Measuring quality of oral anticoagulation care: extending quality measurement to a new field.

Background: Oral anticoagulation with warfarin is an increasingly common medical intervention. Despite its efficacy, warfarin is difficult to manage, contributing to potential for patient harm. Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with comparatively little effort in measuring the quality of oral anticoagulation care once therapy has begun.

Warfarin dose management affects INR control.

Background: Little is known about how patterns of warfarin dose management contribute to percentage time in the therapeutic International Normalized Ratio (INR) range (TTR).

Objectives: To quantify the contribution of warfarin dose management to TTR and to define an optimal dose management strategy.

Patients/methods: We enrolled 3961 patients receiving warfarin from 94 community-based clinics.

Warfarin for atrial fibrillation in community-based practise.

Background: Previous studies of anticoagulation for atrial fibrillation (AF) have predominantly occurred in academic settings or randomized trials, limiting their generalizability.

Objective: To describe the management of patients with AF anticoagulated with warfarin in community-based practise.

Methods: We enrolled 3396 patients from 101 community-based practises in 38 states.

Perceptions of race/ethnicity-based discrimination: a review of measures and evaluation of their usefulness for the health care setting.

Background: To assess discrimination in health care, reliable, valid, and comprehensive measures of racism/discrimination are needed.

Objective: To review literature on measures of perceived race/ethnicity-based discrimination and evaluate their characteristics and usefulness in assessing discrimination from health care providers.

Methods: Literature review of measures of perceived race/ethnicity-based discrimination (1966-2007), using MEDLINE, PsycINFO, and Social Science Citation Index.

Longitudinal approaches to evaluate health care quality and outcomes: the Veterans Health Administration diabetes epidemiology cohorts.

Objective: The Institute of Medicine proposed recently that, while current pay for performance measures should target multiple dimensions of care, including measures of technical quality, they should transition toward longitudinal and health-outcome measures across systems of care. This article describes the development of the Diabetes Epidemiology Cohorts (DEpiC), which facilitates evaluation of intermediate "quality of care" outcomes and surveillance of adverse outcomes for veterans with diabetes served by the Veterans Health Administration (VHA) over multiple years.

Methods: The Diabetes Epidemiology Cohorts is a longitudinal research database containing records for all diabetes patients in the VHA since 1998.

Understanding uncontrolled hypertension: is it the patient or the provider?

The relative contributions of adherence and treatment intensity to blood pressure (BP) control are not well understood. The authors studied patients with uncontrolled hypertension (N=410) from 3 primary care clinics in the Veterans Affairs (VA) medical system. A questionnaire was used to assess patient adherence to therapy, and VA system pharmacy fills were used to assess the intensity of the antihypertensive regimen.

The accuracy of clinician perceptions of "usual" blood pressure control.

Background: The term "clinical inertia" is used to describe the failure to manage a chronic condition aggressively enough to bring it under control. The underlying mechanisms for clinical inertia remain poorly understood.

Objective: To describe one potential mechanism for clinical inertia, seen through the lens of clinician responses to a computerized hypertension reminder.

Survival in end stage renal disease: calcium carbonate vs. sevelamer.

Background And Objective: There is concern regarding long-term excess calcium intake in end-stage renal disease populations. Because calcium carbonate is an over-the-counter (OTC) medication, few studies have been able to track its use. The Veterans Health Administration (VA) tracks national pharmacy data for both OTC and prescription drugs.

Pharmacoepidemiology in community-dwelling elderly taking antiepileptic drugs.

This study used the national inpatient, outpatient, and pharmacy databases from the US Veterans Health Administration to examine prescribing patterns for older patients with epilepsy and to determine the factors associated with receiving recommended antiepileptic drugs (AEDs) such as lamotrigine, gabapentin, or carbamazepine. Among patients with epilepsy, the AED monotherapy most prescribed was phenytoin (70%), followed by phenobarbital (17%). While the rate of phenytoin use was similar for both previously and newly diagnosed patients with epilepsy, phenobarbital was less commonly used in newly diagnosed patients.

Modulation of nucleosome dynamics in Huntington's disease.

Transcriptional dysregulation and aberrant chromatin remodeling are central features in the pathology of Huntington's disease (HD). In order to more fully characterize these pathogenic events, an assessment of histone profiles and associated gene changes were performed in transgenic N171-82Q (82Q) and R6/2 HD mice. Analyses revealed significant chromatin modification, resulting in reduced histone acetylation with concomitant increased histone methylation, consistent with findings observed in HD patients.

Hypertensive patients' race, health beliefs, process of care, and medication adherence.

Background: African Americans have higher rates of hypertension and worse blood pressure (BP) control than Whites, and poorer medication adherence may contribute to this phenomenon. We explored associations among patients' race, self-reported experiences with clinicians, attitudes and beliefs about hypertension, and ultimately, medication adherence, among a sample with no racial disparities in BP control, to determine what lessons we could learn from patients and providers in this setting.

Methods: We recruited 793 White and African-American (58%) patients previously diagnosed with hypertension from 3 VA medical centers to participate in survey assessments of each of the above dimensions, subsequent to a primary care clinic visit.

Functional status outcomes among white and African-American cardiac patients in an equal access system.

Background: Racial disparities exist in invasive cardiac procedure use and, sometimes, in subsequent functional status outcomes. We explored whether racial differences in functional outcomes occur in settings where differences in access and treatment are minimized.

Methods: We conducted a prospective observational cohort study of 1022 white and African-American cardiac patients with positive nuclear imaging studies in 5 VA hospitals.

Translational therapeutic strategies in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a clinically severe and fatal neurodegenerative disease characterized by a loss of both upper and lower motor neurons, resulting in progressive muscle loss and paralysis. While the exact cause of neuronal death in ALS remains unknown, it is proposed that multiple molecular defects trigger motor neuron cell death. These pathophysiological mechanisms include oxidative stress, mitochondrial impairment, protein aggregation, glutamate cytotoxicity, transcription dysfunction, inflammation, and apoptotic cell death.

Dose ranging and efficacy study of high-dose coenzyme Q10 formulations in Huntington's disease mice.

There is substantial evidence that a bioenergetic defect may play a role in the pathogenesis of Huntington's Disease (HD). A potential therapy for remediating defective energy metabolism is the mitochondrial cofactor, coenzyme Q10 (CoQ10). We have reported that CoQ10 is neuroprotective in the R6/2 transgenic mouse model of HD.

The impact of enhanced incentives on vocational rehabilitation outcomes for dually diagnosed veterans.

This study evaluated the efficacy of adding contingency management techniques to vocational rehabilitation (VR) to improve treatment outcome as measured by entry into competitive employment. Nineteen dually diagnosed veterans who entered VR in the Veterans' Administration's compensated work therapy (CWT) program were randomly assigned to CWT (n = 8) or to CWT with enhanced incentives (n = 11). Over the first 16 weeks of rehabilitation, those in the incentives condition could earn up to dollar 1,006 in cash for meeting two sets of clinical goals: (a) remaining abstinent from drugs and alcohol and (b) taking steps to obtain and maintain a competitive job.

The therapeutic role of creatine in Huntington's disease.

Huntington's disease (HD) is an autosomal dominant and fatal neurological disorder characterized by a clinical triad of progressive choreiform movements, psychiatric symptoms, and cognitive decline. HD is caused by an expanded trinucleotide CAG repeat in the gene coding for the protein huntingtin. No proven treatment to prevent the onset or to delay the progression of HD currently exists.

Documenting pathways to dementia care: relative validity of questionnaire, interview, and medical record formats.

One of the shortcomings of the pathways-to-care literature is the lack of empirical support for the validity of the data collection methods. This study uses three common formats to collect retrospective pathways-to-care data for adults who have been diagnosed with possible or probable Alzheimer's disease (AD) and compares indicators to evaluate their relative validity. Forty family caregivers of adults diagnosed with possible or probable AD were recruited from the caregiver registry of the Boston University Alzheimer's Disease Core Center (BU ADCC).

Agreement between administrative data and patients' self-reports of race/ethnicity.

Objectives: We examined agreement of administrative data with self-reported race/ethnicity and identified correlates of agreement.

Methods: We used Veterans Affairs administrative data and VA 1999 Large Health survey race/ethnicity data.

Results: Relatively low rates of agreement (approximately 60%) between data sources were largely the result of administrative data from patients whose race/ethnicity was unknown, with least agreement for Native American, Asian, and Pacific Islander patients.

Creatine therapy provides neuroprotection after onset of clinical symptoms in Huntington's disease transgenic mice.

While there have been enormous strides in the understanding of Huntington's disease (HD) pathogenesis, treatment to slow or prevent disease progression remains elusive. We previously reported that dietary creatine supplementation significantly improves the clinical and neuropathological phenotype in transgenic HD mice lines starting at weaning, before clinical symptoms appear. We now report that creatine administration started after onset of clinical symptoms significantly extends survival in the R6/2 transgenic mouse model of HD.

Professional caregivers for patients with dementia: predictors of job and career commitment.

The purpose of this study is to identify what factors predict job and career commitment among professional caregivers working with patients with dementia. A secondary analysis was completed using data collected from 77 professional caregivers working in residential dementia special care programs. The findings suggest that professional caregivers' commitment to their jobs and careers is most closely related to their level of involvement in the interpersonal aspects of the work, the degree to which they feel personal growth or benefit, and the level of burden that their work generates.

Cytochrome C and caspase-9 expression in Huntington's disease.

There is increasing evidence implicating apoptosis-mediated cell death in the pathogenesis of neurodegenerative diseases. One important event in the apoptotic cascade is the release of cytochrome c by mitochondria into the cytoplasm, activating caspase-9, leading to the subsequent activation of downstream executioner caspases. In the present study, we examined the distribution of cytochrome c and caspase-9 in Huntington's disease (HD) patients and in a transgenic model of HD (R6/2 line).

Racial differences in health-related beliefs, attitudes, and experiences of VA cardiac patients: scale development and application.

Objectives: To deternine whether there are racial differences in patients' health-related attitudes, beliefs, and experiences regarding invasive cardiac procedures, and to develop psychometrically and conceptually valid scales and single items to assess these dimensions.

Methods: A survey was designed and administered to 854 white and black patients with ischemic heart disease at five VA medical centers. Patients were queried about the domains proposed to be important to treatment decision making by the Health Decision Model: sociodemographic characteristics, social interactions, health care experiences, patient preferences for care, knowledge about diseases and potential treatments, and health beliefs.

Therapeutic efficacy of EGb761 (Gingko biloba extract) in a transgenic mouse model of amyotrophic lateral sclerosis.

EGb761 is a standardized extract of green Gingko biloba, which exerts protective effects against mitochondrial damage and oxidative stress. We examined whether oral administration of 0.022% or 0.