Statins Underused in Veterans with Severely Elevated Cholesterol

MedicalResearch.com Interview with:

Fatima Rodriguez, MD, MPH Division of Cardiovascular Medicine Stanford University Stanford, CA 94305-5406,

Dr. Rodriguez

Fatima Rodriguez, MD, MPH
Division of Cardiovascular Medicine
Stanford University
Stanford, CA 94305-5406,

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Individuals with LDL-cholesterol levels above 190mg/dL are often underdiagnosed and undertreated, yet remain at high-risk of cardiovascular disease. In a national sample of veterans, we identified over 60,000 patients who met criteria for uncontrolled, severe hypercholesterolemia based on an index LDL-C value ≥190mg/dL. We found that only half of these high-risk patients are being treated with statins, and less than 10% are on high-intensity statin therapy as recommended by the 2013 ACC/AHA guidelines. We also found that both older and younger patients were less likely to be treated with statins. Women were less likely to be treated with statins, whereas minority groups and those with a diagnosis of hypertension were more likely to be treated. Disparities in use of statins were also noted by geographic region and hospital teaching status. Continue reading

Vets with Head Injury More Likely To Develop Dementia

MedicalResearch.com Interview with:
Deborah E. Barnes, PhD, MPH Professor, UCSF Weill Institute for Neurosciences Departments of Psychiatry and Epidemiology & Biostatistics University of California, San Francisco: http://profiles.ucsf.edu/deborah.barnes Research Health Sciences Specialist, San Francisco VA Medical Center Senior Investigator, Tideswell at UCSF: http://www.tideswellucsf.org/ Deborah E. Barnes, PhD, MPH

Professor, UCSF Weill Institute for Neurosciences
Departments of Psychiatry and Epidemiology & Biostatistics
University of California, San Francisco: http://profiles.ucsf.edu/deborah.barnes
Research Health Sciences Specialist
San Francisco VA Medical Center

MedicalResearch.com: What is the background for this study? What are the main findings?

  • Previous studies have found a link between moderate to severe head injuries and increased dementia risk.
  • The association between mild head injuries and dementia – especially mild head injury that doesn’t result in loss of consciousness – is less well established
  • We examined the association between mild head injuries with and without loss of consciousness and dementia diagnoses in nearly 360,000 Veterans receiving care in the VA health care system.
  • We found that Veterans with a head injury diagnoses were two to four times more likely to be diagnosed with dementia than those without head injury diagnoses.
  • The risk of dementia diagnosis was doubled in Veterans who experienced head injury without loss of consciousness compared to those with no head injury. 

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Focusing On Employment Early Improves Success In Veterans with PTSD

MedicalResearch.com Interview with:

Dr. Lori Davis, MD Research and Development Service, Tuscaloosa Veterans Affairs (VA) Medical Center, Department of Psychiatry, School of Medicine, University of Alabama, Tuscaloosa Tuscaloosa, Alabama

Dr. Davis

Dr. Lori Davis, MD
Research and Development Service, Tuscaloosa Veterans Affairs (VA) Medical Center,
Department of Psychiatry, School of Medicine, University of Alabama, Tuscaloosa
Tuscaloosa, Alabama

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Symptoms of posttraumatic stress disorder (PTSD) interfere with a person’s ability to function at work, making it harder to stay employed and establish oneself in a career.  Veterans with PTSD are uniquely challenged given their motivation to serve others, be leaders and not be generally receptive to reaching out for help.

Conventional wisdom about PTSD and employment has traditionally been to first commit to treatment, learn coping skills, manage one’s symptoms and then reintegrate into mainstream employment. However, this view is being transformed by our research that suggests a more assertive recovery-oriented approach to the treatment of PTSD that involves returning to meaningful competitive employment as soon as possible.

This study compared Evidence-based Supported Employment (also known as Individual Placement and Support or IPS) integrated within PTSD treatment teams to the treatment as usual Transitional Work model offered within the VA. This multisite trial demonstrated significantly greater effectiveness of the IPS-supported employment over stepwise, transitional work vocational rehabilitation for Veterans living with chronic PTSD.

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Is Trust in Mental Health Clinicians Affected Among Patients Who Access Clinical Notes Online?

MedicalResearch.com Interview with:

Steven K. Dobscha, M.D. Professor, Department of Psychiatry, OHSU Director, VAPORHCS Center to Improve Veteran Involvement in Care Oregon Health & Science University

Dr. Dobscha

Steven K. Dobscha, M.D.
Professor, Department of Psychiatry, OHSU
Director, VAPORHCS Center to Improve Veteran Involvement in Care
Oregon Health & Science University

MedicalResearch.com: What is the background for this study? 

Response: Several health care systems across the United States now offer patients online access to all of their clinical notes (sometimes referred to as progress notes) through electronic health record portals; this type of access has been referred to as OpenNotes (see www.opennotes.org for more information on the national OpenNotes initiative). Veterans have been able to use OpenNotes in the Veterans Health Care (VHA) system since 2013. However, some individuals have expressed concern that online access to clinical notes related to mental health could cause some patient harms.

We are conducting a VA-funded research project with several objectives:
1) to examine benefits and unintended negative consequences of OpenNotes use as perceived by veterans receiving VHA mental health care and by VHA mental health clinicians, and
2) to develop and evaluate brief web-based courses designed to help veterans and clinicians use OpenNotes in ways that optimize Veteran-clinician collaboration and minimize unintended consequences.

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LEAN Methodologies Improved Wait Time In VA Medical Center

MedicalResearch.com Interview with:

Andrew C. Eppstein, MD, FACS Assistant Professor of Clinical Surgery Indiana University School of Medicine Department of Surgery, Division of General Surgery Richard L. Roudebush VA Medical Center Indianapolis, Indiana

Dr. Andrew Eppstein

Andrew C. Eppstein, MD, FACS
Assistant Professor of Clinical Surgery
Indiana University School of Medicine
Department of Surgery, Division of General Surgery
Richard L. Roudebush VA Medical Center
Indianapolis, Indiana

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: A few years ago we encountered long wait times for patients undergoing elective general surgery in our tertiary care VA medical center. Demand had grown and our existing systems were not able to accommodate surgical patients in a timely fashion. By fiscal year (FY) 2012, our wait times averaged 33 days, though patients with malignancies would be moved to the head of the line, pushing more elective cases further back.

To address rising demand and worsening wait times, our Surgery Service convened an analysis of our processes using Lean methodology in collaboration with the Systems Redesign Service. Multidisciplinary meetings were held in 2013 to analyze inefficiencies in the current system and ways to address them to create a streamlined, ideal system. The collaborations included surgeons, nurses, ancillary staff, operating room and sterile processing staff, and hospital administration. Projects were rolled out stepwise in mid-2013 under General Surgery, the busiest surgical service at our institution.

We noted a sharp decline in patient wait times after initiation of reforms such as improved OR flexibility, scheduling process changes, standardization of work within the department, and improved communication practices. These wait times dropped to 26 days in FY 2013 and further to 12 days in FY 2014, while operating volume and overall outpatient evaluations increased, with decreased no-shows to clinic. Our decreased wait times were sustained through the remainder of the observed period.

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Veterans with PTSD Have High Prevalence of Sleep Disorders

MedicalResearch.com Interview with:

Jim Burch, MS, PhD Associate Professor Dept. of Epidemiology & Biostatistics Cancer Prevention & Control Program Arnold School of Public Health University of South Carolina, Columbia, SC and Health Science Specialist WJB Dorn Department of Veterans Affairs Medical Center Columbia, SC

Dr. Jim Burch

Jim Burch, MS, PhD
Associate Professor
Dept. of Epidemiology & Biostatistics
Cancer Prevention & Control Program
Arnold School of Public Health
University of South Carolina, Columbia, SC and
Health Science Specialist
WJB Dorn Department of Veterans Affairs Medical Center
Columbia, SC

MedicalResearch.com: What is the background for this study?

Response: Over 21 million Veterans live in the U.S., and nearly 9 million of them receive healthcare through the Veterans Health Administration, which is the largest integrated healthcare system in the U.S. The military population is particularly vulnerable to sleep disturbances due to their work schedules, living conditions, and other physical and psychological factors that accompany their jobs. However, previous studies have not comprehensively described the scope and characteristics of sleep disorders among Veterans. Sleep is considered a physiological necessity. Inadequate sleep has been associated with a wide range of adverse health outcomes, including an increased risk of chronic diseases such as heart disease and cancer, psychiatric disorders, reduced quality of life, and increased mortality.

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Restless Legs Linked to Higher Mortality in US Veterans

Miklos Z Molnar, MD, PhD, FEBTM, FERA, FASN Associate Professor of Medicine Division of Nephrology, Department of Medicine University of Tennessee Health Science Center Memphis, TN, 38163

MedicalResearch.com Interview with:
Miklos Z Molnar, MD, PhD, FEBTM, FERA, FASN
Associate Professor of Medicine
Division of Nephrology, Department of Medicine
University of Tennessee Health Science Center
Memphis, TN, 38163

Medical Research: What is the background for this study? What are the main findings?

Response: Restless legs syndrome is a common sleep disorder, but there is a paucity of large cohort studies examining the association of restless legs syndrome with clinical outcomes, including all-cause mortality, incident coronary heart disease, stroke and chronic kidney disease.

From a nationally representative prospective cohort of over 3 million US veterans [93% male, median follow-up time of 8.1 years (interquartile range: 7.0–8.5years)] with baseline estimated glomerular filtration rate ≥60 mL/min/1.73 m2, a propensity-matched cohort of 7392 patients was created, and the association between incident restless legs syndrome and the following was examined:

  • (1) all-cause mortality;
  • (2) incident coronary heart disease;
  • (3) incident strokes; and
  • (4) incident chronic kidney disease defined as estimated glomerular filtration rate <60 mL/min/1.73 m2.

Compared with restless legs syndrome-negative patients, incident restless legs syndrome was associated with 88% higher mortality risk [hazard ratio and 95% confidence interval: 1.88 (1.70–2.08)], and almost four times higher risk of coronary heart disease and stroke [hazard ratio: 3.97 (3.26–4.84) and 3.89 (3.07–4.94), respectively]. The risk of incident chronic kidney disease was also significantly higher in incident restless legs syndrome patients [hazard ratio: 3.17 (2.74–3.66)] compared with restless legs syndrome-negative counterparts. These associations was independent from other confounders such as demographic data, comorbidities and other sleep disorders (sleep apnea and periodic limb movements in sleep).

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ESCAPE Study Evaluates Stepped Care For Chronic Pain in Veterans

Matthew J. Bair, MD, MS Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication Richard L. Roudebush Veterans Affairs Medical Center, Department of Medicine, Indiana University School of Medicine, Health Services Research, Regenstrief Institute, Inc, Indianapolis, IndianaMedicalResearch.com Interview with:
Matthew J. Bair, MD, MS
Research Service, Veterans Affairs Health Services Research and Development, Center for Health Information and Communication
Richard L. Roudebush Veterans Affairs Medical Center,
Department of Medicine, Indiana University School of Medicine, Health Services Research, Regenstrief Institute, Inc, Indianapolis, Indiana

MedicalResearch.com: What is the background for this study?

Dr. Bair: Despite the prevalence and functional, psychological, and economic impact of chronic pain, there have been few intervention studies to treat chronic pain in Veterans.

MedicalResearch.com: What are the main findings?

Dr. Bair: A stepped-care intervention that combined analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in Veterans with chronic musculoskeletal pain.

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Lesbian and Bisexual Veterans Have Increased Risk of Alcohol Misuse

Keren Lehavot, PhD Research Clinical Psychologist VA Puget Sound Health Care System Assistant Professor Department of Psychiatry & Behavioral Sciences University of WashingtonMedicalResearch.com Interview with:
Keren Lehavot, PhD
Research Clinical Psychologist
VA Puget Sound Health Care System
Assistant Professor
Department of Psychiatry & Behavioral Sciences
University of Washington

Medical Research: What are the main findings of the study?

Dr. Lehavot: Alcohol misuse is a significant public health concern among women living in the U.S. Women who have served in the military are a unique population who report relatively high rates of hazardous drinking, and those who identify as lesbian or bisexual (LB) may be at especially high risk for alcohol misuse. While previous research suggests that lesbian or bisexual veterans report higher rates of alcohol misuse than their heterosexual counterparts, mediators that might explain this disparity have not been identified. To that end, we examined the role of civilian and military traumas and mental health symptoms (i.e., depression, post-traumatic stress disorder) in explaining disparities in alcohol misuse between sexual minority and heterosexual women veterans across the U.S. Women veterans were recruited using the Internet to participate in an online, anonymous, national survey.

Findings indicated that lesbian or bisexual veterans scored significantly higher on an alcohol misuse measure than heterosexual women veterans. LB veterans also reported higher rates of childhood trauma, physical victimization in adulthood both during the military and as a civilian, and mental health symptoms, partly accounting for their higher rates of alcohol misuse.

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Combat Factors Associated With Pain and Opioid Use Among Veterans

MedicalResearch.com Interview with:Walter Reed Army Institute of ResearchDr. Robin L. Toblin
LCDR Robin L. Toblin, PhD, MPH (USPHS)
Clinical Research Psychologist
Walter Reed Army Institute of Research


MedicalResearch: What are the main findings of your study?

Dr. Toblin: Our study focused on chronic pain and opioid use in an infantry brigade three months after returning from war. We surveyed 2597 soldiers. The main findings showed that 44.0% reported experiencing chronic pain (pain for three months or longer) and 15.1% reported taking an opioid pain reliever in the past month. We also found that among those using opioids, 44.1% reported no or mild pain. Combat factors were associated with pain and opioid use, especially combat injuries.

Based on that, the key message of our findings is that war is hard on the body. We’re concerned about the level of pain and the levels of opioid use among infantry soldiers.

MedicalResearch: Were any of the findings unexpected?

Dr. Toblin:  We were surprised by the high rate of chronic pain. We know that a lot of soldiers come home injured and that war is hard on the body, but we didn’t expect nearly half of these young, and otherwise healthy, men and women to report chronic pain. We were also surprised that almost half of those using opioids reported no or mild pain given that opioids should generally be prescribed only for moderate to severe pain because of their addictive nature. Our data doesn’t show, though, if that’s due to acute pain, medications working well, or misuse.

MedicalResearch: What should clinicians and patients take away from your report?

Dr. Toblin:  A takeaway for clinicians is that while the current Army practice guidelines for the use of opioids to treat chronic pain recommend caution in their prescription, the Army and other services should examine prescription practices to ensure that opioid use is consistent with those guidelines and standards of care. They should also ensure that nonopioid alternatives are considered whenever possible due to their addictive nature. Further, they should continue enacting the recommendations from the Army’s 2010 Pain Management Task Force Report and continue enrolling as many returning soldiers in the Army’s comprehensive pain management program as possible.

For soldiers experiencing pain, they should address their pain as early as possible at military treatment facilities before the pain becomes more difficult to treat. They should also request nonopioid alternatives when possible.

MedicalResearch: What recommendations do you have for future research as a result of this study?

Dr. Toblin:  We hope that future studies could examine both use and misuse and the reasons for people’s use within a survey. It would also be helpful if soldiers’ pharmacy and pain management visits could be linked to surveys that addressed pain. Some other research our group hopes to examine using our available data includes how the prevalence and risk factors for chronic pain and opioid use changes over time and the relationship between chronic pain and sleep, another major concern for the Army.

Citation:

Toblin RL, Quartana PJ, Riviere LA, Walper K, Hoge CW. Chronic Pain and Opioid Use in US Soldiers After Combat Deployment. JAMA Intern Med. Published online June 30, 2014. doi:10.1001/jamainternmed.2014.2726.