Publications

OBJECTIVE

To inform development of intensive management programs for high-cost patients, this study investigated the relationship between psychiatric diagnoses and patterns of health care utilization among high-cost patients in the Department of Veterans Affairs (VA) health care system.

METHODS

The costliest 5% of patients who received care in the VA in fiscal year 2010 were assigned to five mutually exclusive hierarchical groups on the basis of diagnosis codes: no mental health condition, serious mental illness, substance use disorder, posttraumatic stress disorder (PTSD), and depression. Multivariable linear regression was used to examine associations between diagnostic groups and use of mental health and non-mental health care and costs of care, with adjustment for sociodemographic characteristics. The proportion of costs generated by mental health care was estimated for each group.

RESULTS

Among 261,515 high-cost VA patients, rates of depression, substance use disorder, PTSD, and serious mental illness were 29%, 20%, 17%, and 13%, respectively. Individuals in the serious mental illness and substance use disorder groups were younger and had fewer chronic general medical conditions and higher adjusted rates of mental health care utilization; they also had a greater proportion of costs generated by mental health care (41% and 31%, respectively) compared with individuals in the PTSD and depression groups (18% and 11%, respectively).

CONCLUSIONS

Optimal management of high-risk, high-cost patients may require stratification by psychiatric diagnoses, with integrated care models for patients with multiple chronic conditions and comorbid mental health conditions and intensive mental health services for patients whose primary needs stem from mental health conditions.

BACKGROUND

The protective effect of colonoscopy against proximal colorectal cancer is variable and depends on the detection and complete removal of precancerous polyps.

OBJECTIVE

To estimate the efficacy of colonoscopy in a medical center with open-access screening colonoscopy since 1998.

DESIGN

Nested case-control study with incidence density sampling.

SETTING

University-affiliated Veterans Affairs Medical Center.

PATIENTS

Colorectal cancer (CRC) cases and control subjects selected from screening age patients matched by age, gender, and date of first primary care visit.

MAIN OUTCOME MEASUREMENT

Colonoscopy preceding the CRC diagnosis date.

RESULTS

A total of 20.2% of CRC cases had a colonoscopy in the preceding 10 years compared with 49.0% of control subjects (adjusted odds ratio [aOR], 0.20; 95% confidence interval [CI], 0.11-0.34). Colonoscopy was strongly associated with decreased odds of both distal CRC (aOR, 0.16; 95% CI, 0.07-0.34) and proximal CRC (aOR, 0.26; 95% CI, 0.11-0.58). The fraction of cases attributed to interval cancers was 10.5%. Missed lesions predominantly localized to the cecum and rectum, and recurrent lesions clustered in the hepatic flexure. Cecal intubation rate was 93% (98% in adequately prepped patients), and the adenoma detection rate was 45.2% in the control group.

LIMITATIONS

Single-center, retrospective case-control design.

CONCLUSION

In an open access colonoscopy program characterized by a high cecal intubation rate and adenoma detection rate, colonoscopy was strongly associated with reduced odds of both distal and proximal CRC. Among interval cancers, missed lesions clustered in the cecum and rectum and recurrent lesions in the hepatic flexure.

BACKGROUND

Sudden cardiac death occurs commonly in the end-stage renal disease population receiving dialysis, with 25% dying of sudden cardiac death over 5 years. Despite this high risk, surprisingly few prospective studies have studied clinical- and dialysis-related risk factors for sudden cardiac death and arrhythmic precursors of sudden cardiac death in end-stage renal disease.

METHODS/DESIGN

We present a brief summary of the risk factors for arrhythmias and sudden cardiac death in persons with end-stage renal disease as the rationale for the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease (PACE) study, a prospective cohort study of patients recently initiated on chronic hemodialysis, with the overall goal to understand arrhythmic and sudden cardiac death risk. Participants were screened for eligibility and excluded if they already had a pacemaker or an automatic implantable cardioverter defibrillator. We describe the study aims, design, and data collection of 574 incident hemodialysis participants from the Baltimore region in Maryland, U.S.A.. Participants were recruited from 27 hemodialysis units and underwent detailed clinical, dialysis and cardiovascular evaluation at baseline and follow-up. Cardiovascular phenotyping was conducted on nondialysis days with signal averaged electrocardiogram, echocardiogram, pulse wave velocity, ankle, brachial index, and cardiac computed tomography and angiography conducted at baseline. Participants were followed annually with study visits including electrocardiogram, pulse wave velocity, and ankle brachial index up to 4 years. A biorepository of serum, plasma, DNA, RNA, and nails were collected to study genetic and serologic factors associated with disease.

DISCUSSION

Studies of modifiable risk factors for sudden cardiac death will help set the stage for clinical trials to test therapies to prevent sudden cardiac death in this high-risk population.

BACKGROUND

APOL1 genotype is associated with advanced kidney disease in African Americans, but the pathogenic mechanisms are unclear. Here, associations of APOL1 genotype with urine biomarkers of glomerular and tubular injury and kidney function decline were evaluated.

STUDY DESIGN

Observational study.

SETTING & PARTICIPANTS

431 human immunodeficiency virus (HIV)-infected African American women enrolled in Women's Interagency HIV Study (WIHS).

PREDICTOR

APOL1 genotype.

OUTCOMES

Albumin-creatinine ratio (ACR), 4 tubular injury biomarkers (interleukin 18 [IL-18], kidney injury molecule 1 [KIM-1], neutrophil gelatinase-associated lipocalin [NGAL], and α1-microglobulin [A1M]), and kidney function estimated using the CKD-EPI cystatin C equation.

MEASUREMENTS

Participants were genotyped for APOL1 single-nucleotide polymorphisms rs73885319 (G1 allele) and rs71785313 (G2 allele). Urine biomarkers were measured using stored samples from 1999-2000. Cystatin C was measured using serum collected at baseline and 4- and 8-year follow-ups.

RESULTS

At baseline, ACRs were higher among 47 women with 2 APOL1 risk alleles versus 384 women with 0/1 risk allele (median, 24 vs 11mg/g; P<0.001). Compared with women with 0/1 risk allele, women with 2 risk alleles had 104% higher ACRs (95% CI, 29-223mg/g) and 2-fold greater risk of ACR>30 (95% CI, 1.17-3.44) mg/g after multivariable adjustment. APOL1 genotype showed little association with urine IL-18:Cr ratio, KIM-1:Cr ratio, and NGAL:Cr ratio (estimates of -5% [95% CI, -24% to 18%], -20% [95% CI, -36% to -1%], and 10% [95% CI, -26% to 64%], respectively) or detectable urine A1M (prevalence ratio, 1.13; 95% CI, 0.65-1.97) in adjusted analyses. Compared with women with 0/1 allele, women with 2 risk alleles had faster eGFR decline, by 1.2 (95% CI, 0.2 to 2.2) mL/min/1.73m(2) per year, and 1.7- and 3.4-fold greater rates of incident chronic kidney disease (95% CI, 1.1 to 2.5) and 10% annual eGFR decline (95% CI, 1.7 to 6.7), respectively, with minimal attenuation after adjustment for glomerular and tubular injury biomarker levels.

LIMITATIONS

Results may not be generalizable to men.

CONCLUSIONS

Among HIV-infected African American women, APOL1-associated kidney injury appears to localize to the glomerulus, rather than the tubules.