Ascertainment of Testosterone Prescribing Practices in the VA.

Background: Prescribing of exogenous testosterone is increasing. Because of the risks associated with testosterone, it is important to follow evidence-based procedures when initiating therapy.

Objective: We evaluated whether dispensing of testosterone was preceded by appropriate ascertainment of androgen deficiency, and consideration of potential contraindications, in accordance with practice guidelines.

Genomic and clinical effects associated with a relaxation response mind-body intervention in patients with irritable bowel syndrome and inflammatory bowel disease.

Introduction: Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD) can profoundly affect quality of life and are influenced by stress and resiliency. The impact of mind-body interventions (MBIs) on IBS and IBD patients has not previously been examined.

Methods: Nineteen IBS and 29 IBD patients were enrolled in a 9-week relaxation response based mind-body group intervention (RR-MBI), focusing on elicitation of the RR and cognitive skill building.

Antiepileptic drug prescribing patterns in Iraq and Afghanistan war veterans with epilepsy.

Objective: We examined patterns of antiepileptic drug (AED) use in a cohort of Iraq/Afghanistan war veterans (IAVs) who were previously identified as having epilepsy. We hypothesized that clinicians would be more likely to prescribe newer AEDs and would select specific AEDs to treat seizures based on patient characteristics including gender and comorbidities.

Methods: From the cohort of IAVs previously identified with epilepsy between fiscal years 2009 and 2010, we selected those who received AEDs from the Veterans Health Administration in FY2010.

Variability in estimated glomerular filtration rate values is a risk factor in chronic kidney disease progression among patients with diabetes.

Background: It is unknown whether variability of estimated Glomerular Filtration Rate (eGFR) is a risk factor for dialysis or death in patients with chronic kidney disease (CKD). This study aimed to evaluate variability of estimated Glomerular Filtration Rate (eGFR) as a risk factor for dialysis or death to facilitate optimum care among high risk patients.

Methods: A longitudinal retrospective cohort study of 70,598 Veterans Health Administration veteran patients with diabetes and CKD (stage 3-4) in 2000 with up to 5 years of follow-up.

Ten things to remember about common factor theory.

Recently, we (Laska, Gurman, & Wampold, 2014, pp. 467-481) discussed the implications of taking a common factor approach for practice and policy. In this response to the commentary on our article, we reiterate 10 things that need to be remembered about common factor theory.

Reevaluation of a clinical resource for assessment of delirium, dementia, and depression.

There is a perennial need to extend geriatrics knowledge and expertise to primary care providers to meet the unique needs of older patients. Reaching the target population of providers in an effective manner presents challenges for educators and evaluation of education programs. Gaps in a previous dissemination of an Assessment Guide for delirium, dementia, and depression were addressed through a multimodal strategy to reach a greater proportion of the intended audience, primary care clinicians, and to further evaluate the clinical impact of this learning resource.

A tale of 2 countries: the cost of my mother's cardiac care in the United States and India.

When my mother fell ill while visiting me in the United States, I had the opportunity to compare costs of surgical cardiac care in the United States and India. I faced challenges in making well-informed decisions in the United States due to the lack of cost transparency and the minimal flexibility offered in choice of care, whereas in India costs are readily available and allow most people to freely choose their preferred type of care.

Examining Warfarin Dosing Decisions to Improve Anticoagulation Management.

: Adherence to relatively simple warfarin dosing algorithms has been found to be effective for improving anticoagulation control, and in turn for reducing adverse events. Achieving consistent use of such algorithms by clinicians managing the care is a known challenge. : To examine warfarin management patterns at anticoagulation clinics in light of algorithm-recommended management and to develop a methodology for quality assurance around this issue.

Improving quality measurement for anticoagulation: adding international normalized ratio variability to percent time in therapeutic range.

Background: Among patients receiving warfarin, percent time in therapeutic range (TTR) and international normalized ratio (INR) variability predict adverse events individually. Here, we examined what is added to the prediction of adverse events by using both measures together.

Methods And Results: We included 40 404 patients anticoagulated for atrial fibrillation, aged 65+, within the Veterans Health Administration.

Retaining homeless veterans in outpatient care: a pilot study of mobile phone text message appointment reminders.

Objectives: We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows.

Methods: We sent 2 text message reminders to participants (n = 20) before each of their outpatient appointments at an urban Veterans Affairs medical center. Evaluation included pre- and postsurvey questionnaires, open-ended questions, and review of medical records.

False discovery rate control is a recommended alternative to Bonferroni-type adjustments in health studies.

Objectives: Procedures for controlling the false positive rate when performing many hypothesis tests are commonplace in health and medical studies. Such procedures, most notably the Bonferroni adjustment, suffer from the problem that error rate control cannot be localized to individual tests, and that these procedures do not distinguish between exploratory and/or data-driven testing vs. hypothesis-driven testing.

Identification of metabolites from liquid chromatography-coulometric array detection profiling: gas chromatography-mass spectrometry and refractionation provide essential information orthogonal to LC-MS/microNMR.

Liquid chromatography-coulometric array detection (LC-EC) is a sensitive, quantitative, and robust metabolomics profiling tool that complements the commonly used mass spectrometry (MS) and nuclear magnetic resonance (NMR)-based approaches. However, LC-EC provides little structural information. We recently demonstrated a workflow for the structural characterization of metabolites detected by LC-EC profiling combined with LC-electrospray ionization (ESI)-MS and microNMR.

Explaining racial disparities in anticoagulation control: results from a study of patients at the Veterans Administration.

Higher rates of stroke, major hemorrhage, and death among black patients receiving warfarin, compared with white patients, is likely related to poorer anticoagulation control. The research team investigated patient-level and site-level factors that might account for this group difference. A summary measure of anticoagulation control (percent time in therapeutic range [TTR]), patient characteristics, and site-level process of care measures were obtained for 9572 black and 88 481 white patients at the Veterans Health Administration.

Pathways to poor anticoagulation control.

Background: While a considerable amount is known about which patient-level factors predict poor anticoagulation control with warfarin, measured by percent time in therapeutic range (TTR), less is known about predictors of time above or below target.

Objective: To identify predictors of different patterns of international normalized ratio (INR) values that account for poor control, including 'erratic' patterns, where more time is spent both above and below INR target, and unidirectional patterns, where time out of range is predominantly in one direction (low or high).

Methods: We studied 103 897 patients receiving warfarin with a target INR of 2-3 from 100 Veterans Health Administration sites between October 2006 and September 2008.

Comparing patient-level and site-level anticoagulation control as predictors of adverse events.

Introduction: Percent time in therapeutic range (TTR) is increasingly used to summarize anticoagulation control over time among patients receiving warfarin. Higher TTR improves outcomes of care, but studies have varied regarding whether TTR is best summarized as center-based percent time in therapeutic range (cTTR) or as individual percent time in therapeutic range (iTTR). Our aim was to compare cTTR to iTTR in predicting ischemic stroke, major hemorrhage, and all-cause mortality.

Expanding the lens of evidence-based practice in psychotherapy: a common factors perspective.

In this article, we examine the science and policy implications of the common factors perspective (CF; Frank & Frank, 1993; Wampold, 2007). As the empirically supported treatment (EST) approach, grounded in randomized controlled trials (RCTs), is the received view (see Baker, McFall, & Shoham, 2008; McHugh & Barlow, 2012), we make the case for the CF perspective as an additional evidence-based approach for understanding how therapy works, but also as a basis for improving the quality of mental health services. Finally, we argue that it is time to integrate the 2 perspectives, and we challenge the field to do so.

Detecting adverse events in surgery: comparing events detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators.

Background: The Patient Safety Indicators (PSIs) use administrative data to screen for select adverse events (AEs). In this study, VA Surgical Quality Improvement Program (VASQIP) chart review data were used as the gold standard to measure the criterion validity of 5 surgical PSIs. Independent chart review was also used to determine reasons for PSI errors.

A conceptual model for culture change evaluation in nursing homes.

This article describes the development and particulars of a new, comprehensive model of nursing home culture change, the Nursing Home Integrated Model for Producing and Assessing Cultural Transformation (Nursing Home IMPACT). This model is structured into four categories, "meta constructs," "care practices," "workplace practices," and "environment of care," with multiple domains under each. It includes detailed, triangulated assessment methods capturing various stakeholder perspectives for each of the model's domains.

A novel method for detecting 7-methyl guanine reveals aberrant methylation levels in Huntington disease.

Guanine methylation is a ubiquitous process affecting DNA and various RNA species. N-7 guanine methylation (7-MG), although relatively less studied, could have a significant role in normal transcriptional regulation as well as in the onset and development of pathological conditions. The lack of a sensitive method to accurately quantify trace amounts of altered bases such as 7-MG has been a major deterrent in delineating its biological function(s).

Improving the identification of postoperative wound dehiscence missed by the Patient Safety Indicator algorithm.

Background: The Patient Safety Indicator (PSI) Postoperative Wound Dehiscence (PWD) is an administrative data-based algorithm that flags cases using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 54.61 (abdominal wall disruption reclosure). We examined how often PWD missed events and explored ways to improve event identification.

Uniformity of evidence-based treatments in practice? Therapist effects in the delivery of cognitive processing therapy for PTSD.

Objective: Various factors contribute to the effective implementation of evidence-based treatments (EBTs). In this study, cognitive processing therapy (CPT) was administered in a Veterans Affairs (VA) posttraumatic stress disorder (PTSD) specialty clinic in which training and supervision were provided following VA implementation guidelines. The aim was to (a) estimate the proportion of variability in outcome attributable to therapists and (b) identify characteristics of those therapists who produced better outcomes.