Diagnostic accuracy of computed tomography coronary angiography in patients with a zero calcium score

To evaluate the diagnostic accuracy of 64-slice CT coronary angiography (CT-CA) for the detection of significant coronary artery stenosis in patients with zero on the Agatston Calcium Score (CACS). We enrolled 279 consecutive patients (96 male, mean age 48±12 years) with suspected coronary artery disease. Patients were symptomatic (n=208) or asymptomatic (n=71), and underwent conventional coronary angiography (CAG). For CT-CA we administered an IV bolus of 100 ml of iodinated contrast material. CT-CA was compared to CAG using a threshold for significant stenosis of ≤50%. The prevalence of disease demonstrated at CAG was 15% (1.4% in asymptomatic). The population at CAG showed no or non-significant disease in 85% (238/279), single vessel disease in 9% (25/279), and multi-vessel disease in 6% (16/279). Sensitivity, specificity, and positive and negative predictive values of CT-CA vs. CAG on the patient level were 100%, 95%, 76%, and 100% in the overall population and 100%, 100%, 100%, and 100% in asymptomatic patients, respectively. CT-CA proves high diagnostic performance in patients with or without symptoms and with zero CACS. The prevalence of significant disease detected by CT-CA was not negligible in asymptomatic patients. The role of CT-CA in asymptomatic patients remains uncertain

Prevalence of dual sensory impairment and its association with traumatic brain injury and blast exposure in OEF/OIF Veterans

Background: Many service members deployed to the Afghanistan and Iraq theatre of operations are returning with multiple injuries, including traumatic brain injury (TBI) and sensory impairment. Studies of sensory impairment among patients with TBI have focused either on the auditory or visual modality. However, their co-prevalence, termed dual sensory impairment (DSI), is not well-documented. We examined self-reported rates of auditory and visual impairment in Afghanistan and Iraq war Veterans receiving TBI evaluations

Predictors of Employment Status in Male and Female Post-9/11 Veterans Evaluated for Traumatic Brain Injury

The article of record as published may be found at http://dx.doi.org/10.1097/HTR.0000000000000404The goal of this study was to investigate predictors of employment status in male and female post- 9/11 Veterans evaluated for traumatic brain injury (TBI) in the Veterans Health Administration. Prior research suggests there are gender differences in psychosocial characteristics among this cohort. Methods: This was a crosssectional analysis of post-9/11 Veterans who completed a TBI evaluation between July 2009 and September 2013. Results: Women had lower prevalence of deployment-related TBI (65.5%) compared with men (75.3%), but the percentages of those unemployed across the TBI diagnostic categories were similar for men (38%) and women (39%). Adjusted log-binomial regression found that unemployment was significantly associated with age, education, marital status, moderate/severe TBI, suspected posttraumatic stress disorder, depression, and drug abuse/dependence, and neurobehavioral symptom severity for men, whereas for women only more severe affective and cognitive symptoms were associated with unemployment. Conclusions: Although the unemployment rate was similar across gender, there was a clearer pattern of demographic and health factors, including TBI severity, that was significantly associated with employment status in men. There may be other factors contributing to the female Veteran unemployment rate, underscoring the need to investigate unique contributors to unemployment, as well as how treatment and employment services can be expanded and tailored for post-9/11 Veterans.Investigator Initiated Research Awards #11-078 and #11-358Career Development Award (10-029)Presidential Early Career Award for Scientists and Engineers (USA 14-275)National Institute of Mental Health (5R25MH08091607)VA HSR&D Service, Quality Enhancement Research InitiativeThis material is based upon work supported in part by the Department of Veterans Affairs (VA),Veterans Health Administration, Office of Research and Development Health Services Research and Development (HSR&D) service’s Investigator Initiated Research Awards #11-078 and #11-358 (Dr Pogoda). Dr Iverson’s contribution was supported by her HSR&D Ca- reer Development Award (10-029) and a Presidential Early Career Award for Scientists and Engineers (USA 14-275). Dr Iverson is an investigator with the Implementation Research Institute (IRI) at the George Warren Brown School of Social Work, Washington University in St Louis, through an award from the National Institute of Mental Health (5R25MH08091607) and VA HSR&D Service, Quality Enhancement Research Initiative

Factors associated with internal medicine physician job attitudes in the Veterans Health Administration

Abstract Background US healthcare organizations increasingly use physician satisfaction and attitudes as a key performance indicator. Further, many health care organizations also have an academically oriented mission. Physician involvement in research and teaching may lead to more positive workplace attitudes, with subsequent decreases in turnover and beneficial impact on patient care. This article aimed to understand the influence of time spent on academic activities and perceived quality of care in relation to job attitudes among internal medicine physicians in the Veterans Health Administration (VHA). Methods A cross-sectional survey was conducted with inpatient attending physicians from 36 Veterans Affairs Medical Centers. Participants were surveyed regarding demographics, practice settings, workplace staffing, perceived quality of care, and job attitudes. Job attitudes consisted of three measures: overall job satisfaction, intent to leave the organization, and burnout. Analysis used a two-level hierarchical model to account for the nesting of physicians within medical centers. The regression models included organizational-level characteristics: inpatient bed size, urban or rural location, hospital teaching affiliation, and performance-based compensation. Results A total of 373 physicians provided useable survey responses. The majority (72%) of respondents reported some level of teaching involvement. Almost half (46%) of the sample reported some level of research involvement. Degree of research involvement was a significant predictor of favorable ratings on physician job satisfaction and intent to leave. Teaching involvement did not have a significant impact on outcomes. Perceived quality of care was the strongest predictor of physician job satisfaction and intent to leave. Perceived levels of adequate physician staffing was a significant contributor to all three job attitude measures. Conclusions Expanding opportunities for physician involvement with research may lead to more positive work experiences, which could potentially reduce turnover and improve system performance

Longitudinal Change in FEV1 and FVC in Chronic Spinal Cord Injury

Rationale: Although respiratory dysfunction is common in chronic spinal cord injury (SCI), determinants of longitudinal change in FEV1 and FVC have not been assessed

A method to reduce imbalance for site-level randomized stepped wedge implementation trial designs

Abstract Background Controlled implementation trials often randomize the intervention at the site level, enrolling relatively few sites (e.g., 6–20) compared to trials that randomize by subject. Trials with few sites carry a substantial risk of an imbalance between intervened (cases) and non-intervened (control) sites in important site characteristics, thereby threatening the internal validity of the primary comparison. A stepped wedge design (SWD) staggers the intervention at sites over a sequence of times or time waves until all sites eventually receive the intervention. We propose a new randomization method, sequential balance, to control time trend in site allocation by minimizing sequential imbalance across multiple characteristics. We illustrate the new method by applying it to a SWD implementation trial. Methods The trial investigated the impact of blended internal-external facilitation on the establishment of evidence-based teams in general mental health clinics in nine US Department of Veterans Affairs medical centers. Prior to randomization to start time, an expert panel of implementation researchers and health system program leaders identified by consensus a series of eight facility-level characteristics judged relevant to the success of implementation. We characterized each of the nine sites according to these consensus features. Using a weighted sum of these characteristics, we calculated imbalance scores for each of 1680 possible site assignments to identify the most sequentially balanced assignment schemes. Results From 1680 possible site assignments, we identified 34 assignments with minimal imbalance scores, and then randomly selected one assignment by which to randomize start time. Initially, the mean imbalance score was 3.10, but restricted to the 34 assignments, it declined to 0.99. Conclusions Sequential balancing of site characteristics across groups of sites in the time waves of a SWD strengthens the internal validity of study conclusions by minimizing potential confounding. Trial registration Registered at ClinicalTrials.gov as clinical trials # NCT02543840; entered 9/4/2015

Time course and heterogeneity of treatment effect of the collaborative chronic care model on psychiatric hospitalization rates: A survival analysis using routinely collected electronic medical records.

BackgroundHealth systems are undergoing widespread adoption of the collaborative chronic care model (CCM). Care structured around the CCM may reduce costly psychiatric hospitalizations. Little is known, however, about the time course or heterogeneity of treatment effects (HTE) for CCM on psychiatric hospitalization.RationaleAssessment of CCM implementation support on psychiatric hospitalization might be more efficient if the timing were informed by an expected time course. Further, understanding HTE could help determine who should be referred for intervention.Objectives(i) Estimate the trajectory of CCM effect on psychiatric hospitalization rates. (ii) Explore HTE for CCM across demographic and clinical characteristics.MethodsData from a stepped wedge CCM implementation trial were reanalyzed using 5 570 patients in CCM treatment and 46 443 patients receiving usual care. Time-to-event data was constructed from routine medical records. Effect trajectory of CCM on psychiatric hospitalization was simulated from an extended Cox model over one year of implementation support. Covariate risk contributions were estimated from subset stratified Cox models without using simulation. Ratios of hazard ratios (RHR) allowed comparison by trial arm for HTE analysis, also without simulation. No standard Cox proportional hazards models were used for either estimating the time-course or heterogeneity of treatment effect.ResultsThe effect of CCM implementation support increased most rapidly immediately after implementation start and grew more gradually throughout the rest of the study. On the final study day, psychiatric hospitalization rates in the treatment arm were 17% to 49% times lower than controls, with adjustment for all model covariates (HR 0.66; 95% CI 0.51-0.83). Our analysis of HTE favored usual care for those with a history of prior psychiatric hospitalization (RHR 4.92; 95% CI 3.15-7.7) but favored CCM for those with depression (RHR 0.61; 95% CI: 0.41-0.91). Having a single medical diagnosis, compared to having none, favored CCM (RHR 0.52; 95% CI 0.31-0.86).ConclusionReduction of psychiatric hospitalization is evident immediately after start of CCM implementation support, but assessments may be better timed once the effect size begins to stabilize, which may be as early as six months. HTE findings for CCM can guide future research on utility of CCM in specific populations

Concordance of clinician judgment of mild traumatic brain injury history with a diagnostic standard

The article of record as published may be located at http://dx.doi.org/10.1682/JRRD.2013.05.0115The concordance of Department of Veterans Affairs (VA) clinician judgment of mild traumatic brain injury (mTBI) history with American Congress of Rehabilitation Medicine (ACRM)-based criteria was examined for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans. In order to understand inconsistencies in agreement, we also examined the associations between evaluation outcomes and conceptually relevant patient characteristics, deployment-related events, current self-reported health symptoms, and suspected psychiatric conditions. The Veteran sample comprised 14,026 OIF/OEF VA patients with deployment-related mTBI history (n = 9,858) or no history of mTBI (n = 4,168) as defined by ACRM-based criteria. In the majority of cases (76.0%), clinician judgment was in agreement with the ACRM-based criteria. The most common inconsistency was between clinician judgment (no) and ACRM-based criteria (yes) for 21.3% of the patients. Injury etiology, current self-reported health symptoms, and suspected psychiatric conditions were additional factors associated with clinician diagnosis and ACRM-based criteria disagreement. Adherence to established diagnostic guidelines is essential for accurate determination of mTBI history and for understanding the extent to which mTBI symptoms resolve or persist over time in OIF/OEF Veterans

Concordance of clinician judgment of mild traumatic brain injury history with a diagnostic standard

The article of record as published may be located at http://dx.doi.org/10.1682/JRRD.2013.05.0115The concordance of Department of Veterans Affairs (VA) clinician judgment of mild traumatic brain injury (mTBI) history with American Congress of Rehabilitation Medicine (ACRM)-based criteria was examined for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans. In order to understand inconsistencies in agreement, we also examined the associations between evaluation outcomes and conceptually relevant patient characteristics, deployment-related events, current self-reported health symptoms, and suspected psychiatric conditions. The Veteran sample comprised 14,026 OIF/OEF VA patients with deployment-related mTBI history (n = 9,858) or no history of mTBI (n = 4,168) as defined by ACRM-based criteria. In the majority of cases (76.0%), clinician judgment was in agreement with the ACRM-based criteria. The most common inconsistency was between clinician judgment (no) and ACRM-based criteria (yes) for 21.3% of the patients. Injury etiology, current self-reported health symptoms, and suspected psychiatric conditions were additional factors associated with clinician diagnosis and ACRM-based criteria disagreement. Adherence to established diagnostic guidelines is essential for accurate determination of mTBI history and for understanding the extent to which mTBI symptoms resolve or persist over time in OIF/OEF Veterans