The accuracy and completeness for receipt of colorectal cancer care using Veterans Health Administration administrative data.

The National Comprehensive Cancer Network and the American Society of Clinical Oncology have established guidelines for the treatment and surveillance of colorectal cancer (CRC), respectively. Considering these guidelines, an accurate and efficient method is needed to measure receipt of care

Next generation software environments : principles, problems, and research directions

The past decade has seen a burgeoning of research and development in software environments. Conferences have been devoted to the topic of practical environments, journal papers produced, and commercial systems sold. Given all the activity, one might expect a great deal of consensus on issues, approaches, and techniques. This is not the case, however. Indeed, the term "environment" is still used in a variety of conflicting ways. Nevertheless substantial progress has been made and we are at least nearing consensus on many critical issues.The purpose of this paper is to characterize environments, describe several important principles that have emerged in the last decade or so, note current open problems, and describe some approaches to these problems, with particular emphasis on the activities of one large-scale research program, the Arcadia project. Consideration is also given to two related topics: empirical evaluation and technology transition. That is, how can environments and their constituents be evaluated, and how can new developments be moved effectively into the production sector

Sexual Risk Behaviour among HIV-Positive Individuals in Clinical Care in Urban KwaZulu-Natal, South Africa

Objectives: To assess the prevalence and predictors of unprotected sex among HIV+ individuals in clinical care in urban KwaZulu-Natal, South Africa. Design: Cross-sectional survey of 152 HIV+ individuals attending a hospital-based HIV-clinic. Methods: Structured interviews were conducted by bilingual interviewers. Sexual risk behaviour in the preceding 3 months was assessed via event counts. Results: In one of the first studies of its kind in South Africa we found that nearly half of the sample reported vaginal or anal sex during the preceding 3 months, and 30% of these patients reported unprotected vaginal or anal sex. Among sexually active patients, a total of 171 unprotected sex events were reported, 40% of which were with partners perceived to be HIV negative or HIV-status unknown. Nine such partners were potentially exposed to HIV. Alcohol use during sex, being forced to have sex, sex with a perceived HIV+ partner, and sex with a casual partner predicted more unprotected sex, whereas HIV-status disclosure was related to less unprotected sex. Conclusions: HIV+ individuals in clinical care in South Africa may engage in unprotected sex that place others at risk of HIV infection and themselves at risk for infection with STIs. With a national ARV rollout currently underway in South Africa, increasing numbers of HIV+ individuals are entering care. This affords a crucial opportunity to link HIV prevention with HIV care, an approach that aims to reduce transmission risk behaviour among HIV+ individuals and is consistent with international agencies’ current prevention priorities

Underuse and Overuse of Colonoscopy for Repeat Screening and Surveillance in the Veterans Health Administration

Regular screening with colonoscopy lowers colorectal cancer incidence and mortality. We aimed to determine patterns of repeat and surveillance colonoscopy and identify factors associated with over- and underuse of colonoscopy

Factors Associated with Survival of Veterans with Gastrointestinal Neuroendocrine Tumors

Background. Gastrointestinal (GI) neuroendocrine tumor (NET) incidence has been increasing; however, GI NET within the national Veterans Affairs (VA) health system has not been described. Methods. We used the VA Central Cancer Registry to identify the cohort of patients diagnosed with GI NET in 1995–2009. Cox regression models were constructed to explore factors associated with survival. Results. We included 1793 patients with NET of the stomach (9%), duodenum (10%), small intestine (24%), colon (19%) or rectum (38%). Twenty percent were diagnosed in 1995–1999, 35% in 2000–2004, and 45% in 2005–2009. Unadjusted 5-year survival rates were: stomach 56%, duodenum 66%, small intestine 52%, colon 67%, and rectum 84%. Factors associated with shorter survival were increasing age, hazard ratio (HR) 1.05 (95% CI 1.04–1.06), NET location [compared to rectum: stomach HR 2.26 (95% CI 1.68–3.05), duodenum HR 1.70 (95% CI 1.26–2.28), small intestine HR 1.85 (95% CI 1.42–2.42), and colon 1.83 (95% CI 1.41–2.39)], stage [compared to in situ/local: regional HR 1.15 (95% CI 0.90–1.47), distant HR 2.38 (95% CI 1.87–3.05)], and earlier period of diagnosis [compared to 1995–1999: 2000–2004 HR 0.70 (95% CI 0.59–0.85), 2005–2009 HR 0.43 (95% CI 0.34–0.54)]. Conclusions. The incidence of GI NET has also increased over time in the VA system with similar survival rates to those observed in non-VA settings. Worsened survival was associated with older age, tumor site, advanced stage, and earlier year of diagnosis

An electronic family health history tool to identify and manage patients at increased risk for colorectal cancer: protocol for a randomized controlled trial.

BackgroundColorectal cancer is the fourth most commonly diagnosed cancer in the United States. Approximately 3-10% of the population has an increased risk for colorectal cancer due to family history and warrants more frequent or intensive screening. Yet, < 50% of that high-risk population receives guideline-concordant care. Systematic collection of family health history and decision support may improve guideline-concordant screening for patients at increased risk of colorectal cancer. We seek to test the effectiveness of a web-based, systematic family health history collection tool and decision support platform (MeTree) to improve risk assessment and appropriate management of colorectal cancer risk among patients in the Department of Veterans Affairs primary care practices.MethodsIn this ongoing randomized controlled trial, primary care providers at the Durham Veterans Affairs Health Care System and the Madison VA Medical Center are randomized to immediate intervention or wait-list control. Veterans are eligible if assigned to enrolled providers, have an upcoming primary care appointment, and have no conditions that would place them at increased risk for colorectal cancer (such as personal history, adenomatous polyps, or inflammatory bowel disease). Those with a recent lower endoscopy (e.g. colonoscopy, sigmoidoscopy) are excluded. Immediate intervention patients put their family health history information into a web-based platform, MeTree, which provides both patient- and provider-facing decision support reports. Wait-list control patients access MeTree 12 months post-consent. The primary outcome is the risk-concordant colorectal cancer screening referral rate obtained via chart review. Secondary outcomes include patient completion of risk management recommendations (e.g. colonoscopy) and referral for genetic consultation. We will also conduct an economic analysis and an assessment of providers' experience with MeTree clinical decision support recommendations to inform future implementation efforts if the intervention is found to be effective.DiscussionThis trial will assess the feasibility and effectiveness of patient-collected family health history linked to decision support to promote risk-appropriate screening in a large healthcare system such as the Department of Veterans Affairs.Trial registrationClinicalTrials.gov, NCT02247336 . Registered on 25 September 2014

Use of RE-AIM to develop a multi-media facilitation tool for the patient-centered medical home

<p>Abstract</p> <p>Background</p> <p>Much has been written about how the medical home model can enhance patient-centeredness, care continuity, and follow-up, but few comprehensive aids or resources exist to help practices accomplish these aims. The complexity of primary care can overwhelm those concerned with quality improvement.</p> <p>Methods</p> <p>The RE-AIM planning and evaluation model was used to develop a multimedia, multiple-health behavior tool with psychosocial assessment and feedback features to facilitate and guide patient-centered communication, care, and follow-up related to prevention and self-management of the most common adult chronic illnesses seen in primary care.</p> <p>Results</p> <p>The <it>Connection to Health </it>Patient Self-Management System, a web-based patient assessment and support resource, was developed using the RE-AIM factors of reach (<it>e.g</it>., allowing input and output via choice of different modalities), effectiveness (<it>e.g</it>., using evidence-based intervention strategies), adoption (<it>e.g</it>., assistance in integrating the system into practice workflows and permitting customization of the website and feedback materials by practice teams), implementation (<it>e.g</it>., identifying and targeting actionable priority behavioral and psychosocial issues for patients and teams), and maintenance/sustainability (<it>e.g</it>., integration with current National Committee for Quality Assurance recommendations and clinical pathways of care). <it>Connection to Health </it>can work on a variety of input and output platforms, and assesses and provides feedback on multiple health behaviors and multiple chronic conditions frequently managed in adult primary care. As such, it should help to make patient-healthcare team encounters more informed and patient-centered. Formative research with clinicians indicated that the program addressed a number of practical concerns and they appreciated the flexibility and how the <it>Connection to Health </it>program could be customized to their office.</p> <p>Conclusions</p> <p>This primary care practice tool based on an implementation science model has the potential to guide patients to more healthful behaviors and improved self-management of chronic conditions, while fostering effective and efficient communication between patients and their healthcare team. RE-AIM and similar models can help clinicians and media developers create practical products more likely to be widely adopted, feasible in busy medical practices, and able to produce public health impact.</p

Quality of colonoscopy reporting in community practice

Quality endoscopy reporting is essential when community endoscopists perform colonoscopies for veterans who cannot be scheduled at a Veterans Health Administration (VA) facility