Salt Lake City, UT, United States
Salt Lake City, UT, United States

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Lafleur J.,University of Utah | Lafleur J.,Decision Enhancement and Surveillance Center | Nelson R.E.,IDEAS Center | Nelson R.E.,University of Utah | And 4 more authors.
Osteoporosis International | Year: 2012

Absolute risk assessment is now the preferred approach to guide osteoporosis treatment decisions. Data collected passively during routine healthcare operations can be used to develop discriminative absolute risk assessment rules in male veterans. These rules could be used to develop computerized clinical decision support tools that might improve fracture prevention. Introduction: Absolute risk assessment is the preferred approach to guiding treatment decisions in osteoporosis. Current recommended risk stratification rules perform poorly in men, among whom osteoporosis is overlooked and undertreated. A potential solution lies in clinical decision support technology. The objective of this study was to determine whether data passively collected in routine healthcare operations could identify male veterans at highest risk with acceptable discrimination. Methods: Using administrative and clinical databases for male veterans ≥50 years old who sought care in 2005-2006, we created risk stratification rules for hip and any major fracture. We identified variables related to known or theoretical risk factors and created prognostic models using Cox regression. We validated the rules and estimated optimism. We created risk scores from hazards ratios and used them to predict fractures with logistic regression. Results: The predictive models had C-statistics of 0.81 for hip and 0.74 for any major fracture, suggesting good to acceptable discrimination. For hip fracture, the cut-point that maximized percentage classified correctly (accuracy) predicted 165 of 227 hip fractures (73%) and missed 62 (27%). All hip fractures in patients with prior fracture were identified and 67% in patients without. For any major fracture, the maximal-accuracy cut-point predicted 611 of 987 (62%) and missed 376 (38%); the rule predicted all 134 fractures in patients with prior fracture and 56% in patients without. Conclusion: Data collected passively in routine healthcare operations can identify male veterans at highest risk for fracture with discrimination that exceeds that reported for other methods applied in men. © 2011 International Osteoporosis Foundation and National Osteoporosis Foundation.


Sauer B.,Decision Enhancement and Surveillance Center | Nebeker J.,Decision Enhancement and Surveillance Center | Shen S.,Decision Enhancement and Surveillance Center | Rupper R.,Decision Enhancement and Surveillance Center | And 5 more authors.
F1000Research | Year: 2014

Purpose: We present a framework for detecting possible adverse drug reactions (ADRs) using the Utah Medicaid administrative data. We examined four classes of ADRs associated with treatment of dementia by acetylcholinesterase inhibitors (AChEIs): known reactions (gastrointestinal, psychological disturbances), potential reactions (respiratory disturbance), novel reactions (hepatic, hematological disturbances), and death. Methods: Our cohort design linked drug utilization data to medical claims from Utah Medicaid recipients. We restricted the analysis to 50 years-old and older beneficiaries diagnosed with dementia-related diseases. We compared patients treated with AChEI to patients untreated with anti-dementia medication therapy. We attempted to remove confounding by establishing propensity-score-matched cohorts for each outcome investigated; we then evaluated the effects of drug treatment by conditional multivariable Cox-proportional-hazard regression. Acute and transient effects were evaluated by a crossover design using conditional logistic regression. Results: Propensity-matched analysis of expected reactions revealed that AChEI treatment was associated with gastrointestinal episodes (Hazard Ratio [HR]: 2.02; 95%CI: 1.28-3.2), but not psychological episodes, respiratory disturbance, or death. Among the unexpected reactions, the risk of hematological episodes was higher (HR: 2.32; 95%CI: 1.47-3.6) in patients exposed to AChEI. AChEI exposure was not associated with an increase in hepatic episodes. We also noted a trend, identified in the case-crossover design, toward increase odds of experiencing acute hematological events during AChEI exposure (Odds Ratio: 3.0; 95% CI: 0.97 - 9.3). Conclusions: We observed an expected association between AChEIs treatment and gastrointestinal disturbances and detected a signal of possible hematological ADR after treatment with AChEIs in this pilot study. Using this analytic framework may raise awareness of potential ADEs and generate hypotheses for future investigations. Early findings, or signal detection, are considered hypothesis generating since confirmatory studies must be designed to determine if the signal represents a true drug safety problem. © 2014 Sauer B et al.


Clark E.,Geriatric Research | Clark E.,Mount Sinai School of Medicine | Fitzgerald J.T.,Geriatric Research | Fitzgerald J.T.,University of Michigan | And 6 more authors.
Gerontology and Geriatrics Education | Year: 2011

Current geriatrics workforce projections indicate that clinicians who care for adults will need basic geriatrics knowledge and skills to address the geriatric syndromes and issues that limit functional independence and complicate medical management. This is most evident for the clinicians caring for veterans in the Department of Veterans Affairs hospitals and clinics nationwide. Geriatric Research, Education and Clinical Centers (GRECCs), whose staff are geriatric-content experts, have developed a number of programs to tackle this daunting educational task. This article introduces three different programs designed and implemented by GRECCs to train currently practicing health care providers in the Veterans Health Administration medical clinics. It also describes the successes and lessons learned from these three programs. © Taylor & Francis Group, LLC.


Bakdash J.Z.,Center for Human Factors in Patient Safety | Bakdash J.Z.,Decision Enhancement and Surveillance Center | Bakdash J.Z.,University of Utah | Drews F.A.,Center for Human Factors in Patient Safety | And 2 more authors.
Human Factors and Ergonomics In Manufacturing | Year: 2012

Use of current health care equipment for medical procedures (e.g., central line insertions and central line care) is primarily dependent on the cognition of the health care worker. That is, the present design of equipment (typically numerous, separately packaged individual items) provides minimal information about the optimal order of procedure steps and no defenses against human error, such as omitting steps in procedure. In this article, we propose patient safety may be improved by redesigning equipment to integrate a "checklist" using sequencing, color coding, and visual icons. We hypothesize this reduces cognitive demand by off-loading knowledge into the world, creating affordances that provide guidance reducing the likelihood of errors and promoting adherence to best practices. © 2011 Wiley Periodicals, Inc.


Gundlapalli A.V.,Decision Enhancement and Surveillance Center | Gundlapalli A.V.,University of Utah | Nelson R.E.,Decision Enhancement and Surveillance Center | Nelson R.E.,University of Utah | And 7 more authors.
PLoS ONE | Year: 2015

We describe the rates and predictors of initiation of treatment for chronic hepatitis C (HCV) infection in a large cohort of HCV positive Veterans seen in U.S. Department of Veterans Affairs (VA) facilities between January 1, 2004 and December 31, 2009. In addition, we identify the relationship between homelessness among these Veterans and treatment initiation. Univariate and multivariable Cox Proportional Hazards regression models with timevarying covariates were used to identify predictors of initiation of treatment with pegylated interferon alpha plus ribavirin. Of the 101,444 HCV treatment-naïve Veterans during the study period, rates of initiation of treatment among homeless and non-homeless Veterans with HCV were low and clinically similar (6.2% vs. 7.4%, p<0.0001). For all U.S. Veterans, being diagnosed with genotype 2 or 3, black or other/unknown race, having Medicare or other insurance increased the risk of treatment. Veterans with age >50 years, drug abuse, diabetes, and hemoglobin < 10 g/dL showed lower rates of treatment. Initiation of treatment for HCV in homeless Veterans is low; similar factors predicted initiation of treatment. Additionally, exposure to treatment with medications for diabetes predicted lower rates of treatment. As newer therapies become available for HCV, these results may inform further studies and guide strategies to increase treatment rates in all U.S. Veterans and those who experience homelessness.


LaFleur J.,University of Utah | LaFleur J.,Decision Enhancement and Surveillance Center | Nelson R.E.,Decision Enhancement and Surveillance Center | Nelson R.E.,University of Utah | And 3 more authors.
Heart | Year: 2011

Background: The healthy user bias is usually overlooked as an explanation in studies in which a strong association is found between poor patient medication adherence and worse disease outcomes. Such studies are increasing in frequency across disease states and influence clinical practice. Adherence to antihypertensive medications was studied to illustrate confounding in such studies. Methods: Using data from veterans with hypertension starting antihypertensive treatment, causal models were developed that predicted the risks of hospitalisation, myocardial infarction (MI) and death associated with poor adherence (<80%) while adjusting for patient demographics, baseline disease severity and disease comorbidity. In a second set of otherwise identical models, adjustment was made for time-varying blood pressure (BP), thus controlling for adherence effects that were mediated through the main pharmacological effects of the drugs. It was hypothesised that the second set of models would reveal a positive association between poor adherence and adverse disease outcomes that is largely explained by unmeasured confounders, including health-related behaviours. Results: The models that did not adjust for time-varying BP levels showed that patients with poor adherence had statistically significantly increased risks of 3.7% for hospitalisation, 28.1% for MI and 23.3% for death. These estimates exceed the benefits of these drugs demonstrated by clinical trials. When controlling for time-varying BP, the increased risks were similar (3.4% for hospitalisation, 27.7% for MI and 23.4% for death). The findings were consistent across a range of adherence thresholds (50-90%) and when allowing disease status variables to vary. Conclusions: The associations between poor adherence and outcomes are largely independent of the pharmacological effects of the drugs on BP control as well as commonly measured patient covariates. This finding suggests that even carefully designed observational adherence studies using rich clinical data are impossibly confounded and probably overestimate the true magnitude of the effect. Clinical practice guidelines based on reported adherence effects should be reconsidered.


Alder S.,University of Utah | Wuthrich A.,University of Utah | Haddadin B.,University of Utah | Donnelly S.,HealthInsight | And 6 more authors.
American Journal of Health Education | Year: 2010

Background: The Inter-Mountain Project on Antibiotic Resistance and Therapy (IMPART) is an intervention that addresses emerging antimicrobial resistance and the reduction of unnecessary antimicrobial use. Purpose: This study assesses the design and implementation of the community intervention component of IMPART. Methods: The study was conducted in 12 rural Utah and Idaho communities. Following initial implementation, the intervention was evaluated and redesigned based on health behavior theory. Community penetration and intercept interview data were analyzed using multi-level logistic regression. Results: Over 10% of interview respondents were familiar with IMPART. Those exposed to intervention materials tended to be younger, female, and more likely to have had a family member with recent respiratory illness. Of those who had seen the project Self-Care Guide, 62% reported having a copy and 32% had talked to others about the information it contained. Correct responses to antibiotic knowledge questions were higher among those with high (OR=2.02) and low exposure (OR=1.27) to the intervention versus no exposure. Discussion: Theoretically-based community interventions such as IMPART can be used to promote appropriate, positively framed health behaviors. Translation to Health Education Practice: IMPART serves as an example of how health interventions can benefit from health behavior theory.


Gundlapalli A.V.,Decision Enhancement and Surveillance Center | Gundlapalli A.V.,University of Utah | Redd A.,Decision Enhancement and Surveillance Center | Redd A.,University of Utah | And 8 more authors.
Studies in Health Technology and Informatics | Year: 2014

There are limited data on resources utilized by US Veterans prior to their identification as being homeless. We performed visual analytics on longitudinal medical encounter data prior to the official recognition of homelessness in a large cohort of OEF/OIF Veterans. A statistically significant increase in numbers of several categories of visits in the immediate 30 days prior to the recognition of homelessness was noted as compared to an earlier period. This finding has the potential to inform prediction algorithms based on structured data with a view to intervention and mitigation of homelessness among Veterans. © 2014 The authors and IOS Press. All rights reserved.

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