Melissa Skanderson

VA Long Beach Healthcare System, Long Beach, California, United States

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Publications (46)206.47 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Women veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers. Secondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs. Of the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01-1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs. The main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics. Published by Elsevier Inc.
    Women s Health Issues 11/2014; 24(6):605-12. · 1.61 Impact Factor
  • Clinical Infectious Diseases 10/2014; · 9.42 Impact Factor
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    ABSTRACT: Background Despite American Heart Association recommendations of diet/lifestyle modification and statin therapy to achieve low-density lipoprotein cholesterol (LDL) control, women are less likely than men to be screened and achieve treatment goals. This study determined whether the provider and patient response to electronic medical record (EMR) notification of an elevated LDL varied by patient sex in veterans. Methods Provider responses to EMR clinical reminders for an elevated LDL (≥100 mg/dL) were assessed in men (n = 40,738) and women (n = 1,025) veterans with ischemic heart disease or diabetes between October 2008 and September 2009. Responses were classified into four types: 1) Whether the patient refused medication, 2) the provider ordered or adjusted medication, 3) treatment was deferred/medications were not changed, or 4) medications were contraindicated. Logistic regression with generalized estimating equations was used to compare clinical reminder responses between men and women patients. Findings Providers were less likely to order or adjust medications for women (adjusted odds ratio [OR], 0.75; 95% CI, 0.63, 0.88) and women were more likely than men to refuse medication (adjusted OR, 1.71; 95% CI, 1.34, 2.17). These associations were not modified by degree of LDL elevation or use of lipid-lowering medications. Conclusion These results indicate that poorer cholesterol control in at risk women is likely a consequence of both provider and patient factors.
    Women s Health Issues 10/2014; 24(5):575–580. · 1.61 Impact Factor
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    ABSTRACT: HIV infection is associated with increased risk of cardiovascular disease (CVD) in men. Whether HIV is an independent risk factor for CVD in women has not yet been established.
    Journal of the American Heart Association. 09/2014; 3(5).
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    ABSTRACT: Whether patients receive guideline-concordant opioid therapy (OT) is largely unknown and may vary based on provider and patient characteristics. We assessed the extent to which HIV-infected and uninfected patients initiating long-term (≥90-days) OT received care concordant with American Pain Society/American Academy of Pain Medicine and Department of Veterans Affairs/Department of Defense guidelines by measuring receipt of 17 indicators during the first 6 months of OT. Of 20,753 patients, HIV-infected patients (n= 6,604) were more likely than uninfected patients to receive a primary care provider (PCP) visit within 1-month (52.0% vs. 30.9%) and 6-months (90.7% vs. 73.7%) and urine drug tests (UDTs) within 1-month (14.8% vs. 11.5%) and 6-months (19.5% vs. 15.4%; all p < .001). HIV-infected patients were also more likely to receive OT concurrent with sedatives (24.6% vs. 19.6%) and an untreated substance use disorder (SUD; 21.6% vs. 17.2%). Among both patient groups, only modest changes in guideline-concordance were observed over time: UDTs and OT concurrent with untreated SUDs increased, while sedative co-prescriptions decreased (all p for trend < .001). Over a 10-year period, on average, patients received no more than 40% of recommended indicators. OT guideline-concordant care is rare in primary care, varies by patient/provider characteristics, and has undergone few changes over time.
    The journal of pain : official journal of the American Pain Society. 08/2014;
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    ABSTRACT: Background: HIV is associated with end-organ diseases of aging via unclear mechanisms. Longitudinally assessing how HIV infection and ART initiation affect biomarkers of end organ function/disease could clarify these mechanisms. We investigated longitudinal changes in clinical biomarkers following 1) HIV infection and 2) ART initiation with evidence of viral suppression. Methods: Cohort: Veterans Aging Cohort Study Virtual Cohort (VACS VC). VACS VC is a longitudinal cohort of HIV infected (HIV+) and race-ethnicity, sex, age, and clinical site-matched uninfected Veterans enrolled in the same calendar year. Inclusion criteria: a negative and successively positive (>six months) HIV antibody test. We used Wilcoxon signedrank tests to analyze 1) the effect of HIV infection on lipids, renal, hepatic and hematologic/cardiovascular biomarkers and 2)whether ART initiation with HIV-1 RNA<500 cpm reverts any changes back to pre-HIV levels. Results: 422 Veterans had at least 1 biomarker measurement available prior to HIV infection and prior to ART initiation. 297 had at least 1 biomarker measurement available prior to HIV infection and after ART initiation with evidence of viral suppression. Mean age prior to HIV infection was 43 years. HIV infection was associated with reduction in total cholesterol, HDL cholesterol, LDL cholesterol, serum albumin, ALT, platelet count, hemoglobin and elevation of FIB-4 score and triglycerides. These changes occurred without significant changes in BMI. ART initiation (with HIV-1 RNA<500cpm) did not reverse alteration in triglycerides, LDL cholesterol, hemoglobin, or FIB-4 to pre-HIV infection levels. Conclusions: HIV infection is associated with longitudinal changes in serum levels of several biomarkers of end-organ function/disease and mortality. Multiple biomarkers (triglycerides, LDL cholesterol, hemoglobin, and FIB-4 ) remain altered from levels prior to HIV infection levels even following inititiation of ART and evidence of viral suppression. These results give insights into underlying mechanisms of increased risk for aging-related chronic diseases in the context of HIV infection.
    Current HIV Research 07/2014; 12(1):50-9. · 2.14 Impact Factor
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    ABSTRACT: Abstract Background: Women Veterans who suffered military sexual trauma (MST) may be at high risk for unintended pregnancy and benefit from contraceptive services. The objective of this study is to compare documented provision of contraceptives to women Veterans using the Department of Veterans Affairs (VA) health system who report or deny MST. Methods: This retrospective cohort study included women Veterans aged 18-45 years who served in Operation Enduring or Iraqi Freedom and had at least one visit to a VA medical center between 2002 and 2010. Data were obtained from VA administrative and clinical databases. Chi-squared tests and logistic regression were conducted to evaluate the association between MST, ascertained by routine clinical screening, and first documented receipt of hormonal or long-acting contraception. Results: Of 68,466 women Veterans, 13% reported, 59% denied and 28% had missing data for the MST screen. Among the entire study cohort, 30% of women had documented receipt of a contraceptive method. Women reporting MST were significantly more likely than those denying MST to receive a method of contraception (adjusted odds ratio [aOR] 1.12, 95% confidence interval [CI] 1.07-1.18) including an intrauterine device (odds ratio [OR] 1.29, 95% CI 1.17-1.41) or contraceptive injection (OR 1.17, 95% CI 1.05-1.29). Women who were younger, unmarried, seen at a women's health clinic, or who had more than one visit were more likely to receive contraception. Conclusions: A minority of women Veterans of reproductive age receive contraceptive services from the VA. Women Veterans who report MST, and particularly those who seek care at VA women's health clinics, are more likely to receive contraception.
    Journal of Women's Health 05/2014; · 1.90 Impact Factor
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    ABSTRACT: HIV-infected patients may be at particular risk for acetaminophen-induced hepatotoxicity, but acetaminophen use in the context of liver injury has been incompletely examined among HIV-infected patients. Among a sample of HIV-infected patients, we aimed to determine acetaminophen exposure, assess the cross-sectional association between acetaminophen exposure and advanced hepatic fibrosis, and determine whether factors associated with acetaminophen exposure varied by HCV status. We conducted a cross-sectional analysis of the Veterans Aging Cohort Study. Advanced hepatic fibrosis was defined as a FIB-4 > 3.25, a composite score calculated based on age, alanine aminotransferase, aspartate aminotransferase, and platelet count. Multivariable ordered polytomous logistic regression was used to determine the association between FIB-4 status and acetaminophen exposure stratified by HCV status. Among HIV-infected patients (n = 14 885), 31% received at least one acetaminophen prescription. Among those receiving acetaminophen, acetaminophen overuse was common among both HIV-monoinfected and HIV/HCV-coinfected patients (846 [31%] vs 596[32%], p = 0.79). After stratifying by HCV status, those with evidence of advanced liver fibrosis were equally likely to be exposed to acetaminophen. Furthermore, HIV-monoinfected patients with an alcohol use disorder were more likely to have acetaminophen overuse (OR [95%CI] = 1.56 [1.21-2.02]). Strategies to minimize acetaminophen exposure, especially for HIV-monoinfected patients, are warranted. Copyright © 2013 John Wiley & Sons, Ltd.
    Pharmacoepidemiology and Drug Safety 12/2013; 22(12):1352-1356. · 2.90 Impact Factor
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    ABSTRACT: IMPORTANCE Whether people infected with human immunodeficiency virus (HIV) are at an increased risk of acute myocardial infarction (AMI) compared with uninfected people is not clear. Without demographically and behaviorally similar uninfected comparators and without uniformly measured clinical data on risk factors and fatal and nonfatal AMI events, any potential association between HIV status and AMI may be confounded. OBJECTIVE To investigate whether HIV is associated with an increased risk of AMI after adjustment for all standard Framingham risk factors among a large cohort of HIV-positive and demographically and behaviorally similar (ie, similar prevalence of smoking, alcohol, and cocaine use) uninfected veterans in care. DESIGN AND SETTING Participants in the Veterans Aging Cohort Study Virtual Cohort from April 1, 2003, through December 31, 2009. PARTICIPANTS After eliminating those with baseline cardiovascular disease, we analyzed data on HIV status, age, sex, race/ethnicity, hypertension, diabetes mellitus, dyslipidemia, smoking, hepatitis C infection, body mass index, renal disease, anemia, substance use, CD4 cell count, HIV-1 RNA, antiretroviral therapy, and incidence of AMI. MAIN OUTCOME MEASURE Acute myocardial infarction. RESULTS We analyzed data on 82 459 participants. During a median follow-up of 5.9 years, there were 871 AMI events. Across 3 decades of age, the mean (95% CI) AMI events per 1000 person-years was consistently and significantly higher for HIV-positive compared with uninfected veterans: for those aged 40 to 49 years, 2.0 (1.6-2.4) vs 1.5 (1.3-1.7); for those aged 50 to 59 years, 3.9 (3.3-4.5) vs 2.2 (1.9-2.5); and for those aged 60 to 69 years, 5.0 (3.8-6.7) vs 3.3 (2.6-4.2) (P < .05 for all). After adjusting for Framingham risk factors, comorbidities, and substance use, HIV-positive veterans had an increased risk of incident AMI compared with uninfected veterans (hazard ratio, 1.48; 95% CI, 1.27-1.72). An excess risk remained among those achieving an HIV-1 RNA level less than 500 copies/mL compared with uninfected veterans in time-updated analyses (hazard ratio, 1.39; 95% CI, 1.17-1.66). CONCLUSIONS AND RELEVANCE Infection with HIV is associated with a 50% increased risk of AMI beyond that explained by recognized risk factors.
    JAMA Internal Medicine 03/2013; · 13.25 Impact Factor
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    ABSTRACT: Background. The Veterans Aging Cohort Study (VACS) Index is associated with allcause mortality, hospitalization and medical intensive care unit admission, and functional performance in HIV infected individuals. It is also associated with markers of inflammation and may thus reflect physiologic frailty. The current analysis explores the association between physiologic frailty, as assessed by the VACS Index, and fragility fracture.Methods. HIV infected men from VACS were included. We identified hip, vertebral, and upper arm fractures using ICD-9-CM codes. We used Cox regression models to assess fragility fracture risk factors. Covariates included the VACS Index and its components (age, hepatitis C status, FIB-4, estimated glomerular filtration rate, hemoglobin, HIV-RNA, CD4 count), as well as previously identified risk factors for fragility fractures.Results. We included 40,115 HIV infected male Veterans. They experienced 588 first fragility fractures over 6.0±3.9 years. The VACS Index score (HR: 1.15; 95% CI: 1.11, 1.19), white race (1.92; 1.63, 2.28), body mass index (0.94; 0.92, 0.96), alcohol-related diagnoses (1.65; 1.26, 2.17), cerebrovascular disease (1.95; 1.14, 3.33), proton pump inhibitor (PPI) use (1.87; 1.54, 2.27), and protease inhibitor use (1.25; 1.04, 1.50) were Powered by Editorial Manager® and Preprint Manager® from Aries Systems Corporation associated with fracture risk. Components of the VACS Index score most strongly associated with fracture risk were age (1.40; 1.27, 1.54), log HIVRNA (0.91; 0.88, 0.94) and hemoglobin (0.82; 0.78, 0.86).Conclusions. Frailty, as measured by the VACS Index, is an important predictor of fragility fractures among HIV infected male Veterans.
    Clinical Infectious Diseases 02/2013; · 9.42 Impact Factor
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    ABSTRACT: Contraceptive use among women Veterans may not be adequately captured using administrative and pharmacy codes. Clinical progress notes may provide a useful alternative. The objectives of this study were to validate the use of administrative and pharmacy codes to identify contraceptive use in Veterans Health Administration data, and to determine the feasibility and validity of identifying contraceptive use in clinical progress notes. The study included women Veterans who participated in the Women Veterans Cohort Study, enrolled in the Veterans Affairs Connecticut Health Care System, completed a baseline survey, and had clinical progress notes from one year prior to survey completion. Contraceptive ICD-9-CM codes, V-codes, CPT codes, and pharmacy codes were identified. Progress notes were annotated to identify contraceptive use. Self-reported contraceptive use was identified from a baseline survey of health habits and healthcare practices and utilization. Sensitivity, specificity, and positive predictive value were calculated comparing administrative and pharmacy contraceptive codes and progress note-based contraceptive information to self-report survey data. Results showed that administrative and pharmacy codes were specific but not sensitive for identifying contraceptive use. For example, oral contraceptive pill codes were highly specific (1.00) but not sensitive (0.41). Data from clinical progress notes demonstrated greater sensitivity and comparable specificity. For example, for oral contraceptive pills, progress notes were both specific (0.85) and sensitive (0.73). Results suggest that the best approach for identifying contraceptive use, through either administrative codes or progress notes, depends on the research question.
    Perspectives in health information management / AHIMA, American Health Information Management Association 01/2013; 10:1e.
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    ABSTRACT: Rural-dwelling persons with HIV infection face barriers to maintaining high levels of antiretroviral adherence. We compared adherence among 1,782 rural and 18,519 urban veterans initiating antiretroviral therapy in the Veterans Affairs (VA) healthcare system in the United States between 1998 and 2007. Residence was determined using rural urban commuting area codes and adherence using pharmacy-based refill measures. The median proportion of days covered (PDC) by combination antiretroviral therapy in the first year of treatment ranged from 0.72 among urban residents to 0.79 among rural-small town/remote residents (p < 0.0001). In multivariable logistic regression, predictors of high adherence (PDC greater than 0.90) were residence in a rural-small town/remote setting (odds ratio 1.24, 95 % CI 1.09-1.56, relative to urban), increasing age, white race, absence of an alcohol or substance use disorder, and absence of hepatitis C infection. Results may differ outside VA healthcare, where there may be fewer resources to support adherence among rural-dwelling persons with HIV.
    AIDS and Behavior 10/2012; · 3.49 Impact Factor
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    ABSTRACT: BACKGROUND: Opioids are increasingly prescribed, but there are limited data on opioid receipt by HIV status. OBJECTIVES: To describe patterns of opioid receipt by HIV status and the relationship between HIV status and receiving any, high-dose, and long-term opioids. DESIGN: Cross-sectional analysis of the Veterans Aging Cohort Study. PARTICIPANTS: HIV-infected (HIV+) patients receiving Veterans Health Administration care, and uninfected matched controls. MAIN MEASURES: Pain-related diagnoses were determined using ICD-9 codes. Any opioid receipt was defined as at least one opioid prescription; high-dose was defined as an average daily dose ≥120 mg of morphine equivalents; long-term opioids was defined as ≥90 consecutive days, allowing a 30 day refill gap. Multivariable models were used to assess the relationship between HIV infection and the three outcomes. KEY RESULTS: Among the HIV+ (n = 23,651) and uninfected (n = 55,097) patients, 31 % of HIV+ and 28 % of uninfected (p < 0.001) received opioids. Among patients receiving opioids, HIV+ patients were more likely to have an acute pain diagnosis (7 % vs. 4 %), but less likely to have a chronic pain diagnosis (53 % vs. 69 %). HIV+ patients received a higher mean daily morphine equivalent dose than uninfected patients (41 mg vs. 37 mg, p = 0.001) and were more likely to receive high-dose opioids (6 % vs. 5 %, p < 0.001). HIV+ patients received fewer days of opioids than uninfected patients (median 44 vs. 60, p < 0.001), and were less likely to receive long-term opioids (31 % vs. 34 %, p < 0.001). In multivariable analysis, HIV+ status was associated with receipt of any opioids (AOR 1.40, 95 % CI 1.35, 1.46) and high-dose opioids (AOR 1.22, 95 % CI 1.07, 1.39), but not long-term opioids (AOR 0.94, 95 % CI 0.88, 1.01). CONCLUSIONS: Patients with HIV infection are more likely to be prescribed opioids than uninfected individuals, and there is a variable association with pain diagnoses. Efforts to standardize approaches to pain management may be warranted in this highly complex and vulnerable patient population.
    Journal of General Internal Medicine 08/2012; · 3.42 Impact Factor
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    ABSTRACT: BACKGROUND:: HIV-infected patients with substance use experience suboptimal health outcomes, possibly because of variations in care. OBJECTIVES:: To assess the association between substance use and the quality of HIV care (QOC) received. RESEARCH DESIGN:: Retrospective cohort study. SUBJECTS:: HIV-infected patients enrolled in the Veterans Aging Cohort Study. MEASURES:: We collected self-report substance use data and abstracted 9 HIV quality indicators (QIs) from medical records. Independent variables were unhealthy alcohol use (AUDIT-C score ≥4) and illicit drug use (self-report of stimulants, opioids, or injection drug use in past year). Main outcome was the percentage of QIs received, if eligible. We estimated associations between substance use and QOC using multivariable linear regression. RESULTS:: The majority of the 3410 patients were male (97.4%) and black (67.0%) with a mean age of 49.1 years (SD = 8.8). Overall, 25.8% reported unhealthy alcohol use, 22% illicit drug use, and participants received 81.5% (SD = 18.9) of QIs. The mean percentage of QIs received was lower for those with unhealthy alcohol use versus not (59.3% vs. 70.0%, P < 0.001) and those using illicit drugs vs. not (57.8% vs. 70.7%, P < 0.001). In multivariable models, unhealthy alcohol use (adjusted β -2.74; 95% confidence interval: -4.23 to -1.25) and illicit drug use (adjusted β -3.51; 95% CI: -4.99 to -2.02) remained inversely associated with the percentage of QIs received. CONCLUSIONS:: Although the overall QOC for these HIV-infected Veteran patients was high, gaps persist for those with unhealthy alcohol and illicit drug use. Interventions that address substance use in HIV-infected patients may improve the QOC received.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 07/2012; 61(2):171-178. · 4.39 Impact Factor
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    ABSTRACT: We assessed smoking data from the Veterans Health Administration (VHA) electronic medical record (EMR) Health Factors dataset. To assess the validity of the EMR Health Factors smoking data, we first created an algorithm to convert text entries into a 3-category smoking variable (never, former, and current). We compared this EMR smoking variable to 2 different sources of patient self-reported smoking survey data: (a) 6,816 HIV-infected and -uninfected participants in the 8-site Veterans Aging Cohort Study (VACS-8) and (b) a subset of 13,689 participants from the national VACS Virtual Cohort (VACS-VC), who also completed the 1999 Large Health Study (LHS) survey. Sensitivity, specificity, and kappa statistics were used to evaluate agreement of EMR Health Factors smoking data with self-report smoking data. For the EMR Health Factors and VACS-8 comparison of current, former, and never smoking categories, the kappa statistic was .66. For EMR Health Factors and VACS-VC/LHS comparison of smoking, the kappa statistic was .61. Based on kappa statistics, agreement between the EMR Health Factors and survey sources is substantial. Identification of current smokers nationally within the VHA can be used in future studies to track smoking status over time, to evaluate smoking interventions, and to adjust for smoking status in research. Our methodology may provide insights for other organizations seeking to use EMR data for accurate determination of smoking status.
    Nicotine & Tobacco Research 09/2011; 13(12):1233-9. · 2.48 Impact Factor
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    ABSTRACT: Whether hepatitis C virus (HCV) confers additional coronary heart disease (CHD) risk among human immunodeficiency virus (HIV) infected individuals is unclear. Without appropriate adjustment for antiretroviral therapy, CD4 count, and HIV-1 RNA and substantially different mortality rates among those with and without HIV and HCV infection, the association between HIV, HCV, and CHD may be obscured. We analyzed data on 8579 participants (28% HIV+, 9% HIV+HCV+) from the Veterans Aging Cohort Study Virtual Cohort who participated in the 1999 Large Health Study of Veteran Enrollees. We analyzed data collected on HIV and HCV status, risk factors for and the incidence of CHD, and mortality from January 2000 to July 2007. We compared models to assess CHD risk when death was treated as a censoring event and as a competing risk. During the median 7.3 years of follow-up, there were 194 CHD events and 1186 deaths. Compared with HIV-HCV- Veterans, HIV+HCV+ Veterans had a significantly higher risk of CHD regardless of whether death was adjusted for as a censoring event (adjusted hazard ratio, 2.03; 95% confidence interval, 1.28 to 3.21) or a competing risk (adjusted HR, 2.45; 95% confidence interval, 1.83 to 3.27 respectively). Compared with HIV+HCV- Veterans, HIV+HCV+ Veterans also had a significantly higher adjusted risk of CHD regardless of whether death was treated as a censored event (adjusted hazard ratio, 1.93; 95% confidence interval, 1.02 to 3.62) or a competing risk (adjusted hazard ratio, 1.46; 95% confidence interval, 1.03 to 2.07). HIV+HCV+ Veterans have an increased risk of CHD compared with HIV+HCV- and HIV-HCV- Veterans.
    Circulation Cardiovascular Quality and Outcomes 06/2011; 4(4):425-32. · 5.04 Impact Factor
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    ABSTRACT: The objective of this study was to compare the 1-year VA health care service use and costs between male and female Veterans returning from deployment in Afghanistan and Iraq. Using VA administrative data, measures of health care service use and costs were computed for male and female veterans in the year after last deployment. Service use and cost measures included inpatient care, outpatient care, prescription drugs, and fee basis care. Unadjusted differences by gender were evaluated using chi-square and t-tests, and differences adjusted for age, race/ethnicity, education, branch of service, rank, and service-connected status were evaluated using generalized linear models with log links. Study findings indicated that although unadjusted total costs were higher for males than females, this difference did not remain after adjusting for covariates. However, adjusted inpatient costs were lower for women compared to those for men, and outpatient and pharmacy costs were higher.
    Military medicine 03/2011; 176(3):265-9. · 0.77 Impact Factor
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    ABSTRACT: Treatment rates for hepatitis C virus (HCV) are low in actual clinical settings. However, the proportion of patients eligible for treatment, especially among those coinfected with HIV, is not well known. Our aim was to determine and compare the rates for HCV treatment eligibility among HCV and HCV-HIV-coinfected persons. We assembled a national cohort of HCV-infected veterans in care from 1998-2003, using the VA National Patient Care Database for demographic/clinical information, the Pharmacy Benefits Management database for pharmacy records, and the Decision Support Systems database for laboratory data. We compared the HCV-monoinfected and HCV-HIV-coinfected subjects for treatment indications and eligibility using current treatment guidelines. Of the 27,452 subjects with HCV and 1225 with HCV-HIV coinfection, 74.0% and 84.6% had indications for therapy and among these, 43.9% of HCV-monoinfected and 28.4% of HCV-HIV-coinfected subjects were eligible for treatment. Anemia, decompensated liver disease (DLD), chronic obstructive pulmonary disease (COPD), recent alcohol abuse, and coronary artery disease were the most common contraindications in the HCV, and anemia, DLD, renal failure, recent drug abuse, and COPD in the HCV-HIV-coinfected group. Among those eligible for treatment, only 23% of the HCV-monoinfected and 15% of the HCV-HIV-coinfected subjects received any treatment for HCV. Most veterans with HCV are not eligible for treatment according to the current guidelines. Even for those who are eligible for treatment, only a minority is prescribed treatment. Several contraindications are modifiable and aggressive management of those may improve treatment prescription rates.
    AIDS research and human retroviruses 02/2011; 27(9):973-9. · 2.18 Impact Factor
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    ABSTRACT: we sought to describe gender differences in medical and mental health conditions and health care utilization among veterans who used Veterans Health Administration (VA) services in the first year after combat in Iraq and Afghanistan. this is an observational study, using VA administrative and clinical data bases, of 163,812 Operation Enduring Freedom/Operation Iraqi Freedom veterans who had enrolled in VA and who had at least one visit within 1 year of last deployment. female veterans were slightly younger (mean age, 30 years vs. 32 for men; p <.0001), twice as likely to be African American (30% vs. 15%; p <.0001), and less likely to be married (32% vs. 49%; p < .0001). Women had more visits to primary care (2.6 vs. 2.0; p < .001) and mental health (4.0 vs. 3.6; p < .001) clinics and higher use of community care outside the VA (14% vs. 10%; p < .001). After adjustment for significant demographic differences, women were more likely to have musculoskeletal and skin disorders, mild depression, major depression, and adjustment disorders, whereas men were more likely to have ear disorders and posttraumatic stress disorder. Thirteen percent of women sought care for gynecologic examination, 10% for contraceptive counseling, and 7% for menstrual disorders. female veterans had similar rates of physical conditions, but higher rates of some mental health disorders and additionally, used the VA for reproductive health needs. They also had slightly greater rates of health care service use. These findings highlight the complexity of female Veteran health care and support the development of enhanced comprehensive women's health services within the VA.
    Women s Health Issues 01/2011; 21(1):92-7. · 1.61 Impact Factor
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    ABSTRACT: Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) may experience significant stress during military service that can have lingering effects. Little is known about mental health problems or treatment among pregnant OEF/OIF women veterans. The aim of this study was to determine the prevalence of mental health problems among veterans who received pregnancy-related care in the Veterans Health Administration (VHA) system. Data from the Defense Manpower Data Center (DMDC) deployment roster of military discharges from October 1, 2001, through April 30, 2008, were used to assemble an administrative cohort of female OEF/OIF veterans enrolled in care at the VHA (n = 43,078). Pregnancy and mental health conditions were quantified according to ICD-9-CM codes and specifications. Mental healthcare use and prenatal care were assessed by analyzing VHA stop codes. During the study period, 2966 (7%) women received at least one episode of pregnancy-related care, and 32% of veterans with a pregnancy and 21% without a pregnancy received one or more mental health diagnoses (p < 0.0001). Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or schizophrenia as those without a pregnancy. Women OEF/OIF veterans commonly experience mental health problems after military service. The burden of mental health conditions is higher among women with an identified instance of pregnancy than among those without. Because women do not receive pregnancy care at the VHA, however, little is known about ongoing concomitant prenatal and mental healthcare or about pregnancy outcomes among these women veterans.
    Journal of Women's Health 11/2010; 19(12):2159-66. · 1.90 Impact Factor

Publication Stats

859 Citations
206.47 Total Impact Points

Institutions

  • 2004–2014
    • VA Long Beach Healthcare System
      Long Beach, California, United States
  • 2013
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
  • 2007–2013
    • Yale University
      • • Department of Internal Medicine
      • • Section of General Internal Medicine
      New Haven, Connecticut, United States
    • Medical College of Wisconsin
      • Department of Medicine
      Milwaukee, WI, United States
  • 2009–2011
    • University of Pittsburgh
      • VA Center for Health Equity Research and Promotion
      Pittsburgh, Pennsylvania, United States
  • 2006
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States