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ABSTRACT: Objective: The measurement of alcohol consumption is an essential component of research in patients at risk for or infected with HIV. Daily estimation measures such as the Timeline Followback (TLFB) have been validated, yet the optimal time window and its performance in non-treatment-seeking medical clinic subjects and among those with HIV are not known. Method: In 1,519 HIV-infected and 1,612 uninfected men receiving medical care in general medical or infectious disease clinics, we compared the association between 7-, 14-, and 30-day TLFB reports, obtained via telephone, of alcohol consumption using Spearman's correlation coefficients. To evaluate agreement between 7-, 14-, and 30-day reports of heavy episodic drinking, we evaluated percent agreement, sensitivity, and kappa statistics, considering 30-day report as the gold standard. Results: The estimated prevalence of heavy episodic drinking was progressively higher for longer TLFB intervals (7 days: 6.3%; 14 days: 8.0%; 30 days: 9.5%). Correlation coefficients with 30- day TLFB were higher for 14 days (.94) than for 7 days (.86) overall (p < .001) and among HIV-infected (.94 vs. .86, p < .001) and uninfected (.95 vs. .87, p < 001). Correlations were similar by HIV status. When considered overall and by HIV status, the sensitivity, percent agreement, and kappa statistics are better for heavy episodic drinking based on 14 days compared with 7 days. Conclusions: A TLFB for alcohol consumption of 14 days is preferable to 7 days for non-treatment-seeking patients in medical clinics with and without HIV infection when compared with 30 days. (J. Stud. Alcohol Drugs, 74, 500-504, 2013).
Journal of studies on alcohol and drugs 05/2013; 74(3):500-504. · 2.25 Impact Factor
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ABSTRACT: BACKGROUND & AIMS: There have been few studies of the effects of pre-treatment anemia on outcomes of patients with chronic hepatitis C virus (HCV) infection. Anemic individuals are less likely to receive treatment for HCV infection because hemolytic anemia is a frequent side-effect of therapies. We investigated the effects of HCV therapy on mortality of patients with chronic HCV infection and anemia. METHODS: We performed a retrospective analysis of 200,139 HCV-infected Veterans using data from the Electronically Retrieved Cohort of Hepatitis C-Infected Veterans (2001-2008). The effects of treatment and treatment duration upon survival were compared based on data from 1820 treated and 27,690 untreated anemic HCV-infected Veterans. The association between HCV treatment and mortality was estimated using Cox proportional hazard models, with adjustments for potential confounders. The main outcome was all-cause mortality. RESULTS: In multivariable analysis, pre-treatment anemia was significantly associated with African-American race (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.95-2.11), chronic kidney disease (OR, 3.36; 95% CI, 3.23-3.51), and decompensated liver disease (OR, 3.69; 95% CI, 3.53-3.86). All-cause mortality for treated, anemic, HCV-infected Veterans was lower (54.2/1000 person-years; 95% CI, 49.2-59.7/1000 person years) than for untreated, anemic HCV-infected Veterans (146.8/1000 person-years; 95% CI, 144.2-149.4/1000 person-years). The adjusted hazards ratio (HR) for treatment of HCV in anemic Veterans was 0.45 (95% CI, 0.39-0.51), which was reduced after exclusion of co-morbidities (HR, 0.28; 95% CI, 0.22-0.37). CONCLUSION: Based on a retrospective analysis of a Veterans database, HCV therapy increases survival of individuals with pre-treatment anemia. Additional studies are needed to determine strategies to increase rates of HCV therapy for this group.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 01/2013; · 5.64 Impact Factor
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Kathleen M Akgün,
Kirsha Gordon,
Margaret Pisani,
Terri Fried, Kathleen A McGinnis,
Janet P Tate,
Adeel A Butt,
Cynthia L Gibert,
Laurence Huang,
Maria C Rodriguez-Barradas,
David Rimland,
Amy C Justice,
Kristina Crothers
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ABSTRACT: OBJECTIVE:: With improved survival of HIV-infected persons on antiretroviral therapy and growing prevalence of non-AIDS diseases, we asked whether the VACS Index, a composite measure of HIV-associated and general organ dysfunction predictive of all-cause mortality, predicts hospitalization and medical intensive care unit (MICU) admission. We also asked whether AIDS and non-AIDS conditions increased risk after accounting for VACS Index score. METHODS:: We analyzed data from the Veterans Aging Cohort Study (VACS), a prospective study of HIV-infected Veterans receiving care between 2002-2008. Data were obtained from the electronic medical record, VA administrative databases and patient questionnaires, and were used to identify comorbidities and calculate baseline VACS Index scores. The primary outcome was first hospitalization within 2 years of VACS enrollment. We used multivariable Cox regression to determine risk factors associated with hospitalization and logistic regression to determine risk factors for MICU admission, given hospitalization. RESULTS:: 1141/3410 (33.5%) patients were hospitalized within 2 years; 203/1141 (17.8%) included a MICU admission. Median VACS Index scores were 25 (no hospitalization), 34 (hospitalization only) and 51 (MICU). In adjusted analyses, a 5-point increment in VACS Index score was associated with 10% higher risk of hospitalization and MICU admission. In addition to VACS Index score, Hispanic ethnicity, current smoking, hazardous alcohol use, chronic obstructive pulmonary disease, hypertension, diabetes and prior AIDS-defining event predicted hospitalization. Among those hospitalized, VACS Index score, cardiac disease and prior cancer predicted MICU admission. CONCLUSIONS:: The VACS Index predicted hospitalization and MICU admission as did current smoking, hazardous alcohol use, and AIDS and certain non-AIDS diagnoses.
JAIDS Journal of Acquired Immune Deficiency Syndromes 10/2012; · 4.43 Impact Factor
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ABSTRACT: BACKGROUND: Brief measures of unhealthy alcohol use have not been well validated among people with HIV. We compared the Alcohol Use Disorders Identification Test (AUDIT) to reference standards for unhealthy alcohol use based on 30-day Timeline Follow Back (TLFB) and Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM), among 837 male HIV-infected and -uninfected patients in the Veterans Aging Cohort Study. METHODS: Three reference standards were (i) Risky drinking-based on TLFB >14 drinks over 7 consecutive days or >4 drinks on 1 day; (ii) Alcohol dependence-based on a CIDI-SAM diagnosis; and (iii) Unhealthy alcohol use-risky drinking or a CIDI-SAM diagnosis of abuse or dependence. Various cutoffs for the AUDIT, AUDIT-C, and heavy episodic drinking were compared with the reference standards. RESULTS: Mean age of patients was 52 years, 53% (444) were HIV-infected, and 53% (444) were African American. Among HIV-infected and -uninfected patients, the prevalence of risky drinking (14 vs. 12%, respectively), alcohol dependence (8 vs. 7%), and unhealthy alcohol use (22 vs. 20%) was similar. For risky drinking and alcohol dependence, multiple cutoffs of AUDIT, AUDIT-C, and heavy episodic drinking provided good sensitivity (≥80%) and specificity (≥90%). For unhealthy alcohol use, few cutoffs provided sensitivity ≥80%; however, many cutoffs provided good specificity. For all 3 alcohol screening measures, sensitivity improved when heavy episodic drinking was included with the cutoff. Sensitivity of measures for risky drinking and unhealthy alcohol use was lower in HIV-infected than in uninfected patients. CONCLUSIONS: For identifying risky drinking, alcohol dependence, and unhealthy alcohol use, AUDIT-C performs as well as AUDIT and similarly in HIV-infected and -uninfected patients. Cutoffs should be based on the importance of specific operating characteristics for the intended research or clinical use. Incorporating heavy episodic drinking increased sensitivity for detecting alcohol dependence and unhealthy alcohol use.
Alcoholism Clinical and Experimental Research 10/2012; · 3.34 Impact Factor
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P Todd Korthuis,
David A Fiellin, Kathleen A McGinnis,
Melissa Skanderson,
Amy C Justice,
Adam J Gordon,
Donna Almario Doebler,
Steven M Asch,
Lynn E Fiellin,
Kendall Bryant,
Cynthia L Gibert,
Stephen Crystal,
Matthew Bidwell Goetz,
David Rimland,
Maria C Rodriguez-Barradas,
Kevin L Kraemer
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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. · 4.43 Impact Factor
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Emily A. Wang, Kathleen A. McGinnis,
David A. Fiellin,
Joseph L. Goulet,
Kendall Bryant,
Cynthia L. Gibert,
David A. Leaf,
Kristin Mattocks,
Lynn E. Sullivan,
Nicholas Vogenthaler,
Amy C. Justice,
for the VACS Project Team
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ABSTRACT: BACKGROUND AND OBJECTIVEFood insecurity negatively impacts HIV disease outcomes in international settings. No large scale U.S. studies have investigated
the association between food insecurity and severity of HIV disease or the mechanism of this possible association. The objective
of this study was to examine the impact of food insecurity on HIV disease outcomes in a large cohort of HIV-infected patients
receiving antiretroviral medications.
DESIGNThis is a cross-sectional study.
PARTICIPANTS AND SETTINGParticipants were HIV-infected patients enrolled in the Veterans Aging Cohort Study between 2002–2008 who were receiving antiretroviral
medications.
MAIN MEASUREMENTSParticipants reporting “concern about having enough food for you or your family in the past 30days” were defined as food
insecure. Using multivariable logistic regression, we explored the association between food insecurity and both low CD4 counts
(<200 cells/μL) and unsuppressed HIV-1 RNA (>500 copies/mL). We then performed mediation analysis to examine whether antiretroviral
adherence or body mass index mediates the observed associations.
KEY RESULTSAmong 2353 HIV-infected participants receiving antiretroviral medications, 24% reported food insecurity. In adjusted analyses,
food insecure participants were more likely to have an unsuppressed HIV-1 RNA (AOR 1.37, 95% CI 1.09, 1.73) compared to food
secure participants. Mediation analysis revealed that neither antiretroviral medication adherence nor body mass index contributes
to the association between food insecurity and unsuppressed HIV-1 RNA. Food insecurity was not independently associated with
low CD4 counts.
CONCLUSIONSAmong HIV-infected participants receiving antiretroviral medications, food insecurity is associated with unsuppressed viral
load and may render treatment less effective. Longitudinal studies are needed to test the potential causal association between
food insecurity, lack of virologic suppression, and additional HIV outcomes.
KEY WORDSfood insecurity–HIV–patients–antiretrovirals
Journal of General Internal Medicine 04/2012; 26(9):1012-1018. · 2.83 Impact Factor
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Robert L. Cook, Kathleen A. McGinnis,
Jeffrey H. Samet,
David A. Fiellin,
Maria C. Rodriquez-Barradas,
Kevin L. Kraemer,
Cynthia L. Gibert,
R. Scott Braithwaite,
Joseph L. Goulet,
Kristin Mattocks,
Stephen Crystal,
Adam J. Gordon,
Krisann K. Oursler,
Amy C. Justice
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ABSTRACT: BACKGROUNDHealth care providers may be concerned that prescribing erectile dysfunction drugs (EDD) will contribute to risky sexual behavior.
OBJECTIVESTo identify characteristics of men who received EDD prescriptions, determine whether EDD receipt is associated with risky
sexual behavior and sexually transmitted diseases (STDs), and determine whether these relationships vary for certain sub-groups.
DESIGNCross-sectional study.
PARTICIPANTSTwo thousand seven hundred and eighty-seven sexually-active, HIV-infected and HIV-uninfected men recruited from eight Veterans
Health Affairs outpatient clinics. Data were obtained from participant surveys, electronic medical records, and administrative
pharmacy data.
MEASURESEDD receipt was defined as two or more prescriptions for an EDD, risky sex as having unprotected sex with a partner of serodiscordant
or unknown HIV status, and STDs, according to self-report.
RESULTSOverall, 28% of men received EDD in the previous year. Eleven percent of men reported unprotected sex with a serodiscordant/unknown
partner in the past year (HIV-infected 15%, HIV-uninfected 6%, P < 0.001). Compared to men who did not receive EDD, men who received EDD were equally likely to report risky sexual behavior
(11% vs. 10%, p = 0.9) and STDs (7% vs 7%, p = 0.7). In multivariate analyses, EDD receipt was not significantly associated with risky sexual behavior or STDs in the
entire sample or in subgroups of substance users or men who had sex with men.
CONCLUSIONEDD receipt was common but not associated with risky sexual behavior or STDs in this sample of HIV-infected and uninfected
men. However, risky sexual behaviors persist in a minority of HIV-infected men, indicating ongoing need for prevention interventions.
KEY WORDSHIV infection-risky sexual behavior-STDs-men-phosphodiesterase inhibitors
Journal of General Internal Medicine 04/2012; 25(2):115-121. · 2.83 Impact Factor
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Kathleen A McGinnis,
Cynthia A Brandt,
Melissa Skanderson,
Amy C Justice,
Shahida Shahrir,
Adeel A Butt,
Sheldon T Brown,
Matthew S Freiberg,
Cynthia L Gibert,
Matthew Bidwell Goetz,
Joon Woo Kim,
Margaret A Pisani,
David Rimland,
Maria C Rodriguez-Barradas,
Jason J Sico,
Hilary A Tindle,
Kristina Crothers
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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. · 2.58 Impact Factor
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ABSTRACT: We sought to determine the impact of naltrexone on hepatic enzymes and HIV biomarkers in HIV-infected patients.
We used data from the Veterans Aging Cohort Study-Virtual Cohort, an electronic database of administrative, pharmacy, and laboratory data. We restricted our sample to HIV-infected patients who received an initial oral naltrexone prescription of at least 7 days duration. We examined aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and HIV biomarker (CD4 and HIV RNA) values for the 365 days prior to, during, and for the 365 days post-naltrexone prescription. We also examined cases of liver enzyme elevation (LEE; defined as >5 times baseline ALT or AST or >3.5 times baseline if baseline ALT or AST was >40 IU/l).
Of 114 HIV-infected individuals, 97% were men, 45% white, 57% Hepatitis C co-infected; median age was 49 years; 89% of the sample had a history of alcohol dependence and 32% had opioid dependence. Median duration of naltrexone prescription was 49 (interquartile range 30 to 83) days, representing 9,525 person-days of naltrexone use. Mean ALT and AST levels remained below the upper limit of normal. Two cases of LEE occurred. Mean CD4 count remained stable and mean HIV RNA decreased after naltrexone prescription.
In HIV-infected patients, oral naltrexone is rarely associated with clinically significant ALT or AST changes and does not have a negative impact on biologic parameters. Therefore, HIV-infected patients with alcohol or opioid dependence can be treated with naltrexone.
Alcoholism Clinical and Experimental Research 07/2011; 36(2):318-24. · 3.34 Impact Factor
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Emily A Wang, Kathleen A McGinnis,
David A Fiellin,
Joseph L Goulet,
Kendall Bryant,
Cynthia L Gibert,
David A Leaf,
Kristin Mattocks,
Lynn E Sullivan,
Nicholas Vogenthaler,
Amy C Justice
[show abstract]
[hide abstract]
ABSTRACT: Food insecurity negatively impacts HIV disease outcomes in international settings. No large scale U.S. studies have investigated the association between food insecurity and severity of HIV disease or the mechanism of this possible association. The objective of this study was to examine the impact of food insecurity on HIV disease outcomes in a large cohort of HIV-infected patients receiving antiretroviral medications.
This is a cross-sectional study.
Participants were HIV-infected patients enrolled in the Veterans Aging Cohort Study between 2002-2008 who were receiving antiretroviral medications.
Participants reporting "concern about having enough food for you or your family in the past 30 days" were defined as food insecure. Using multivariable logistic regression, we explored the association between food insecurity and both low CD4 counts (<200 cells/μL) and unsuppressed HIV-1 RNA (>500 copies/mL). We then performed mediation analysis to examine whether antiretroviral adherence or body mass index mediates the observed associations.
Among 2353 HIV-infected participants receiving antiretroviral medications, 24% reported food insecurity. In adjusted analyses, food insecure participants were more likely to have an unsuppressed HIV-1 RNA (AOR 1.37, 95% CI 1.09, 1.73) compared to food secure participants. Mediation analysis revealed that neither antiretroviral medication adherence nor body mass index contributes to the association between food insecurity and unsuppressed HIV-1 RNA. Food insecurity was not independently associated with low CD4 counts.
Among HIV-infected participants receiving antiretroviral medications, food insecurity is associated with unsuppressed viral load and may render treatment less effective. Longitudinal studies are needed to test the potential causal association between food insecurity, lack of virologic suppression, and additional HIV outcomes.
Journal of General Internal Medicine 05/2011; 26(9):1012-8. · 2.83 Impact Factor
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Robert L Cook, Kathleen A McGinnis,
Jeffrey H Samet,
David A Fiellin,
Maria C Rodriguez-Barradas,
Kevin L Kraemer,
Cynthia L Gibert,
R Scott Braithwaite,
Joseph L Goulet,
Kristin Mattocks,
Stephen Crystal,
Adam J Gordon,
Krisann K Oursler,
Amy C Justice
Journal of General Internal Medicine 08/2010; · 2.83 Impact Factor
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ABSTRACT: To determine whether alcohol consumption is associated with cardiovascular disease (CVD) among HIV-infected veterans.
Using established thresholds for alcohol consumption, we analyzed cross-sectional data from 4743 men (51% HIV infected) from the Veterans Aging Cohort Study, a prospective cohort of HIV-infected veterans and demographically similar HIV-uninfected veterans. Using logistic regression, we estimated the odds ratio (OR) for the association between alcohol consumption and prevalent CVD.
Among HIV-infected and HIV-uninfected men, respectively, hazardous drinking (33.2% vs. 30.9%,), alcohol abuse and dependence (20.9% vs. 26.2%), and CVD (14.6% vs. 19.8%) were common. Among HIV-infected men, hazardous drinking [OR = 1.43, 95% confidence interval (CI) = 1.05 to 1.94] and alcohol abuse and dependence (OR = 1.55, 95% CI = 1.07 to 2.23) were associated with a higher prevalence of CVD compared with infrequent and moderate drinking. Among HIV-uninfected men, past drinkers had a higher prevalence of CVD (OR = 1.30, 95% CI = 1.01 to 1.67). For HIV-infected and HIV-uninfected men, traditional risk factors and kidney disease were associated with CVD.
Among HIV-infected men, hazardous drinking and alcohol abuse and dependence were associated with a higher prevalence of CVD compared with infrequent and moderate drinking even after adjusting for traditional CVD risk factors, antiretroviral therapy, and CD4 count.
JAIDS Journal of Acquired Immune Deficiency Syndromes 12/2009; 53(2):247-53. · 4.43 Impact Factor
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ABSTRACT: Treatment completion rates for hepatitis C virus (HCV) infection in clinical practice settings are unknown.
We assembled a national cohort of HCV-infected veterans-in-care from 1998 to 2003, using the VA National Patient Care Database for demographical/clinical information, Pharmacy Benefits Management database for pharmacy records and the Decision Support Systems database for laboratory data. We used logistic regression to determine the factors predicting treatment non-completion for HCV.
We identified 134,934 HCV-infected veterans of whom 16,043 [11.9%; 95% confidence interval (CI) 11.7-12.1] were prescribed treatment for HCV. Among the 10,641 veterans with >1 year of follow-up, 2396 (22.5%; 95% CI 21.7-23.3) completed a 48-week course. Non-completers were more likely to have pre-treatment anaemia, coronary artery disease, depression, substance abuse, used standard interferon, higher comorbidity count, and been treated at a low-volume treatment site (defined as sites initiating HCV treatment for <200 individuals). In multivariable analyses, treatment completion was positively associated with pegylated interferon use [odds ratio (OR) 1.59, 95% CI 1.40-1.80] and site treatment volume (OR 1.87, 95% CI 1.56-2.24 for sites initiating treatment for >200 individuals) and negatively associated with pre-treatment anaemia (OR 0.68, 95% CI 0.58-0.80 for haemoglobin 10-14 g/dl) and depression (OR 0.78, 95% CI 0.69-0.89). Human immunodeficiency virus coinfection and minority race were not associated with failing to complete treatment.
Among veterans-in-care with known HCV, 11.9% initiate therapy of whom 22.5% (one in 56 with known HCV infection) complete a 48-week course of treatment. Higher completion rates among higher volume treatment sites suggest that some factors associated with non-completion (pre-treatment depression and anaemia), may be modifiable with experience.
Liver international: official journal of the International Association for the Study of the Liver 11/2009; 30(2):240-50. · 3.82 Impact Factor
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ABSTRACT: The Timeline Followback (TLFB) interview has become state-of-the-science for the collection of retrospective self-reports of daily alcohol consumption. Such data are especially useful for addressing questions of the co-occurrence of quantity of alcohol consumption and other behaviors, such as HIV-related risky sex, on the event level. The purpose of this study was to determine if the TLFB could be used effectively by self-administration compared with the more costly telephone interview in a large, multisite observational study of HIV-positive and HIV-negative adults.
An experimental design was used to compare self-administered and telephone-administered TLFB modes in a subsample (N=70) of the Veterans Aging Cohort Study, an ongoing longitudinal study of more than 6,000 HIV-positive and HIV-negative men and women presenting for treatment at eight Department of Veterans Affairs Infectious Disease or General Medicine clinics. Participants were randomly assigned to one of four experimental groups defined by mode and sequence of a TLFB administration on two occasions occurring within 1 week: telephone-telephone, telephone-self, self-telephone, and self-self.
Analyses showed no differences in median total number of drinks reported between modes of TLFB administration or sequence of mode of administration. The same findings held for classification of participants as "hazardous" drinkers. Additional analyses showed good-to-excellent test-retest reliability of self-reports for both modes of TLFB administration.
The data derived from this study provide strong experimental evidence for the utility of the self-administered, 30-day TLFB in collecting daily alcohol consumption in large observational studies of HIV-positive and HIV-negative individuals.
Journal of studies on alcohol and drugs 06/2008; 69(3):468-71. · 2.25 Impact Factor
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ABSTRACT: Screening for hazardous drinking may fail to detect a substantial proportion of individuals harmed by alcohol. We investigated whether considering an individual's usual drinking quantity or threshold for alcohol-induced cognitive impairment improves the prediction of nonadherence with prescribed medications.
Cross-sectional analysis of participants in a large, multi-site cohort study. We used the timeline followback to reconstruct 30-day retrospective drinking histories and the timeline followback modified for adherence to reconstruct 30-day medication adherence histories among 3,152 individuals in the Veterans Aging Cohort Study, 1,529 HIV infected and 1,623 uninfected controls. We categorized daily alcohol consumption by using quantity alone, quantity after adjustment for the individual's mean daily alcohol consumption, and self-reported level of impairment corresponding to each quantity. A standard drink was defined as 14 g of ethanol. Nonadherence was defined as the proportion of days with > or =1 medication doses missed or taken > or =2 hours late, and clinically significant nonadherence was defined as > or =5% absolute increase in the proportion of days with nonadherence.
The mean adjusted- and impairment-based methods showed greater discrimination of nonadherence risk compared to the measure based on quantity alone (quantity-based categorization, 3.2-fold increase; quantity adjusted for mean daily consumption, 4.6-fold increase, impairment-based categorization, 3.6-fold increase). The individualized methods also detected greater numbers of days with clinically significant nonadherence associated with alcohol. Alcohol was associated with clinically significant nonadherence at a lower threshold for HIV infected versus uninfected patients (2 standard drinks vs. 4 standard drinks) using quantity-based categorization, but this difference was no longer apparent when individualized methods were used.
Tailoring screening questions to an individual's usual level of alcohol consumption or threshold for impairment improves the ability to predict alcohol-associated medication nonadherence.
Alcoholism Clinical and Experimental Research 06/2008; 32(9):1645-51. · 3.34 Impact Factor
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ABSTRACT: Using nationally representative National Health Interview Survey (NHIS) data from 1999 through 2002, this study examines the health services access and utilization patterns of U.S. Hispanic adolescents under age 18 years classified as: Cubans, Puerto Ricans and Dominicans, Mexicans or Mexican Americans, Central and South Americans, and mixed Hispanic and non-Hispanic White. Consistent with previous studies on ethnic patterns in child and adult health, Hispanic American children do better than non-Hispanic Whites with respect to certain health status measures such as school absence. There is considerable heterogeneity in health status and health care utilization in the Hispanic subgroup, indicating the necessity of separating Hispanic subgroups for analytic purposes.
Social Work in Public Health 02/2007; 23(2-3):167-91. · 0.31 Impact Factor
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ABSTRACT: To explore the relationship of HIV, hepatitis C (HCV), and alcohol abuse/dependence to risk for hepatocellular carcinoma and non-Hodgkin's lymphoma (NHL).
Male veterans (n = 14,018) with a first HIV diagnosis in the Veterans Affairs Healthcare System from October 1997 to September 2004; and 28,036 age-, race-, sex-, and location-matched HIV-negative veterans were identified. We examined the incidence of hepatocellular carcinoma and NHL and presence of HCV and alcohol abuse/dependence using International Classification of Diseases, ninth revision (ICD-9-CM) codes. HIV-positive to HIV-negative incident rate ratios (IRRs) and 95% CIs for the occurrence of hepatocellular carcinoma and NHL were calculated using Poisson regression models.
HIV-positive veterans were at greater risk for hepatocellular carcinoma than HIV-negative veterans (IRR = 1.68; 95% CI, 1.02 to 2.77). After adjusting for HCV infection and alcohol abuse/dependence, HIV status was not independently associated with hepatocellular cancer (IRR = 0.96; 95% CI, 0.56 to 1.63). HIV-positive veterans had 9.71 times (95% CI, 6.99 to 13.49) greater risk of NHL than HIV-negative veterans. After adjusting for HCV and alcohol abuse/dependence, the IRR for NHL comparing HIV-positive with HIV-negative veterans is similar (IRR = 10.03, 95% CI, 7.19 to 13.97).
HIV-positive veterans have a higher relative incidence of hepatocellular carcinoma and NHL than HIV-negative veterans. For hepatocellular carcinoma, this association appears to be largely explained by the higher prevalence of HCV and alcohol abuse/dependence. Efforts to decrease hepatocellular carcinoma among persons with HIV should focus primarily on detecting and treating HCV and reducing heavy alcohol use.
Journal of Clinical Oncology 12/2006; 24(31):5005-9. · 18.37 Impact Factor
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ABSTRACT: Alcohol use is a frequent root cause of homelessness, and both homelessness and alcohol use influence the quality and quantity of interactions with health care providers.
The objectives of this study are to compare rates of homelessness and alcohol use in a cohort of human immunodeficiency virus (HIV)-infected persons and to evaluate the influence of homelessness and alcohol use on utilization of health services. RESEARCH DESIGN AND MEASURES: Data were obtained from the Veterans Aging Cohort 3-Site Study, a cohort study of 881 HIV-infected veterans at 3 VA hospitals. In a baseline survey, we assessed current and past history of homelessness and levels of alcohol consumption. Health care service utilization (ambulatory visits, emergency room visits, and hospital admissions) for the preceding 6 months was determined by self-report and VA administrative records. Logistic regression was used to assess whether homelessness and drinking variables were associated with health care visits in the past 6 months.
Among HIV-infected veterans with complete data (n = 839), 62 (7%) were currently homeless, and 212 (25.3%) had a past, but not current, history of homelessness. Among the currently homeless, 36% reported alcohol consumption, 34% were hazardous drinkers, 46% were binge drinkers, and 26% had a diagnosis of alcohol abuse. When adjusting for age, severity of HIV disease, and use of illicit drugs, hazardous drinking (adjusted odds ratio [AOR] 0.68, 95% confidence interval [CI] 0.49-0.93) and current homelessness (AOR 0.56, 95% CI 0.32-0.97) were associated with less than 2 outpatient clinic visits. HIV-infected veterans who were homeless in the past were more likely to be hospitalized in the prior 6 months than those never homeless (AOR 1.51, 95% CI 1.07-2.11).
Although homeless HIV-infected veterans tend to use inpatient services more than nonhomeless HIV infected veterans, they were less likely to achieve optimum outpatient care. Alcohol use complicates the effect of homelessness on adherence to outpatient care and is associated with increased inpatient utilization among HIV-infected veterans.
Medical Care 09/2006; 44(8 Suppl 2):S37-43. · 3.41 Impact Factor
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ABSTRACT: We assess the effects of racial or ethnic concordance between caregivers and interventionists on caregiver attrition, change in depression, and change in burden in a multisite randomized clinical trial.
Family caregivers of patients with Alzheimer's disease were randomized to intervention or control groups at six sites from 1996 to 2000. Interventionists provided psychosocial interventions aimed at decreasing caregiver depression and burden. This analysis included 694 caregivers who received face-to-face interventions from 36 interventionists at five sites. We modeled caregiver loss to follow-up at 12 months and changes in depression and burden from baseline by racial or ethnic concordance by using random effects logistic and linear regression models, controlling for caregiver age, gender, race or ethnicity, relation to care recipient, interventionist race or ethnicity, and care recipient activities of daily living. The loss to follow-up model also controlled for care recipient institutionalization and death.
Overall, there was no difference in caregiver loss to follow-up or change in depression or burden by racial or ethnic concordance. African-American caregivers with an interventionist of the same race or ethnicity had greater decreases in depression than did African-American caregivers with interventionists of a different race or ethnicity. However, this finding has to be interpreted cautiously because there were only two African-American interventionists.
Although these initial findings do not provide conclusive evidence on whether racial or ethnic concordance is associated with intervention outcomes for caregivers of Alzheimer's disease patients, these results, along with the paucity of research studies evaluating this issue, suggest that the effects of racial or ethnic concordance in research should be systematically examined in future studies.
The Gerontologist 09/2006; 46(4):449-55. · 2.48 Impact Factor
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ABSTRACT: Although alcohol problems are common in human immunodeficiency virus (HIV)-infected patients, their impact on health care services use in HIV-infected patients is not well understood.
We sought to examine the association between alcohol problems and health care services use in HIV-infected and HIV-uninfected patients.
We undertook a prospective analysis of 16,048 HIV-infected veterans and 32,096 age-, race-, gender-, and region-matched HIV-uninfected controls identified through the national Veterans Affairs electronic administrative medical record database. We identified subjects with alcohol problems using ICD-9-CM codes for alcohol diagnoses and/or alcohol-related complications.
We measured outpatient visits, emergency department visits, and inpatient hospitalizations over 12 months of follow-up.
In adjusted analyses, HIV-infected veterans with alcohol problems were significantly more likely than HIV-uninfected veterans without alcohol problems to have at least 1 outpatient visit and at least 1 inpatient hospitalization and, among those with any health services use, to have significantly greater rates for outpatient visits (Incidence rate ratio [IRR] 2.17; 95% confidence interval [CI] 2.06-2.28; P < 0.001), emergency department visits (IRR 1.46; 95% CI 1.35-1.58; P < 0.001), and inpatient hospitalizations (IRR 1.46; 95% CI 1.30-1.64; P < 0.001). The incidence rates for outpatient visits, mental health visits, emergency department visits, and inpatient hospitalizations were significantly higher in HIV-infected veterans with alcohol problems than in HIV-infected veterans without alcohol problems. We did not find a consistent interaction effect between alcohol problems and HIV status.
Alcohol problems are associated with greater outpatient, emergency department, and inpatient health care utilization in HIV-infected and HIV-uninfected veterans. However, alcohol does not appear to have a stronger effect on health services use in HIV-infected veterans compared with HIV-uninfected veterans.
Medical Care 08/2006; 44(8 Suppl 2):S44-51. · 3.41 Impact Factor
