Cigarette Smoking, Reduction and Quit Attempts: Prevalence Among Veterans With Coronary Heart Disease.

INTRODUCTION: Cigarette smoking increases the risk of illness and early death for people with coronary heart disease. In 2010, Brown estimated prevalence rates for smoking among veterans and nonveterans with or without coronary heart disease in the United States, based on the 2003 through 2007 data from the Behavioral Risk Factor Surveillance System (BRFSS). Recent changes in BRFSS methods promise more accurate estimates for veterans. To inform assessment of efforts to reduce smoking, we sought to provide prevalence rates for smoking behaviors among US veterans with coronary heart disease and to compare rates for veterans with those for civilians. METHODS: We conducted a cross-sectional analysis of participants who responded to BRFSS from 2009 to 2012. Accounting for complex BRFSS sampling, we estimated national prevalence rates by sex for smoking status, frequency, and quit attempts; for those with and those without coronary heart disease; for civilians; for veterans and active duty personnel combined; and, after adjusting for BRFSS mingling of active duty personnel and veterans, for veterans only. We examined differences between veterans and civilians by using age-standardized national estimates. RESULTS: Among men with coronary heart disease, more veterans than civilians smoked and more were daily smokers, but veterans were no more likely to attempt to quit. Among women with coronary heart disease, we found no differences between civilians and veterans. CONCLUSION: Cigarette smoking is more prevalent among male veterans with coronary heart disease than among their civilian counterparts. Not distinguishing active duty personnel from veterans can materially affect prevalence estimates intended to apply solely to veterans.

Surveyed Enrollees in Veterans Affairs Health Care: How They Differ From Eligible Veterans Surveyed by BRFSS.

OBJECTIVES: We described differences in demographic and socioeconomic characteristics between Veterans enrolled in the Veterans Health Administration (VHA) and Veterans eligible to enroll for Veterans Affairs health care. Knowledge of these differences is important in planning better services for Veterans who enroll and in encouraging additional enrollment. METHODS: We compared characteristics of enrollees and eligible Veterans in 2012. To describe enrollees, we used aggregate data from administrative records and results from VHA's Survey of Veteran Enrollees' Health and Reliance Upon VA. To describe eligible Veterans, we analyzed individual-level data from the Behavioral Risk Factor Surveillance System. RESULTS: Elderly individuals are more heavily represented among enrollees than eligible Veterans, and elderly enrollees are less likely to describe their health as good to excellent. Enrollees are more than twice as likely as eligible Veterans to have annual household incomes below $16,000. Representation of minorities is roughly the same among enrollees as eligible Veterans. CONCLUSIONS: Our results are consistent with VHA as a safety net provider with respect to income, age, and disease burden.

A sustained virologic response reduces risk of all-cause mortality in patients with hepatitis C.

BACKGROUND & AIMS: The effectiveness of hepatitis C virus (HCV) treatment with pegylated interferon and ribavirin usually is evaluated by the surrogate end point of sustained virologic response (SVR), although the ultimate goal of antiviral treatment is to reduce mortality. The impact of SVR on all-cause mortality is not well documented by HCV genotype or in populations in routine medical practice with substantial comorbidities. METHODS: From the US Department of Veterans Affairs (VA), we identified all patients infected with HCV genotypes 1, 2, or 3, without human immunodeficiency virus co-infection or hepatocellular carcinoma before HCV treatment with pegylated interferon and ribavirin, who started HCV treatment from January 2001 to June 2007, stopped treatment by June 2008, and had a posttreatment HCV RNA test result of SVR or no SVR. Mortality data from VA and non-VA sources were available through 2009. RESULTS: HCV genotypes 1, 2, or 3 cohorts consisted of 12,166, 2904, and 1794 patients, respectively, with SVR rates of 35%, 72%, and 62%, respectively. Each cohort had high rates of comorbidities. During a median follow-up period of approximately 3.8 years, 1119 genotype-1, 220 genotype-2, and 196 genotype-3 patients died. In genotype-specific multivariate survival models that controlled for demographic factors, comorbidities, laboratory characteristics, and treatment characteristics, an SVR was associated with substantially reduced mortality risk for each genotype (genotype-1 hazard ratio, 0.70; P < .0001; genotype-2 hazard ratio, 0.64; P = .006; genotype-3 hazard ratio, 0.51; P = .0002). CONCLUSIONS: An SVR reduced mortality among patients infected with HCV of genotypes 1, 2, or 3 who were being treated by routine medical practice and had substantial comorbidities.

National quality forum performance measures for HIV/AIDS care: the Department of Veterans Affairs' experience.

BACKGROUND: Information technology promises to improve health care through reporting of standardized quality-of-care measures. In 2008, the National Quality Forum (NQF) first endorsed performance measures for human immunodeficiency virus (HIV)/AIDS care. Little is known about performance on these measures in routine medical practice. We assessed performance using available electronic data for the large, diverse population with HIV in the Department of Veterans Affairs (VA) and evaluated the influence of patient and resource factors. METHODS: In a retrospective analysis of observational data for 21 564 patients with HIV receiving VA medical care in 2008, we determined performance rates for 10 NQF measures for HIV/AIDS care for the VA nationwide and for 73 facilities with caseloads of 100 or more patients with HIV. RESULTS: National rates for 6 measures were greater than 80%; the remaining measures and their rates were as follows: annual syphilis screening (54%), tuberculosis screening (65%), Pneumocystis pneumonia prophylaxis (72%), and HIV RNA control (73%). For all measures, rates varied across facilities. In multivariate logistic regression models, African Americans and hard drug users were less likely to access care and less likely to receive HIV-specific care but more likely to receive indicated general medical care. Resource factors (number of primary care/infectious disease outpatient visits, duration of care, and larger facility caseload) were associated with increased likelihood of receipt of indicated general and HIV-specific care. CONCLUSIONS: National performance rates were generally high, but variation in rates across facilities revealed room for improvement. Both patient and resource factors had an impact on the likelihood of receipt of indicated care.

Clinical Case Registries: simultaneous local and national disease registries for population quality management.

The Department of Veterans Affairs (VA) has a system-wide, patient-centric electronic medical record system (EMR) within which the authors developed the Clinical Case Registries (CCR) to support population-centric delivery and evaluation of VA medical care. To date, the authors have applied the CCR to populations with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Local components use diagnosis codes and laboratory test results to identify patients who may have HIV or HCV and support queries on local care delivery with customizable reports. For each patient in a local registry, key EMR data are transferred via HL7 messaging to a single national registry. From 128 local registry systems, over 60,000 and 320,000 veterans in VA care have been identified as having HIV and HCV, respectively, and entered in the national database. Local and national reports covering demographics, resource usage, quality of care metrics and medication safety issues have been generated.

Predictors of response of US veterans to treatment for the hepatitis C virus.

UNLABELLED: The currently recommended treatment for hepatitis C virus (HCV) infection is pegylated interferon alfa (PEG-INF) and ribavirin, which can be difficult to tolerate. More information about predicting sustained virologic response (SVR) may allow more informed treatment decisions to be made. This retrospective observational cohort study identified predictors of SVR to PEG-INF and ribavirin in routine medical practice at 121 Department of Veterans Affairs facilities. Among 5,944 patients infected with HCV genotypes 1, 2, or 3 who had been treated with PEG-INF and ribavirin, SVR rates were 20%, 52%, and 43%, respectively, and discontinuation rates were 68% (prior to 48 weeks), 34% (24 weeks), and 41% (24 weeks), respectively. In multivariate analysis, significant predictors of decreased likelihood of genotype 1 patients having an SVR were being African American, clinical liver disease, diabetes, low cholesterol, low hemoglobin, low platelet count, and treatment at a low-volume facility. Predictors of increased likelihood of genotype 1 patients having an SVR were low-level HCV viremia, elevated ALT quotient, and receiving PEG-INF 2A (rather than 2B). For genotype 2 patients, increasing body mass index, prior use of interferon, and low platelet count were negative predictors; only low-level HCV viremia was a positive predictor. For genotype 3 patients, only receiving PEG-INF 2A affected the likelihood of an SVR; its effect was positive. CONCLUSION: Among patients for whom HCV treatment is initiated during routine medical care, multiple factors including form of PEG-INF received affect the SVR rate for genotype 1 patients. Few of these factors affect the rate for genotype 2 patients, and even fewer do so for genotype 3 patients.

Effects of hepatitis C virus coinfection on survival in veterans with HIV treated with highly active antiretroviral therapy.

BACKGROUND: With highly active antiretroviral therapy (HAART) available for patients with HIV, hepatitis C virus (HCV) infection has emerged as a potentially important cause of mortality in coinfected patients. Several studies have investigated the effect of coinfection on mortality, with conflicting results. METHODS: The study cohort consisted of HIV-infected veterans on HAART receiving care at US Department of Veterans Affairs facilities. Inclusion was based on first HAART prescription between January 1997 and February 2003, HCV antibody test result, and baseline CD4 and HIV viral load results within 1 year of starting HAART. We fitted Cox proportional hazards models to study the effect of HCV serostatus on survival time from HAART initiation, controlling for patient demographic and clinical characteristics, facility characteristics, HAART exposure, HAART response, and HCV treatment. RESULTS: Of 12,216 patients in the study cohort, 38% were HCV-seropositive. During an observation time averaging 3.5 years, 2087 patients died. The adjusted hazard ratio for HCV-seropositive patients was 1.56 (95% confidence interval [CI]: 1.42-1.70; P<0.0001) without a HAART exposure measure and 1.38 (95% CI: 1.26-1.51; P<0.0001) with the measure. We obtained similar results in analyses also controlling for HAART response. CONCLUSIONS: HCV seropositivity was independently associated with increased risk of death in a large cohort of HAART-treated HIV-infected veterans. Given the success of HAART in extending the lives of HIV patients, HCV has become an important predictor of their mortality.