Dawn Provenzale

San Francisco VA Medical Center, San Francisco, California, United States

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Publications (138)1069.4 Total impact

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    ABSTRACT: The current study was performed to determine whether patient characteristics, including race/ethnicity, were associated with patient-reported care coordination for patients with colorectal cancer (CRC) who were treated in the Veterans Affairs (VA) health care system, with the goal of better understanding potential goals of quality improvement efforts aimed at improving coordination. The nationwide Cancer Care Assessment and Responsive Evaluation Studies survey involved VA patients with CRC who were diagnosed in 2008 (response rate, 67%). The survey included a 4-item scale of patient-reported frequency ("never," "sometimes," "usually," and "always") of care coordination activities (scale score range, 1-4). Among 913 patients with CRC who provided information regarding care coordination, demographics, and symptoms, multivariable logistic regression was used to examine odds of patients reporting optimal care coordination. VA patients with CRC were found to report high levels of care coordination (mean scale score, 3.50 [standard deviation, 0.61]). Approximately 85% of patients reported a high level of coordination, including the 43% reporting optimal/highest-level coordination. There was no difference observed in the odds of reporting optimal coordination by race/ethnicity. Patients with early-stage disease (odds ratio [OR], 0.60; 95% confidence interval [95% CI], 0.45-0.81), greater pain (OR, 0.97 for a 1-point increase in pain scale; 95% CI, 0.96-0.99), and greater levels of depression (OR, 0.97 for a 1-point increase in depression scale; 95% CI, 0.96-0.99) were less likely to report optimal coordination. Patients with CRC in the VA reported high levels of care coordination. Unlike what has been reported in settings outside the VA, there appears to be no racial/ethnic disparity in reported coordination. However, challenges remain in ensuring coordination of care for patients with less advanced disease and a high symptom burden. Cancer 2015. © 2015 American Cancer Society. © 2015 American Cancer Society.
    Cancer 03/2015; DOI:10.1002/cncr.29341 · 4.90 Impact Factor
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    ABSTRACT: The impact of financial burden among patients with cancer has not yet been measured in a way that accounts for inter-relationships between quality of life, perceived quality of care, disease status, and sociodemographic characteristics. In a national, prospective, observational, population- and health care systems-based cohort study, patients with colorectal or lung cancer were enrolled from 2003 to 2006 within 3 months of diagnosis. For this analysis, surviving patients who were either disease free or had advanced disease were resurveyed a median 7.3 years from diagnosis. Structural equation modeling was used to investigate relationships between financial burden, quality of life, perceived quality of care, and sociodemographic characteristics. Among 1,000 participants enrolled from five geographic regions, five integrated health care systems, or 15 Veterans Administration Hospitals, 89% (n = 889) were cancer free, and 11% (n = 111) had advanced cancer. Overall, 48% (n = 482) reported difficulties living on their household income, and 41% (n = 396) believed their health care to be "excellent." High financial burden was associated with lower household income (adjusted odds ratio [OR] = 0.61 per $20k per year, P < .001) and younger age (adjusted OR = 0.63 per 10 years; P < .001). High financial burden was also associated with poorer quality of life (adjusted beta = -0.06 per burden category; P < .001). Better quality of life was associated with fewer perceptions of poorer quality of care (adjusted OR = 0.85 per 0.10 EuroQol units; P < .001). Financial burden is prevalent among cancer survivors and is related to patients' health-related quality of life. Future studies should consider interventions to improve patient education and engagement with regard to financial burden. Copyright © 2014 by American Society of Clinical Oncology.
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    ABSTRACT: Collaboration between policy, research, and clinical partners is crucial to achieving proven quality care. The Veterans Health Administration has expended great efforts towards fostering such collaborations. Through this, we have learned that an ideal collaboration involves partnership from the very beginning of a new clinical program, so that the program is designed in a way that ensures quality, validity, and puts into place the infrastructure necessary for a reliable evaluation. This paper will give an example of one such project, the Lung Cancer Screening Demonstration Project (LCSDP). We will outline the ways that clinical, policy, and research partners collaborated in design, planning, and implementation in order to create a sustainable model that could be rigorously evaluated for efficacy and fidelity. We will describe the use of the Donabedian quality matrix to determine the necessary characteristics of a quality program and the importance of the linkage with engineering, information technology, and clinical paradigms to connect the development of an on-the-ground clinical program with the evaluation goal of a learning healthcare organization. While the LCSDP is the example given here, these partnerships and suggestions are salient to any healthcare organization seeking to implement new scientifically proven care in a useful and reliable way.
    Journal of General Internal Medicine 10/2014; DOI:10.1007/s11606-014-3026-3 · 3.42 Impact Factor
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    ABSTRACT: Physician non-adherence to repeat colonoscopy guidelines for screening and polyp surveillance in an integrated managed care system Purpose Colonoscopy can decrease colorectal cancer (CRC) mortality; however, performing colonoscopy more frequently than recommended may increase cost and risk. The primary aim of this study was to determine rates and correlates of physician non-adherence to guidelines for colonoscopy screening and polyp surveillance intervals. The effectiveness of cancer screening and prevention programs will be diminished if capacity is reduced by overutilization of colonoscopy due to physician non-adherence to published guidelines. Results from this study can inform efforts to improve these types of programs, enhance provider education, and better align use of colonoscopy for CRC screening and surveillance with clinical guidelines. Methods The VA electronic medical records of 2,443 patients aged 50-64, with a fiscal year 2008 VA facility-performed colonoscopy, and no colonoscopy in prior 10 years, were reviewed and data were abstracted. Additional physician data were merged from the American Medical Association (AMA) masterfile. Patients with incomplete colonoscopies or inadequate bowel preparations were excluded from analysis (n=988). Non-adherence was defined as any recommendation that did not match the guideline follow-up interval. Data were collected from 25 VA hospitals that were randomly selected from 85 qualifying facilities stratified by academic affiliation (academic/non-academic)*geographic region (4)*resource level (complexity score = high vs. medium/low) subgroups that performed ≥500 colonoscopies in fiscal year 2008. Patients were grouped into clinical scenarios based on index colonoscopy results including: no polyp/normal tissue (n=893), hyperplastic polyp only (n=203), low risk adenoma (1-2 adenomas < 1cm; n=231), and higher risk adenoma (3-10 adenomas or any adenoma ≥1 cm or high grade dysplasia; n=128). The proportion of non-adherent recommendations was calculated for each of these four groups. We calculated adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between non-adherence, risk group, and physician characteristics using SUDAAN software (v11.0.0) to account for our complex sample design. Results The overall non-adherence rate was 36% and ranged from 3% to 80% across medical facilities. Non-adherence varied by colonoscopy results: 28% among normal colonoscopies, 52% for hyperplastic polyps, 45% for low risk adenomas and 49% for higher risk adenomas. All non-adherent recommendations dictated a shorter interval. In adjusted analyses, non-adherence was significantly higher for colonoscopies with hyperplastic (OR=3.1, 95% CI (1.7, 5.6), or adenomatous polyps (low risk adenoma OR=2.1, 95% CI (1.1, 4.2); high risk adenoma OR=2.8, 95% CI (1.2, 6.7)) compared to normal colonoscopies. Non-adherence was also significantly associated with geographic region, Charlson comorbidity score, and colonoscopy type. There were higher adjusted odds of non-adherence for colonoscopies performed in the Northeast than the Midwest (OR=4.6, 95% CI (1.8, 11.8)); for increasing comorbidity (OR=1.2 for a 1 unit Charlson score increase, 95% CI (1.1, 1.3)) and for colonoscopies in which the indication was surveillance rather than screening (OR=2.5 95% CI (1.1, 5.6)). No other statistically significant associations were noted. Conclusions In a managed care setting with salaried physicians, over a third of recommendations suggested repeat colonoscopy sooner than guidelines. The strongest predictors of non-adherence were colonoscopy findings and geographic region. Further research should investigate if targeting non-adherence to colonoscopy guidelines can reduce colonoscopy overuse and associated healthcare costs.
    ASSOCIATION OF VA HEMATOLOGY/ONCOLOGY, Portland, Oregon; 09/2014
  • Annals of internal medicine 08/2014; 161(8). DOI:10.7326/M14-1070 · 16.10 Impact Factor
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    ABSTRACT: Patients diagnosed with colorectal cancer (CRC) are at risk for synchronous and metachronous lesions at time of diagnosis or during follow up. We performed a population-based study to evaluate the rate, predictors, and familial risk for synchronous and metachronous CRC in Utah. All newly diagnosed cases of CRC between 1980 and 2010 were obtained from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database. Of the 18,782 patients diagnosed with CRC, 134 were diagnosed with synchronous CRC (0.71%) and 300 with metachronous CRC (1.60%). The risk for synchronous CRC was significantly higher in men (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.02-2.06) and in patients age 65 years or older (OR, 1.50; 95% CI, 1.02-2.21). Synchronous CRCs were more often located in the proximal colon (OR, 1.70; 95% CI, 1.20-2.41). First-degree relatives of cases with synchronous (OR, 1.86; 95% CI, 1.37-2.53), metachronous (OR, 2.34; 95%CI, 1.62-3.36), or solitary CRC (OR, 1.75; 95% CI, 1.63-1.88) were at increased risk for developing CRC, compared to relatives of CRC-free individuals. Four percent of first-degree relatives of patients with synchronous or metachronous cancer developed CRC at younger ages than the age recommended for initiating colorectal cancer screening (based on familial risk), and therefore would not have been screened. Of patients diagnosed with CRC, 2.3% are found to have synchronous lesions or develop metachronous CRC during follow up. Relatives of these patients have a greater risk of CRC than those without a family history of CRC. These results highlight the importance of obtaining a thorough family history and adhering strictly to surveillance guidelines during management of high-risk patients.
    Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 04/2014; 12(12). DOI:10.1016/j.cgh.2014.04.017 · 6.53 Impact Factor
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    Ziad F Gellad, Corrine I Voils, Li Lin, Dawn Provenzale
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    ABSTRACT: Background. Quality indicators for colonoscopy have been developed, but the uptake of these metrics into practice is uncertain. Our aims were to assess physician perceptions regarding colonoscopy quality measurement and to quantify the perceived impact of quality measurement on clinical practice. Methods. We conducted in-person interviews with 15 gastroenterologists about their perceptions regarding colonoscopy quality. Results from these interviews informed the development of a 34-question web-based survey that was emailed to 1,500 randomlyselected members of the American College of Gastroenterology. Results. 160 invitations were undeliverable, and 167 out of 1340 invited physicians (12.5%) participated in the survey. Respondents and nonrespondents did not differ in age, sex, practice setting, or years since training. 38.8% of respondents receive feedback on their colonoscopy quality. The majority of respondents agreed with the use of completion rate (90%) and adenoma detection rate (83%) as quality indicators but there was less enthusiasm for withdrawal time (61%). 24% of respondents reported usually or always removing diminutive polyps solely to increase their adenoma detection rate, and 20% reported prolonging their procedure time to meet withdrawal time standards. Conclusions. A minority of respondents receives feedback on the quality of their colonoscopy. Interventions to increase continuous quality improvement in colonoscopy screening are needed.
    Gastroenterology Research and Practice 03/2014; 2014:510494. DOI:10.1155/2014/510494 · 1.50 Impact Factor
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    ABSTRACT: High-quality supportive care is an essential component of comprehensive cancer care. We implemented a patient-centered quality of cancer care survey to examine and identify predictors of quality of supportive care for bowel problems, pain, fatigue, depression, and other symptoms among 1,109 patients with colorectal cancer. Patients with new diagnosis of colorectal cancer at any Veterans Health Administration medical center nationwide in 2008 were ascertained through the Veterans Affairs Central Cancer Registry and sent questionnaires assessing a variety of aspects of patient-centered cancer care. We received questionnaires from 63% of eligible patients (N = 1,109). Descriptive analyses characterizing patient experiences with supportive care and binary logistic regression models were used to examine predictors of receipt of help wanted for each of the five symptom categories. There were significant gaps in patient-centered quality of supportive care, beginning with symptom assessment. In multivariable modeling, the impact of clinical factors and patient race on odds of receiving wanted help varied by symptom. Coordination of care quality predicted receipt of wanted help for all symptoms, independent of patient demographic or clinical characteristics. This study revealed substantial gaps in patient-centered quality of care, difficult to characterize through quality measurement relying on medical record review alone. It established the feasibility of collecting patient-reported quality measures. Improving quality measurement of supportive care and implementing patient-reported outcomes in quality-measurement systems are high priorities for improving the processes and outcomes of care for patients with cancer.
    Journal of Clinical Oncology 02/2014; 32(8). DOI:10.1200/JCO.2013.49.4302 · 17.88 Impact Factor
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    ABSTRACT: Colorectal cancers (CRC) diagnosed within a few years after an index colonoscopy can arise from missed lesions or the development of a new tumor. We investigated the proportion, characteristics, and factors that predict interval CRCs that develop within 6-60 months of colonoscopy. We performed a population-based cohort study of residents of Utah who underwent colonoscopy examinations from 1995 through 2009 at Intermountain Healthcare or University of Utah Health System, which provide care to >85% of state residents. Colonoscopy results were linked with cancer histories from the Utah Population Database to identify patients who underwent colonoscopy 6-60 months before a diagnosis of CRC (interval cancer). Logistic regression was performed to identify risk factors associated with interval cancers. Of 126,851 patients who received colonoscopies, 2,659 were diagnosed with CRC; 6% of these CRCs (159/2659) developed within 6 to 60 months of a colonoscopy. Sex and age were not associated with interval CRCs. A higher percentage of patients with interval CRC were found to have adenomas at their index colonoscopy (57.2%), compared with patients found to have CRC detected at colonoscopy (36%) or patients who did not develop cancer (26%) (P<.001). Interval CRCs tended to be earlier-stage tumors than those detected at index colonoscopy, and to be proximally located (odds ratio [OR], 2.24; P<.001). Patients with interval CRC were more likely to have a family history of CRC (OR, 2.27; P=.008) and had a lower risk of death than patients found to have CRC at their index colonoscopy (HR, 0.63; P<.001). In a population-based study in Utah, 6% of all patients with CRC had interval cancers (cancer that developed within 6 to 6 months of a colonoscopy). Interval CRCs were associated with the proximal colon, earlier-stage cancer, lower risk of death, higher rate of adenoma, and family history of CRC. These findings indicate that interval colorectal tumors may arise due to distinct biologic features and/or suboptimal management of polyps at colonoscopy.
    Gastroenterology 01/2014; 146(4). DOI:10.1053/j.gastro.2014.01.013 · 13.93 Impact Factor
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    ABSTRACT: Background & Aims Patients diagnosed with colorectal cancer (CRC) are at risk for synchronous and metachronous lesions at time of diagnosis or during follow up. We performed a population-based study to evaluate the rate, predictors, and familial risk for synchronous and metachronous CRC in Utah. Methods All newly diagnosed cases of CRC between 1980 and 2010 were obtained from the Utah Cancer Registry and linked to pedigrees from the Utah Population Database. Results Of the 18,782 patients diagnosed with CRC, 134 were diagnosed with synchronous CRC (0.71%) and 300 with metachronous CRC (1.60%). The risk for synchronous CRC was significantly higher in men (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.02–2.06) and in patients age 65 years or older (OR, 1.50; 95% CI, 1.02–2.21). Synchronous CRCs were more often located in the proximal colon (OR, 1.70; 95% CI, 1.20–2.41). First-degree relatives of cases with synchronous (OR, 1.86; 95% CI, 1.37–2.53), metachronous (OR, 2.34; 95%CI, 1.62–3.36), or solitary CRC (OR, 1.75; 95% CI, 1.63–1.88) were at increased risk for developing CRC, compared to relatives of CRC-free individuals. Four percent of first-degree relatives of patients with synchronous or metachronous cancer developed CRC at younger ages than the age recommended for initiating colorectal cancer screening (based on familial risk), and therefore would not have been screened. Conclusions Of patients diagnosed with CRC, 2.3% are found to have synchronous lesions or develop metachronous CRC during follow up. Relatives of these patients have a greater risk of CRC than those without a family history of CRC. These results highlight the importance of obtaining a thorough family history and adhering strictly to surveillance guidelines during management of high-risk patients.
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    ABSTRACT: Mortality from colorectal cancer can be reduced by early diagnosis and by cancer prevention through polypectomy. These NCCN Guidelines for Colorectal Cancer Screening describe various colorectal screening modalities and recommended screening schedules for patients at average or increased risk of developing colorectal cancer. In addition, the guidelines provide recommendations for the management of patients with high-risk colorectal cancer syndromes, including Lynch syndrome. Screening approaches for Lynch syndrome are also described.
    Journal of the National Comprehensive Cancer Network: JNCCN 12/2013; 11(12):1538-1575. · 4.24 Impact Factor
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    ABSTRACT: Racial disparities in cancer treatment and outcomes are a national problem. The nationwide Veterans Affairs (VA) health system seeks to provide equal access to quality care. However, the relationship between race and care quality for veterans with colorectal cancer (CRC) treated within the VA is poorly understood. We examined the association between race and receipt of National Comprehensive Cancer Network guideline-concordant CRC care. This was an observational, retrospective medical record abstraction of patients with CRC treated in the VA. Two thousand twenty-two patients (white, n = 1,712; African American, n = 310) diagnosed with incident CRC between October 1, 2003, and March 31, 2006, from 128 VA medical centers, were included. We used multivariable logistic regression to examine associations between race and receipt of guideline-concordant care (computed tomography scan, preoperative carcinoembryonic antigen, clear surgical margins, medical oncology referral for stages II and III, fluorouracil-based adjuvant chemotherapy for stage III, and surveillance colonoscopy for stages I to III). Explanatory variables included demographic and disease characteristics. There were no significant racial differences for receipt of guideline-concordant CRC care. Older age at diagnosis was associated with reduced odds of medical oncology referral and surveillance colonoscopy. Presence of cardiovascular comorbid conditions was associated with reduced odds of medical oncology referral (odds ratio, 0.65; 95% CI, 0.50 to 0.89). In these data, we observed no evidence of racial disparities in CRC care quality. Future studies could examine causal pathways for the VA's equal, quality care and ways to translate the VA's success into other hospital systems.
    Journal of Clinical Oncology 09/2013; 31(28). DOI:10.1200/JCO.2013.50.4753 · 17.88 Impact Factor
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    ABSTRACT: Veterans Affairs (VA) manages the largest US integrated health care system. Although quality of VA colorectal cancer (CRC) care is well chronicled, there is a paucity of research examining racial differences in this care. This study examines racial differences in 2 dimensions of quality of VA CRC care: processes (time to treatment) and outcomes (survival). Retrospective data were from the VA External Peer Review Program (EPRP), a nationwide VA quality-monitoring program. Study patients were white and African American men diagnosed with nonmetastatic CRC between 2003 and 2006 who received definitive CRC surgery. We examined 3 quality indicators: time from (1) surgery to initiation of adjuvant chemotherapy (stages II-III disease), (2) surgery to surveillance colonoscopy (stages I-III disease), and (3) surgery to death (stages I-III disease). Unadjusted analyses used log-rank and Wilcoxon tests. Adjusted analyses used Cox proportional hazard models. In unadjusted analyses, there was no evidence of racial differences across the 3 quality measures. In adjusted Cox regression, there were no racial differences in time to initiation of chemotherapy (hazard ratio [HR], 0.82; P = .61) or surgery to death (HR, 0.94; P = .49). In adjusted Cox regression, among those receiving colonoscopy within 7 to 18 months after surgery, white patients experienced slightly shorter median times to surveillance colonoscopy than did African American patients (367 vs. 383 days; HR, 0.63; P = .02). Other than a small racial difference in timing of surveillance colonoscopy, there was little evidence of racial differences in quality of CRC care among VA health care system users.
    Clinical Colorectal Cancer 08/2013; DOI:10.1016/j.clcc.2013.06.004 · 2.91 Impact Factor
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    ABSTRACT: Current strategies fail to identify most patients with esophageal adenocarcinoma (EAC) before the disease becomes advanced and incurable. Given the dismal prognosis associated with EAC, improvements in detection of early-stage esophageal neoplasia are needed. We sought to assess whether differential expression of microRNAs could discriminate between squamous epithelium, Barrett's esophagus (BE), and EAC. We analyzed microRNA expression in a discovery cohort of human endoscopic biopsy samples from 36 patients representing normal squamous esophagus (n = 11), BE (n = 14), and high-grade dysplasia/EAC (n = 11). RNA was assessed using microarrays representing 847 human microRNAs followed by quantitative real-time polymerase chain reaction (qRT-PCR) verification of nine microRNAs. In a second cohort (n = 18), qRT-PCR validation of five miRNAs was performed. Expression of 59 microRNAs associated with BE/EAC in the literature was assessed in our training cohort. Known esophageal cell lines were used to compare miRNA expression to tissue miRNAs. After controlling for multiple comparisons, we found 34 miRNAs differentially expressed between squamous esophagus and BE/EAC by microarray analysis. However, miRNA expression did not reliably differentiate non-dysplastic BE from EAC. In the validation cohort, all five microRNAs selected for qRT-PCR validation differentiated between squamous samples and BE/EAC. Microarray results supported 14 of the previously reported microRNAs associated with BE/EAC in the literature. Cell lines did not generally reflect miRNA expression found in vivo. These data indicate that miRNAs differ between squamous esophageal epithelium and BE/EAC, but do not distinguish between BE and EAC. We suggest prospective evaluation of miRNAs in patients at high risk for EAC.
    Digestive Diseases and Sciences 08/2013; 58(11). DOI:10.1007/s10620-013-2806-7 · 2.55 Impact Factor
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    Ziad F Gellad, Corrine I Voils, Li Lin, Dawn Provenzale
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    ABSTRACT: We investigated physician beliefs and behaviors regarding diminutive colorectal polyps and the contribution of these beliefs to variable detection rates. One hundred sixty-seven members of the American College of Gastroenterology took a Web-based survey. We compared respondents and nonrespondents using demographic and practice information from the American Medical Association Physician Masterfile. Respondents varied in their definition of diminutive polyps. Respondents acknowledged leaving diminutive polyps in place during colonoscopy in various scenarios. Years in practice, confidence in endoscopic histologic diagnosis, and never having seen advanced histology in a diminutive polyp were predictive of leaving polyps in place. The majority of respondents were at least somewhat agreeable to leaving diminutive polyps in place if guidelines endorsed this practice. Gastroenterologists vary in their removal of diminutive polyps. The results have implications for the interpretation and management of variable polyp detection rates.
    The American Journal of Gastroenterology 06/2013; 108(6):873-8. DOI:10.1038/ajg.2012.316 · 9.21 Impact Factor
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    ABSTRACT: Symptom-based conditions such as chronic fatigue syndrome (CFS) and medically unexplained multi-symptom illness (MSI) are fairly common in the general population and are also important veteran's health concerns due to their higher frequency among U.S. veterans who served during the 1990-1991 Gulf War. CFS, MSI, and other symptom-based conditions are often associated with considerable morbidity due to fatigue, chronic pain, neurologic symptoms, and other symptoms that can impair the quality of life. This article discusses several important issues of methodology that arise in population studies of CFS and MSI. These include the exclusion criteria that have been used in population studies to define CFS-like illness and unexplained MSI, the potential for false positive and false negative assessments of illness status, the potential for sex differences, and the poorly understood natural history of these symptom-based conditions across the life span. As an empirical example of these methodology issues, we examined existing data from a 2005 follow-up survey. We found that 64.9% (762 of 1,175) of female Gulf War veterans and 53.4% (2,530 of 4,739) of male Gulf War veterans had 1 or more exclusionary medical conditions. The prevalence among veterans with one or more exclusionary medical conditions increased markedly by age among females and those with a low income.
    05/2013; 21(2):4-10.
  • Digestive Disease Week 2013; 05/2013
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    ABSTRACT: Objectives: Efficient resource use is relevant in all healthcare systems. Although colorectal cancer is common, little has been published regarding the utilization of clinical resources in diagnosis. Study Design: The primary aim was to evaluate the patterns and factors associated with clinical services used to diagnose colorectal cancer at 14 US Department of Veterans Affairs facilities. The secondary aim was to investigate whether using more clinical services was associated with time to diagnosis. Methods: We reviewed medical records for 449 patients with colorectal cancer in an observational study. Study end points were the use of clinical diagnostic services grouped as laboratory tests, imaging studies, and subspecialty consultations. Cumulative logistic regression models were used to explore factors associated with each outcome. Results: Facility variability contributed to the variability of resource use in all models. In adjusted analyses, older patients had higher use of laboratory tests (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.02-1.43) and incidentally discovered colorectal cancer was associated with increased use of consultations (OR, 1.97; 95% CI, 1.27-3.05), imaging studies (OR, 1.70; 95% CI, 1.12-2.58), and laboratory tests (OR, 3.14; 95% CI, 2.06-4.77) compared with screen-detected cancers. There was a strong direct correlation between thenumber of diagnostic services performed and the median time to diagnosis (Spearman correlation coefficient, 0.99; P < .001). Conclusions: Variability in utilization of diagnostic clinical services was associated with patient age, patient presentation, and facility. Increased resource use was highly correlated with increased time to diagnosis.
    The American journal of managed care 05/2013; 19(5):370-6. · 2.17 Impact Factor
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    ABSTRACT: Clinical practice guidelines can be used to help develop measures of quality of cancer care. This article describes the use of a Cancer Care Quality Measurement System (CCQMS) to monitor these measures for colorectal cancer in the Veterans Health Administration (VHA). The CCQMS assessed practice guideline concordance primarily based on colon (14 indicators) and rectal (11 indicators) cancer care guidelines of the NCCN. Indicators were developed with input from VHA stakeholders with the goal of examining the continuum of diagnosis, neoadjuvant therapy, surgery, adjuvant therapy, and survivorship surveillance and/or end-of-life care. In addition, 9 measures of timeliness of cancer care were developed. The measures/indicators formed the basis of a computerized data abstraction tool that produced reports on quality of care in real-time as data were entered. The tool was developed for a 28-facility learning collaborative, the Colorectal Cancer Care Collaborative (C4), aimed at improving colorectal cancer (CRC) care quality. Data on 1373 incident stage I-IV CRC cases were entered over approximately 18 months and were used to target and monitor quality improvement activities. The primary opportunity for improvement involved surveillance colonoscopy and services in patients after curative-intent treatment. NCCN Clinical Practice Guidelines in Oncology were successfully used to develop a measurement system for a VHA research-operations quality improvement partnership.
    Journal of the National Comprehensive Cancer Network: JNCCN 04/2013; 11(4):431-441. · 4.24 Impact Factor
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    ABSTRACT: BACKGROUND: The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer. METHODS: Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy. RESULTS: Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy. CONCLUSIONS: The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens. Cancer 2012. © 2012 American Cancer Society.
    Cancer 02/2013; 119(4). DOI:10.1002/cncr.27815 · 4.90 Impact Factor

Publication Stats

4k Citations
1,069.40 Total Impact Points

Institutions

  • 2014
    • San Francisco VA Medical Center
      San Francisco, California, United States
    • Dana-Farber Cancer Institute
      Boston, Massachusetts, United States
  • 1998–2014
    • Duke University Medical Center
      • Department of Medicine
      Durham, North Carolina, United States
  • 1995–2014
    • Duke University
      • Department of Medicine
      Durham, North Carolina, United States
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 1997–2013
    • University of North Carolina at Chapel Hill
      • • Department of Health Policy & Management
      • • Center for Gastrointestinal Biology and Disease
      North Carolina, United States
  • 2002–2011
    • Minneapolis Veterans Affairs Hospital
      Minneapolis, Minnesota, United States
  • 2008
    • Mayo Clinic
      • Department of Internal Medicine
      Jacksonville, Florida, United States
  • 2004
    • Boston Medical Center
      Boston, Massachusetts, United States
  • 2001–2003
    • North Carolina Clinical Research
      Raleigh, North Carolina, United States
    • University of Alabama at Birmingham
      Birmingham, Alabama, United States
  • 1994
    • Tufts University
      • Division of Gastroenterology
      Boston, GA, United States