Sharfun Ghaus

Timeliness of Care in Veterans With Non-small Cell Lung Cancer

BACKGROUND Timeliness is an important dimension of quality of care for patients with lung cancer. METHODS We reviewed the records of consecutive patients in whom non-small cell lung cancer (NSCLC) had been diagnosed between January 1, 2002, and December 31, 2003, at the Veterans Affairs Palo Alto Health Care System. We used multivariable statistical methods to identify independent predictors of timely care and examined the effect of timeliness on survival. RESULTS We identified 129 veterans with NSCLC (mean age, 67 years; 98% men; 83% white), most of whom had adenocarcinoma (51%) or squamous cell carcinoma (30%). A minority of patients (18%) presented with a solitary pulmonary nodule (SPN). The median time from the initial suspicion of cancer to treatment was 84 days (interquartile range, 38 to 153 days). Independent predictors of treatment within 84 days included hospitalization within 7 days (odds ratio [OR], 8.2; 95% confidence interval [CI], 2.9 to 23), tumor size of > 3.0 cm (OR, 4.8; 95% CI, 1.8 to 12.4), the presence of additional chest radiographic abnormalities (OR, 3.0; 95% CI, 1.1 to 8.5), and the presence of one or more symptoms suggesting metastasis (OR, 2.6; 95% CI, 1.1 to 6.2). More timely care was not associated with better survival time (adjusted hazard ratio, 1.6; 95% CI, 1.3 to 1.9). However, in patients with SPNs, there was a trend toward better survival time when the time to treatment was < 84 days. CONCLUSIONS The time to treatment for patients with NSCLC was often longer than recommended. Patients with larger tumors, symptoms, and other chest radiographic abnormalities receive more timely care. In patients with malignant SPNs, survival may be better when treatment is initiated promptly.

Disparities in lung cancer staging with positron emission tomography in the cancer care outcomes research and surveillance (cancors) study

Introduction:Disparities in treatment exist for nonwhite and Hispanic patients with non-small cell lung cancer, but little is known about disparities in the use of staging tests or their underlying causes. Methods:Prospective, observational cohort study of 3638 patients with newly diagnosed non-small cell lung cancer from 4 large, geographically defined regions, 5 integrated health care systems, and 13 VA health care facilities. Results:Median age was 69 years, 62% were men, 26% were Hispanic or nonwhite, 68% graduated high school, 50% had private insurance, and 41% received care in the VA or another integrated health care system. After adjustment, positron emission tomography (PET) use was 13% lower among nonwhites and Hispanics than non-Hispanic whites (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.77–0.97), 13% lower among those with Medicare than those with private insurance (RR 0.87, 95% CI 0.76–0.99), and 24% lower among those with an elementary school education than those with a graduate degree (RR 0.76, 95% CI 0.57–0.98). Disparate use of PET was not observed among patients who received care in an integrated health care setting, but the association between race/ethnicity and PET use was similar in magnitude across all other subgroups. Further analysis showed that income, education, insurance, and health care setting do not explain the association between race/ethnicity and PET use. Conclusions:Hispanics and nonwhites with non-small cell lung cancer are less likely to receive PET imaging. This finding is consistent across subgroups and not explained by differences in income, education, or insurance coverage.

A Web-based intervention for alcohol misuse in VA primary care.

A Web-Based Intervention for Alcohol Misuse in VA Primary Care Web-based brief alcohol interventions are effective in reducing alcohol consumption among adults and college students who misuse alcohol. These interventions have also been used effectively in ambulatory care clinics, including primary care, hepatitis C clinics, and emergency departments. Users typically complete the intervention, which consists of an initial assessment of alcohol use and related problems, in five to ten minutes. These data are then used to generate personalized feedback comparing a person’s reported alcohol use with that of ageand gender-matched peers and provide information about alcohol-related consequences and risk factors. Despite growing evidence of their effectiveness, brief alcohol interventions have yet to be used to address alcohol misuse by U.S. veterans seeking primary care, where rates of alcohol misuse are estimated to range from 20% to 25%. Therefore, we conducted a pilot study to examine the feasibility of implementing a Web-based brief alcohol intervention in a large Veterans Affairs (VA) primary care clinic. We conducted two focus groups with primary care administrators and clinic staff to determine their interest in and need for this intervention in their clinic. Both groups expressed a desire to implement the protocol but emphasized the need for effective intervention tools that minimally affect clinic operations. On receiving approval from clinic administrators, a single computer and printer were set up within the primary care clinic to be used by eligible patients. Twenty veterans who screened positive (men, ≥4; women, ≥3) on the three-item Alcohol Use Disorders Identification Test–Consumption Items (AUDITC) were invited to participate. Screening was conducted by a clinic nurse at intake. Nurses gave veterans who screened positive a flyer describing the study and obtained informed consent. After completing their primary care visit, veterans were handed off to study staff also at the clinic. Participants were asked to complete the intervention, print out and review their personalized feedback report, and complete a brief set of questionnaires assessing their experience of the study protocol. About half of our sample was Caucasian and reported an annual income of ≤

Do normative perceptions of drinking relate to alcohol use in U.S. Military Veterans presenting to primary care

30,000. More than half of participants (60%) reported a history of receiving treatment for a substance use disorder and AUDIT-C scores in a range indicating alcohol misuse (mean±SD=6.2±2.69 out of 12 points). These results suggest that clinic nurses were referring appropriate patients to the brief alcohol intervention. On completion of the intervention, most participants reported being willing to discuss their alcohol use with a primary care provider or nurse (90%) and to attend a first appointment with an alcohol counselor if recommended by their provider (73%). However, most veterans also reported that they could reduce (83%) or abstain (76%) from using alcohol on their own, which suggests that veterans who screened positive for alcohol misuse were open to discussing their alcohol use with a provider and considering treatment if recommended but also felt able to reduce their alcohol consumption without (or with minimal) assistance. All participants completed a brief questionnaire assessing usability of the brief intervention. A majority of participants (95%) indicated that the program was easy to use and that personalized feedback was easy to understand, and they found the graphics helpful and easy to interpret. Most participants (90%) also felt comfortable disclosing information about their alcohol use via computer, with 90% feeling that their information would be secure and confidential. This is an especially important finding given some initial concern that veterans might feel uncomfortable disclosing private behavior via computer. In terms of perceived effectiveness, almost all participants reported that the brief intervention helped them more clearly understand how their alcohol use may affect their overall health and would recommend it to a friend. Most participants also felt that they would be more likely to reduce their alcohol use (and possibly seek treatment) in the future as a result of the intervention. This pilot study was a first step in establishing the feasibility of a Webbased brief alcohol intervention in VA primary care. Larger studies are needed to determine whether reductions in alcohol use observed in prior studies (with nonveteran populations) generalize to U.S. military personnel who misuse alcohol. This is particularly important in light of findings indicating that veterans may use alcohol excessively to cope with complex negative emotions associated with highly prevalent mental health problems (such as posttraumatic stress disorder).

Facility-Level Analysis of PET Scanning for Staging Among US Veterans With Non-small Cell Lung Cancer

OBJECTIVE The current cross sectional study sought to examine whether perceived social normative beliefs are associated with indicators of alcohol use in a sample of alcohol misusing veterans. METHOD A sample of 107 U.S. Military Veterans presenting to primary care that screened positive for alcohol misuse on the alcohol use disorders identification test-consumption items (AUDIT-C) was recruited. Assessment measures were used to examine social normative beliefs and alcohol-related concerns as they relate to indicators of alcohol use at baseline. RESULTS Our findings indicate mixed support for our two hypotheses in that perceived descriptive norms were associated with alcohol use indicators in the predicted direction; however, this was not the case for alcohol-related concerns. For perceived norms, we found that higher quantity beliefs were significantly related to greater alcohol consumption on a drinking day (p<.01), increased likelihood of dependence (p<.01), and frequency beliefs were significantly related to total number of drinking days (p<.01). Findings for alcohol-related concerns emerged contrary to our hypothesis, with results depicting increased alcohol-related concerns associated with higher alcohol consumption across indicators of use (ps<.01). SUMMARY Findings of the current study suggest that social normative beliefs, specifically misperceptions about descriptive norms, are significantly associated with alcohol consumption in a sample of alcohol misusing veterans presenting to primary care.

Post-traumatic stress disorder and illicit drug use in veterans presenting to primary care with alcohol misuse

BACKGROUND PET scanning has been shown in randomized trials to reduce the frequency of surgery without cure among patients with potentially resectable non-small cell lung cancer (NSCLC). We examined whether more frequent use of PET scanning at the facility level improves survival among patients with NSCLC in real-world practice. METHODS In this prospective cohort study of 622 US veterans with newly diagnosed NSCLC, we compared groups defined by the frequency of PET scan use measured at the facility level and categorized as low (<25%), medium (25%-60%), or high (>60%). RESULTS The median age of the sample was 69 years. Ninety-eight percent were men, 36% were Hispanic or nonwhite, and 54% had moderate or severe comorbidities. At low-, medium-, and high-use facilities, PET scan was performed in 13%, 40%, and 72% of patients, respectively (P<.0001). Baseline characteristics were similar across groups, including clinical stage based on CT scanning. More frequent use of PET scanning was associated with more frequent invasive staging (P<.001) and nonsignificant improvements in downstaging (P=.13) and surgery without cure (P=.12). After a median of 352 days of follow-up, 22% of the sample was still alive, including 22% at low- and medium-use facilities and 20% at high-use facilities. After adjustment and compared with patients at low-use facilities, the hazard of death was greater for patients at high-use facilities (adjusted hazard ratio [HR], 1.35; 95% CI, 1.05-1.74) but not different for patients at medium-use facilities (adjusted HR, 1.14; 95% CI, 0.88-1.46). CONCLUSIONS In this study of veterans with NSCLC, markedly greater use of PET scanning at the facility level was associated with more frequent use of invasive staging and possible improvements in downstaging and surgery without cure, but greater use of PET scanning was not associated with better survival.

Care utilization and patient characteristics of veterans who misuse alcohol.

Abstract Alcohol misuse and post-traumatic stress disorder (PTSD) are highly prevalent among veterans presenting to primary care. PTSD is associated with depression and increased substance use which can complicate the treatment of alcohol misuse. No studies have examined severity of depressive symptoms, rates and type of illicit drug use, and alcohol use severity in veterans with PTSD and alcohol misuse in primary care. Therefore, we examined (a) rates of PTSD and associated mental health comorbidities (depression, suicidal ideation), (b) current and lifetime illicit drug use and (c) alcohol use severity in relation to PTSD status in a sample of veterans presenting to primary care with alcohol misuse. We also tested the hypothesis that greater depressive symptoms, illicit drug use and alcohol use severity would be independently associated with greater likelihood of PTSD, after controlling for age and ethnicity. Veterans (N = 166) were recruited from primary care as part of an intervention study between the years 2010 and 2011. Veterans participating in the study completed an in-person semi-structured interview with study staff. Using the post-traumatic Stress Disorder Checklist-Military version, we found a 16.3% rate of PTSD. PTSD was associated with greater depressive symptoms, rates of suicidal ideation, alcohol use severity, current use of hypnotics and lifetime use of cocaine and amphetamines. Using logistic regression, we found that severity of depressive symptoms and lifetime cocaine use were independently associated with greater likelihood of PTSD, after controlling for age and ethnicity. Treatment implications of these findings are discussed.

A Randomized Controlled Trial of a Web-Delivered Brief Alcohol Intervention in Veterans Affairs Primary Care

Substance abuse treatment utilization and patient characteristics of veterans (N = 167) drinking alcohol at risky levels at a Department of Veterans Affairs hospital were examined. Rates of brief intervention and specialty care were higher than those found in national samples in 2010, but fall short of recommended guidelines. Veterans receiving more care were older, lower-income, and less likely to be in a relationship. Care-receiving veterans had higher rates of mental health comorbidities and mental health treatment in the prior year for an issue other than substance use. Understanding patients’ recent care history may help primary care providers to deliver care effectively.