Stephen L. Luther

Health Outcomes Associated with Military Deployment: Mild Traumatic Brain Injury, Blast, Trauma, and Combat Associations in the Florida National Guard

OBJECTIVES To determine the association between specific military deployment experiences and immediate and longer-term physical and mental health effects, as well as examine the effects of multiple deployment-related traumatic brain injuries (TBIs) on health outcomes. DESIGN Online survey of cross-sectional cohort. Odds ratios were calculated to assess the association between deployment-related factors (ie, physical injuries, exposure to potentially traumatic deployment experiences, combat, blast exposure, and mild TBI) and current health status, controlling for potential confounders, demographics, and predeployment experiences. SETTING Nonclinical. PARTICIPANTS Members (N=3098) of the Florida National Guard (1443 deployed, 1655 not deployed). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Presence of current psychiatric diagnoses and health outcomes, including postconcussive and non-postconcussive symptoms. RESULTS Surveys were completed an average of 31.8 months (SD=24.4, range=0-95) after deployment. Strong, statistically significant associations were found between self-reported military deployment-related factors and current adverse health status. Deployment-related mild TBI was associated with depression, anxiety, posttraumatic stress disorder (PTSD), and postconcussive symptoms collectively and individually. Statistically significant increases in the frequency of depression, anxiety, PTSD, and a postconcussive symptom complex were seen comparing single to multiple TBIs. However, a predeployment TBI did not increase the likelihood of sustaining another TBI in a blast exposure. Associations between blast exposure and abdominal pain, pain on deep breathing, shortness of breath, hearing loss, and tinnitus suggested residual barotrauma. Combat exposures with and without physical injury were each associated not only with PTSD but also with numerous postconcussive and non-postconcussive symptoms. The experience of seeing others wounded or killed or experiencing the death of a buddy or leader was associated with indigestion and headaches but not with depression, anxiety, or PTSD. CONCLUSIONS Complex relationships exist between multiple deployment-related factors and numerous overlapping and co-occurring current adverse physical and psychological health outcomes. Various deployment-related experiences increased the risk for postdeployment adverse mental and physical health outcomes, individually and in combination. These findings suggest that an integrated physical and mental health care approach would be beneficial to postdeployment care.

A cardiovascular profile score in the surveillance of fetal hydrops

Objective. To assess the value of a cardiovascular profile score in the surveillance of fetal hydrops. Methods. In a retrospective study, 102 hydropic fetuses were examined between 15 and 37 completed weeks of gestation with ultrasonographic assessment of hydrops, heart size, and cardiac function, and arterial umbilical and venous Doppler sonography of the ductus venosus (DV) and the umbilical vein (UV). A cardiovascular profile score (CVPS) was constructed by attributing 2 points for normal and taking away 1 or 2 points for abnormal findings in each category. The score of the final examination prior to treatment, delivery, or fetal demise was compared to the fetal outcome in these 102 fetuses after exclusion of terminated pregnancies. The scores of the first and last examinations were compared in 40 fetuses and the relationship between these scores and the evolution of fetal hydrops and fetal outcome was assessed. Results. Twenty-one pregnancies were terminated (21%). Fifty-four of the remaining 81 hydropic fetuses survived (67%) and perinatal death (PNM) occurred in 27 fetuses (33%). The median CVPS was 6.0 (IQR 4.75–8.00) for all fetuses, with a median of 6.0 (IQR 5.00–6.00) in fetuses who died in the perinatal period compared to a median of 7.0 (IQR 4.00–8.00) in those who survived (p < 0.035). All fetuses in this study had a ‘severe’ form of hydrops with skin edema. The best predictor for adverse outcome was the venous Doppler sonography of UV and DV, in particular umbilical venous pulsations. Among fetuses included in the longitudinal arm of the study, the survival rate was 40% and the PNM was 60%, after exclusion of terminated pregnancies. CVPS increased by a median of 1 (IQR 0.00–2.00) point in the last exam for those fetuses that lived, whereas among those fetuses that died, the CVPS decreased by a median 1.5 (IQR 0.25–2.75) points (p < 0.001). Conclusions. The fetal cardiovascular profile score can be used in the surveillance of hydropic fetuses for prediction of the presence of congestive heart failure and as an aid for predicting fetal outcome.

Identifying fall-related injuries: Text mining the electronic medical record

Unintentional injury due to falls is a serious and expensive health problem among the elderly. This is especially true in the Veterans Health Administration (VHA) ambulatory care setting, where nearly 40% of the male patients are 65 or older and at risk for falls. Health service researchers and clinicians can utilize VHA administrative data to identify and explore the frequency and nature of fall-related injuries (FRI) to aid in the implementation of clinical and prevention programs. Here we define administrative data as structured (coded) values that are generated as a result clinical services provided to veterans and stored in databases. However, the limitations of administrative data do not always allow for conclusive decision making, especially in areas where coding may be incomplete. This study utilizes data and text mining techniques to investigate if unstructured text-based information included in the electronic medical record can validate and enhance those records in the administrative data that should have been coded as fall-related injuries. The challenges highlighted by this study include data extraction and preparation from administrative sources and the full electronic medical records, de-indentifying the data (to assure HIPAA compliance), conducting chart reviews to construct a “gold standard” dataset, and performing both supervised and unsupervised text mining techniques in comparison with traditional medical chart review.

Nurse Staffing and Patient Outcomes in Inpatient Rehabilitation Settings

&NA; In rehabilitation nursing, the patient classification systems or acuity models and nurse‐staffing ratios are not supported by empirical evidence. Moreover, there are no studies published characterizing nursing hours per patient day, proportion of RN staff, and impact of agency nurses in inpatient rehabilitation settings. The purpose of this prospective observational study was to describe rehabilitation nurse staffing patterns, to validate the impact of rehabilitation nursing on patient outcomes, and to test whether existing patient measures on severity and outcomes in rehabilitation could be used as a proxy for burden of care to predict rehabilitation nurse staffing ceilings and daily nurse staffing requirements. A total of 54 rehabilitation facilities in the United States, stratified by geography, were randomly selected to participate in the study.

Finding falls in ambulatory care clinical documents using statistical text mining.

OBJECTIVE To determine how well statistical text mining (STM) models can identify falls within clinical text associated with an ambulatory encounter. MATERIALS AND METHODS 2241 patients were selected with a fall-related ICD-9-CM E-code or matched injury diagnosis code while being treated as an outpatient at one of four sites within the Veterans Health Administration. All clinical documents within a 48-h window of the recorded E-code or injury diagnosis code for each patient were obtained (n=26 010; 611 distinct document titles) and annotated for falls. Logistic regression, support vector machine, and cost-sensitive support vector machine (SVM-cost) models were trained on a stratified sample of 70% of documents from one location (dataset Atrain) and then applied to the remaining unseen documents (datasets Atest-D). RESULTS All three STM models obtained area under the receiver operating characteristic curve (AUC) scores above 0.950 on the four test datasets (Atest-D). The SVM-cost model obtained the highest AUC scores, ranging from 0.953 to 0.978. The SVM-cost model also achieved F-measure values ranging from 0.745 to 0.853, sensitivity from 0.890 to 0.931, and specificity from 0.877 to 0.944. DISCUSSION The STM models performed well across a large heterogeneous collection of document titles. In addition, the models also generalized across other sites, including a traditionally bilingual site that had distinctly different grammatical patterns. CONCLUSIONS The results of this study suggest STM-based models have the potential to improve surveillance of falls. Furthermore, the encouraging evidence shown here that STM is a robust technique for mining clinical documents bodes well for other surveillance-related topics.

The role of data warehousing in bioterrorism surveillance

The development of an effective bioterrorism surveillance system requires effective solutions to several critical challenges. The system must support multidimensional historical data, provide real-time surveillance of sensor data, have the capability for pattern recognition to quickly identify abnormal situations, and provide an analytic environment that accelerates investigations by epidemiologists and other responders. The use of real-time or flash data warehousing provides the essential ability to compare unfolding health events with historical patterns of key surveillance indicators. To explore the role of data warehousing in surveillance systems, we study naturally occurring incidents, Florida wildfires from 1996 through 2001, as reasonable facsimiles of bioterrorism attacks. Hospital admissions data on respiratory illnesses during that period are analyzed to uncover patterns that might resemble an airborne biochemical attack. A principal contribution of this research is the adroit use of online analytic processing (OLAP) techniques, along with spatial and statistical analyses, to study the adverse effects of this natural phenomenon. These techniques will provide important capabilities for epidemiologist-in-the-loop surveillance systems, enabling the rapid exploration of unusual situations and guidance for follow-up investigations.

A comparison of patient outcomes and quality of life in persons with neurogenic bowel: standard bowel care program vs colostomy.

Abstract Background/Objective: The purpose of this study was to compare patient outcomes and quality of life for people with neurogenic bowel using either a standard bowel care program or colostomy. Methods: We analyzed survey data from a national sample, comparing outcomes between veterans with spinal cord injury (SCI) who perform bowel care programs vs individuals with colostomies. This study is part of a larger study to evaluate clinical practice guideline implementation in SCI. The sample included 1,503 veterans with SCI. The response rate was 58.4%. For comparison, we matched the respondents with colostomies to matched controls from the remainder of the survey cohort. A total of 74 veterans with SCI and colostomies were matched with 296 controls, using propensity scores. Seven items were designed to elicit information about the respondents satisfaction with their bowel care program, whereas 7 other items were designed to measure bowel-related quality of life. Results: No statistically significant differences in satisfaction or quality of life were found between the responses from veterans with colostomies and those with traditional bowel care programs. Both respondents with colostomies and those without colostomies indicated that they had received training for their bowel care program, that they experienced relatively few complications, such as falls as a result of their bowel care program, and that their quality of life related to bowel care was generally good. However, large numbers of respondents with colostomies (n = 39; 55.7%) and without colostomies (n = 113; 41.7%) reported that they were very unsatisfied with their bowel care program. Conclusion: Satisfaction with bowel care is a major problem for veterans with SCI.

Toward a population health delivery system: first steps in performance measurement.

In spite of the technological sophistication and clinical excellence of the U.S. health care industry and annual health expenditures in excess of a trillion dollars, the overall health status of the American population is comparatively poor. The BCHS in west central Florida sought to improve the health status of the communities that it serves. Known by the acronym CHAPIR, an information-driven health status decision support system was developed, pilot tested, and is now fully implemented throughout the BCHS. The methodological approach, quantitative indicators, report format components, and management implications of the system are described.

Risk assessment of wandering behavior in mild dementia.

This prospective longitudinal study aims to determine the risk factors of wandering‐related adverse consequences in community‐dwelling persons with mild dementia. These adverse consequences include negative outcomes of wandering (falls, fractures, and injuries) and eloping behavior.

Cost consequences of sentinel lymph node biopsy in the treatment of breast cancer: A preliminary analysis

OBJECTIVES To assess whether sentinel lymph node biopsy (SLNB), an alternative to axillary lymph node dissection in treating female breast cancer, affords any cost savings. METHODS We profile cumulative treatment costs of 811 breast cancer patients, 555 of whom received SLNB. Univariate and multivariate statistical tests are used to appraise whether these cost profiles differ between SLNB and other patients. RESULTS The statistical results are mixed. However, none supports the conjecture that SLNB necessarily lowers the cost of treating the average breast patient. CONCLUSIONS SLNB may be cost-effective, but longer term costs and outcomes must be estimated before firm conclusions can be reached.