Thomas E Moritz’s research while affiliated with Edward Hines, Jr. VA Hospital and other places

Importance The costs and utility of teledermatology are important features of implementation. Such an analysis requires a description of the perspective of the entity that will bear the cost.Objective To assess the costs and utility of a store-and-forward teledermatology referral process compared with a conventional referral process from the perspectives of the Department of Veterans Affairs (VA) and society.Design, Setting, and Participants Three hundred ninety-one randomized participants were referred from remote sites of primary care to the dermatology services of 2 VA medical facilities for ambulatory skin conditions from December 2008 through June 2010, and follow-up was completed in March 2011. The time trade-off utility measures and costs were collected during a 9-month period among participants in a 2-site parallel group randomized clinical trial. The perspectives of the VA and society were evaluated. The multiple imputation procedure or weighted means were used for missing data elements. Data were analyzed from January to July 2014.Interventions Referrals were managed using store-and-forward teledermatology or a conventional text-based referral process.Main Outcomes and Measures Total costs from the perspectives of the VA and society incurred during the 9-month follow-up were used to derive per-participant costs. Utility, using the time trade-off method, was the measure of effectiveness.Results From the VA perspective, the total cost for conventional referrals was $66 145 (minimum,$58 697; maximum, $71 635), or$338 (SD, $291) per participant (196 participants); the total cost for teledermatology referrals was$59 917 (mimimum, $51 794; maximum,$70 398), or $308 (SD,$298) per participant (195 participants). The $30 difference in per-participant cost was not statistically significant (95$79 to $20). From the societal perspective, the total cost for conventional referrals was$106 194 (minimum, $98 746; maximum,$111 684), or $542 (SD,$403) per participant (196 participants); the total cost for teledermatology referrals was $89 523 (minimum,$81 400; maximum, $100 400) or$460 (SD, $428) per participant. This$82 difference in per-participant cost was statistically significant (95% CI, −$12 to −$152). From baseline to the 9-month follow-up, the time trade-off utility value improved by 0.02 in the conventional referral group and 0.03 in the teledermatology group. This difference was not statistically significant (P = .50).Conclusions and Relevance Compared with conventional referrals, store-and-forward teledermatology referrals were performed at a comparable cost (VA perspective) or at a lower cost (societal perspective) with no evidence of a difference in utility as measured by the time trade-off method.Trial Registration clinicaltrials.gov Identifier: NCT00488293

Rosiglitazone may be associated with increased risk of cardiovascular (CV) disease in patients with type 2 diabetes (T2D). We evaluated the relationship between patterns of rosiglitazone use and CV outcomes in the Veterans Affairs Diabetes Trial (VADT). Time-dependent survival analyses, case-control and 1:1 propensity matching approaches were used to examine this relationship in the VADT, a randomized controlled study that assessed the effect of intensive glycemic control on CV outcomes in 1791 T2D patients (mean age of 60.4 ± 9 years). Participants were recruited from December 1, 2000, through May 31, 2003, and were followed for 5 to 7.5 years (median 5.6) with the final visit by May 31, 2008. Rosiglitazone (4 mg and 8 mg daily) was initiated per protocol in both intensive-therapy and standard-therapy groups. Main outcomes include a composite CV outcome, CV death, and myocardial infarction (MI). Both daily doses of rosiglitazone were associated with lower risk for the primary composite CV outcome (HR 0.63; 95% CI 0.49-0.81 and HR 0.60; 95% CI 0.49-0.75, respectively) after adjusting for demographic and clinical covariates. A reduction of CV death was also observed (HR 0.25, p < 0.001, for both 4 and 8 mg/day rosiglitazone), however the effect on MI was less evident for 8 mg/day and not significant for 4 mg/day. In older patients with T2D the use of rosiglitazone was associated with decreased risk of the primary CV composite outcome and CV death. Rosiglitazone use did not lead to higher risk of MI. This article is protected by copyright. All rights reserved.

Progression of lipid rich necrotic core elements of atherosclerotic vulnerable plaque (VP) or its rupture leads to a majority of cardiovascular events. Endothelial progenitor cells (EPC) contribute to vascular healing and play a crucial role in repair following ischemic injury primarily by endothelialization of VP and neovascularization of ischemic myocardium. We present the rationale and design of the Plaque Regression and Progenitor Cell Mobilization with Intensive Lipid Elimination Regimen or the PREMIER Trial, which is designed to address the question for the very first time whether a highly intensive low-density lipoprotein (LDL)-lowering therapy with LDL-apheresis could lead to a more rapid and detectable reduction in coronary atheroma volume, along with a robust mobilization of EPC compared to standard statin therapy, in patients selected for percutaneous coronary intervention for an acute coronary syndrome. J. Clin. Apheresis, 2013. © 2013 Wiley Periodicals, Inc.

Aim: Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in adults with type 2 diabetes mellitus. The aim of the present study was to test whether plasma basic fibroblast growth factor (bFGF) levels predict future CVD occurrence in adults from the Veterans Affairs Diabetes Trial (VADT). Methods: Nearly 400 veterans, 40 years of age or older having a mean baseline diabetes duration of 11.4 years were recruited from outpatient clinics at six geographically distributed sites in the VADT. Within the VADT, they were randomly assigned to intensive or standard glycemic treatment, with follow-up as much as seven and one-half years. CVD occurrence was examined at baseline in the patient population and during randomized treatment. Plasma bFGF was determined with a sensitive, specific two-site enzyme-linked immunoassay at the baseline study visit in all 399 subjects and repeated at the year 1 study visit in a randomly selected subset of 215 subjects. Results: One hundred and five first cardiovascular events occurred in these 399 subjects. The best fit model of risk factors associated with the time to first CVD occurrence (in the study) over a seven and one-half year period had as significant predictors: prior cardiovascular event [hazard ratio (HR) 3.378; 95% confidence intervals (CI) 3.079–3.807; P < 0.0001), baseline plasma bFGF (HR 1.008; 95% CI 1.002–1.014; P = 0.01), age (HR 1.027; 95% CI 1.004–1.051; P = 0.019), baseline plasma triglycerides (HR 1.001; 95% CI 1.000–1.002; P = 0.02), and diabetes duration-treatment interaction (P = 0.03). Intensive glucose-lowering was associated with significantly decreased hazard ratios for CVD occurrence (0.38–0.63) in patients with known diabetes duration of 0–10 years, and non-significantly increased hazard ratios for CVD occurrence (0.82–1.78) in patients with longer diabetes duration. Conclusion: High level of plasma bFGF is a predictive biomarker of future CVD occurrence in this population of adult type 2 diabetes.