their provider (41% vs 32%; P=.03) but video subjects were not (35%; P=.33). Video and pamphlet subjects were less likely to intend to have a PSA, relative to controls (63%, 65%, and 74%, respectively). PSA testing rates did not differ significantly across groups. CONCLUSIONS: Mailed interventions enhance patient knowledge and self-reported participation in decision making, and alter screening preferences. The pamphlet and video interventions evaluated are comparable in effectiveness. The lower-cost pamphlet approach is an attractive option for clinics with limited resources.

Group cognitive‐behavioral treatment of binge eating disorder: A comparison of therapist‐led versus self‐help formats

OBJECTIVE The purpose of this study was to compare three group cognitive-behavioral therapy (CBT) treatment models and a waiting list control condition (WL). METHOD Sixty-one women who met DSM-IV criteria for binge eating disorder (BED) received treatment with the same cognitive-behavioral treatment manual in 14 one-hour sessions over an 8-week period. All sessions consisted of psychoeducation for the first 30 min and group discussion for the second half hour. In the therapist-led condition (TL; n = 16), a doctoral therapist led both the psychoeducational component and group discussion. In the partial self-help condition (PSH; n = 19), participants viewed a 30-min psychoeducational videotape, followed by participation in a therapist-led discussion. In the structured self-help condition (SH; n = 15), subjects viewed the 30-min psychoeducational videotape and subsequently led their own 30-min discussion. Eleven subjects were assigned to a wait-list control condition (WL). The primary outcome variables were frequency and duration of self-reported binge eating episodes. RESULTS A mixed effects linear modeling (random regression) analysis indicated that subjects in all three active treatment conditions showed a decrease in binge eating symptoms over time. No group differences in rates of change over time were observed, although analysis of covariance indicated that all three treatment conditions showed significantly greater improvement in binge eating compared to the WL condition. DISCUSSION The findings from this preliminary study suggest that CBT for BED can be delivered effectively in a structured group self-help format.

Health‐Related Quality of Life, Functional Impairment, and Healthcare Utilization by Veterans: Veterans' Quality of Life Study

Objectives: To describe the health status of veterans receiving care in a veterans integrated service network (VISN).

Validity of PTSD diagnoses in VA administrative data: Comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores

Little research has been done on the validity of posttraumatic stress disorder (PTSD) diagnoses that are found in Department of Veterans Affairs (VA) administrative data, even though they are often used in VA research. We compared PTSD diagnoses found in VA administrative data with PTSD Checklist (PCL) scores self-reported by 4,777 newly diagnosed participants in a national postal survey study. Using PCL scores of at least 50 as the gold standard, we compared positive predictive values (PPVs) for at least one versus at least two PTSD diagnoses (found within 4 months of the first) in VA administrative data overall and by subgroups of interest: age, sex, and clinic where first diagnosed. The overall PPV was 75% for at least one PTSD diagnosis and 82% for at least two PTSD diagnoses. Similarly, the PPV significantly increased for all subgroup analyses when at least two PTSD diagnoses were used. The increase in PPV was greatest for those first diagnosed in primary care and for those older than 65. To select a sample of veterans with more definitive PTSD from administrative data, researchers should select those veterans with at least two PTSD diagnoses as opposed to at least one.

Measuring patient knowledge of the risks and benefits of prostate cancer screening

This manuscript describes the development and validation of measures assessing patient knowledge about the risks and benefits of prostate cancer (CaP) screening. The measures described include a 10-item knowledge index and four single-item measures, used in previous studies, that assess knowledge of: CaP natural history and treatment efficacy, expert disagreement over the value of CaP screening, and the accuracy of the prostate specific antigen (PSA) test for CaP. We assessed the validity and reliability of these measures on a sample of 1152 male veteran patients age 50 and older. All knowledge index items had acceptable levels of discrimination, difficulty, and reliability. The index demonstrated strong evidence for construct and criterion validity. Much weaker validity evidence was found for the four single-item knowledge questions. The 10-item index developed in this study provides a valid and reliable tool for assessing patient knowledge of the risks and benefits of CaP screening.