Providence Veterans Affairs Medical Center

Rhode Island, Rhode Island, United States

Providence Veterans Affairs Medical Center

Rhode Island, Rhode Island, United States

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News Article | May 1, 2017
Site: www.futurity.org

Among suicidal patients, an intervention with brief, post-discharge phone calls significantly reduced the likelihood of a future suicide attempt. In a clinical trial involving nearly 1,400 suicidal patients in the emergency departments of eight hospitals, researchers found that the intervention lowered the relative risk of new suicide attempts by 20 percent. In results published in JAMA Psychiatry, emergency department patients who received the intervention composed of specialized screening, safety planning guidance, and periodic follow-up phone check-ins made 30 percent fewer total suicide attempts compared to people who received standard ED care. “We were happy that we were able to find these results,” says Ivan Miller of Butler Hospital and the study’s lead and corresponding author. “We would like to have had an even stronger effect, but the fact that we were able to impact attempts with this population and with a relatively limited intervention is encouraging,” says Miller, professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University. While suicide prevention efforts such as hotlines are well known, published controlled trials of specific interventions have been much rarer, Miller says. This one focuses on an especially high-risk group: emergency department patients who said they had engaged in suicidal ideation or had made an attempt within a week before their ED visit. The trial took place in three phases to create three comparison groups. In the first phase, August 2010 to December 2011, 497 patients received each ED’s usual treatment as a control group. In the second phase, September 2011 to December 2012, 377 patients received additional suicide screening. In the third phase, July 2012 to November 2013, 502 patients received the experimental intervention. Those patients received additional suicide screening from ED physicians, suicide prevention information from nurses, and a personal safety plan that they could opt to fill out to be better prepared for times when they might begin to harbor suicidal thoughts again. Over the next year they also received brief, periodic phone calls from trained providers at Butler Hospital who would discuss suicide risk factors, personal values and goals, safety and future planning, treatment engagement, and problem solving. The intervention was designed to directly involve a designated loved one whenever feasible, as well. In all three phases, patients were briefly screened for suicidality at the ED and were also followed for a year with periodic assessment phone calls. Regardless of phase, patients who demonstrated a specific suicide risk during assessments were connected with the Boys Town suicide prevention hotline. Suicide attempts were not the only measure the researchers employed to understand the potential impact of the intervention. Fortunately, there were so few deaths by suicide among patients (five total deaths) that there could be no statistically valid conclusions drawn from that data point. But the researchers also created a broader suicide composite score, which included not only attempts and deaths, but also interrupted or aborted attempts, and acts to prepare an attempt. Across the three groups, 46.3 percent of the patients reported one or more of these behaviors, but the relative risk declined significantly among people in the intervention compared to the usual care group (by 15 percent), but not among people who received screening alone. While other interventions have also been found to reduce suicide risk, some of the most effective ones have involved providing patients with many hours of psychotherapy. “This intervention was significantly less costly than most other interventions,” he says. The research team is currently engaged in a cost-effectiveness analysis. He notes that the intervention was associated with significant declines in suicide attempts, even though not every patient engaged in the full intervention (e.g. only 37.4 percent reported receiving a safety plan and nearly 40 percent did not complete a follow-up phone call). The intervention’s apparent efficacy also persisted despite the study’s ethical design, in which even people in the control phases received suicide prevention counseling that could have prevented an attempt if they presented an urgent need. The report is one of several from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study led by Miller, Professor Edwin Boudreaux of the University of Massachusetts, and Carlos Camargo of Massachusetts General Hospital and Harvard University. In further studies, the ED-SAFE team is looking at whether more intensive safety planning while patients are in the ED could help further. Miller and his colleagues are also conducting further tests of the phone follow-ups with patients from Butler Hospital and the Providence Veterans Affairs Medical Center. Additional coauthors are from Massachusetts General Hospital; the University of Colorado; the National Institutes of Health; Cape Cod Healthcare; and Brown University. The National Institute of Mental Health funded the research.


News Article | April 29, 2017
Site: www.eurekalert.org

PROVIDENCE, R.I. [Brown University] -- In a clinical trial involving nearly 1,400 suicidal patients in the emergency departments of eight hospitals, a team led by Brown University and Butler Hospital psychologist Ivan Miller found that a multifaceted intervention lowered the relative risk of new suicide attempts by 20 percent. In results published in JAMA Psychiatry, emergency department (ED) patients who received the intervention composed of specialized screening, safety planning guidance and periodic follow-up phone check-ins made 30 percent fewer total suicide attempts compared to people who received standard ED care. "We were happy that we were able to find these results," said Miller, the study's lead and corresponding author and a professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University. "We would like to have had an even stronger effect, but the fact that we were able to impact attempts with this population and with a relatively limited intervention is encouraging." While suicide prevention efforts such as hotlines are well known, published controlled trials of specific interventions have been much rarer, Miller said. This report was one of several from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study led by Miller, Professor Edwin Boudreaux of the University of Massachusetts and Dr. Carlos Camargo of Massachusetts General Hospital and Harvard University. This study might be the largest intervention trial conducted so far in the U.S., Miller said. It focused on an especially high-risk group: emergency department patients who said they had engaged in suicidal ideation or had made an attempt within a week before their ED visit. The trial took place in three phases to create three comparison groups. In the first phase, August 2010 to December 2011, 497 patients received each ED's usual treatment as a control group. In the second phase, September 2011 to December 2012, 377 patients received additional suicide screening. In the third phase, July 2012 to November 2013, 502 patients received the experimental intervention. Those patients received additional suicide screening from ED physicians, suicide prevention information from nurses and a personal safety plan that they could opt to fill out to be better prepared for times when they might begin to harbor suicidal thoughts again. Over the next year they also received brief, periodic phone calls from trained providers at Butler Hospital who would discuss suicide risk factors, personal values and goals, safety and future planning, treatment engagement, and problem solving. The intervention was designed to directly involve a designated loved one whenever feasible, as well. In all three phases, patients were briefly screened for suicidality at the ED and were also followed for a year with periodic assessment phone calls. Regardless of phase, patients who demonstrated a specific suicide risk during assessments were connected with the Boys Town suicide prevention hotline. The number of suicide attempts and the proportion of people attempting suicide declined significantly in the intervention group compared to treatment as usual. The middle group, which received only additional screening, did not show a significant drop compared to the treatment as usual group. Suicide attempts were not the only measure the researchers employed to understand the potential impact of the intervention. Fortunately, there were so few deaths by suicide among patients (only five total) that there could be no statistically valid conclusions drawn from that data point. But the researchers also created a broader suicide composite score which included not only attempts and deaths, but also interrupted or aborted attempts, and acts to prepare an attempt. Across the three groups, 46.3 percent of the patients reported one or more of these behaviors, but the relative risk declined significantly among people in the intervention compared to the usual care group (by 15 percent), but not among people who received screening alone. While other interventions have also been found to reduce suicide risk, some of the most effective ones have involved providing patients with many hours of psychotherapy. "This intervention was significantly less costly than most other interventions," he said. The research team is currently engaged in a cost-effectiveness analysis. He noted that the intervention was associated with significant declines in suicide attempts, even though not every patient engaged in the full intervention (e.g. only 37.4 percent reported receiving a safety plan and nearly 40 percent did not complete a follow-up phone call). The intervention's apparent efficacy also persisted despite the study's ethical design, in which even people in the control phases received suicide prevention counseling that could have prevented an attempt if they presented an urgent need. In further studies, the ED-SAFE team is looking at whether more intensive safety planning while patients are in the ED could help further. Miller and his colleagues are also conducting further tests of the phone follow-ups with patients from Butler Hospital and the Providence Veterans Affairs Medical Center. In addition to Miller, Boudreak and Camargo, the paper's other authors are Drs. Sarah Arias and Richard Jones of Brown; Ashley Sullivan, Janice Espinola and Dr. Kohei Hasegawa of Massachusetts General Hospital; Dr. Michael Allen of the University of Colorado; Dr. Amy Goldstein of the National Institutes of Health; and Dr. Anne Manton of Cape Cod Healthcare. Drs. Lisa Uebelacker, Brandon Gaudiano and Lauren Weinstock of Brown University also contributed to the work. The National Institute of Mental Health (grant: U01MH088278) funded the research.


News Article | April 25, 2017
Site: www.eurekalert.org

ROVIDENCE, R.I. [Brown University] -- Researchers intent on understanding how too little sleep can undermine health have long suspected a relationship between short sleep duration and the actions of specific genes, but finding the genes involved has proven difficult. Now, a team of scientists based at Brown University has identified genes carrying "epigenetic" tags that are likely associated with shorter sleep in young adults. "Before this study, specific genes with epigenetic tags hadn't been linked to how much sleep people get," said Anne Hart, a professor of neuroscience and co-corresponding author of the study online in the journal Sleep. "This is the first time we've found genes important in sleep that might be tagged this way. It's exciting to open up a new area in the sleep field. In the long run, this work should help us understand why getting too little sleep causes so many problems for people and should lead to better treatments for those who have trouble sleeping." Epigenetic tags in genes are chemical alterations of the DNA that accrue based on life experiences, such as stress or exposure to environmental substances. This study focused on a specific epigenetic tag, called DNA methylation, which can affect how genes are expressed and therefore change behaviors like sleep. Previous research showed that methylation might change at the whole genome level with inadequate sleep. But in the new study, the researchers went much deeper and looked for specific genes with different amounts of DNA methylation tags in people who got a normal amount of sleep every night and comparable people who slept considerably less. For this study, the team selected 16 students from the hundreds who participated in a larger sleep study led by co-corresponding author Mary Carskadon, a professor of psychiatry and human behavior at the Warren Alpert Medical School and director of the Sleep for Science lab at the Bradley Hospital. "Our carefully selected sample of college students gave us the possibility to pursue this burning question at a molecular level," Carskadon said. Eight of the students had roughly the amount of sleep recommended for young adults, getting 8.1 hours on average. The other eight students selected for the study were short sleepers, getting only 6.6 hours on average a night. Because sleep and mood are intimately connected, all of the students selected had relatively depressed moods, which allowed the researchers to focus their analysis only on sleep. From donated blood samples, the researchers were able to analyze nearly 500,000 sites for possible methylation differences between the groups. They found 87, corresponding to 52 candidate genes. But how could they know whether any of the 52 genes really had anything to do with sleep? For the answer, they turned to worms. Worm and human sleep is remarkably similar; the same basic genetic and molecular biology mechanisms are important. That makes worms convenient models to study the basic biology of sleep. "If you have a lot of things you want to test, worms are fast and easy to do science in," Hart said. For each of the genes identified in people, the research team asked the question of what difference it might make to sleep to knock out the analogous gene in worms. Six of the genes they knocked out -- including five that had never before been identified as sleep-relevant -- affected sleep in worms. Although knock-out of a gene probably has a bigger impact than methylation, the experiments showed that these genes are likely important in sleep, for worms. The last phase of the research was for the researchers to go back to humans to see if they could replicate the finding of methylation tags of the five new worm-proven genes. They assembled a new cohort of 10 more students, all different from the last group. This time all 10 had better mood scores, meaning they were not depressed at all (thereby controlling for mood). As before, one group had the recommended amount of sleep (an average of about 8 hours) and the other group had short sleep (average of 6.3 hours). One gene, called ZFYVE28, still had significantly different methylation tagging when the normal sleepers and the short sleepers were compared. It's not clear why the other four didn't replicate, Hart said, but maybe those four are only important for sleep in people with depressed moods (which was intentionally different between the first group of students and the second). Intriguingly ZFYVE28 has connections to two molecular pathways already known to be relevant in sleep, Hart said: "Notch" and "EGF." But, she acknowledged, despite the worm knock-out results, there is not yet enough evidence yet to determine whether the methylation differences in ZFYVE28 in humans cause short sleep or accrue because of short sleep. There is at least one test Hart said she can imagine doing to help find an answer: Recruit some normal sleepers. Test their ZFYVE28 methylation. Subject them to a few weeks of restricted sleep. Test the methylation again. If it's substantially different, then maybe short sleep causes the methylation. If not, the possibility would remain open that the changes cause short sleep. Indeed, the research team has proposed a grant for just such a project. For now, ZFYVE28 serves as a test case to show that the method of mixing worm and human experiments to discover the sleep-relevance of epigenetic changes is a productive avenue for sleep research, Hart said. "This is the first good evidence that there will be differences in methylation associated with sleep, which opens up a whole new mechanism for regulating sleep," she said. "Now we can get to the mechanisms of what's going on and what's important." The paper's lead author is Huiyan Huang of Brown. In addition to Hart and Carskadon, the paper's other authors are Melissa Eliot of Brown; Valerie Knopik of Brown and Rhode Island Hospital (RIH); Jon McGeary of Brown, RIH and the Providence Veterans Affairs Medical Center; and Yong Zhu of Yale University. The National Institutes of Health, the Brown Institute for Brain Science, the Norman Prince Neurosciences Institute, the Periodic Breathing Foundation and the Sleep Research Society Foundation supported the research.


Nici L.,Providence Veterans Affairs Medical Center | Bontly T.D.,University of Connecticut | ZuWallack R.,Saint Francis Hospital | Gross N.,Saint Francis Hospital
Annals of the American Thoracic Society | Year: 2014

Self-management in chronic obstructive pulmonary disease, centering on an action plan for the exacerbation and enhanced communication between the patient and health care providers, makes good clinical sense. However, five relatively large trials of self-management in chronic obstructive pulmonary disease have had inconsistent results: only two demonstrated reductions in health care utilization and one had to be discontinued prematurely because of increased mortality. Do these discordant findings require a paradigm shift in our concept of self-management? Probably not - but an analysis of the negative studies can give us valuable insights. There are data to support the idea that patients in the trial that showed increased mortality did not self-manage appropriately. Only 4.5% of these patients called in before starting treatment for their exacerbation, the time to initiation of antibiotics or steroids was unsatisfactorily long, and the intervention arm used minimally more prednisone and antibiotics than the control arm. The reasons for a higher mortality will likely never be known, but it is possible that these high-risk patients may have needed earlier assessment by a trained professional, or that self-management led to overconfidence and treatment delays. We clearly need more effective ways to implement self-management and better define which groups of patients stand to benefit (or be harmed) by this intervention. This will require an investment in well-thought-out clinical trials.


Trivedi A.N.,Providence Veterans Affairs Medical Center | Trivedi A.N.,Brown University | Grebla R.C.,Brown University | Wright S.M.,VA Office of Quality and Performance | Washington D.L.,University of California at Los Angeles
Health Affairs | Year: 2011

Both government and private health care systems have engaged in efforts to improve quality, but the effect of these initiatives on racial and ethnic disparities has not been well studied. In the decade following an organizational transformation, the Veterans Affairs (VA) health care system achieved substantial improvements in quality of care with minimal racial disparities for most process-of-care measures, such as rates of cholesterol screenings. However, in our study we observed a striking disconnect between high levels of performance on widely used process measures and modest levels of improvement in clinical outcomes, such as control of blood pressure, blood glucose, and cholesterol levels. We also observed a gap in clinical outcomes of as much as nine percentage points between African American veterans and white veterans. Almost all of the disparity in outcomes in the VA was explained by within-facility disparity, which suggests that VA medical centers need to measure and address racial gaps in care for their patient populations. Moreover, because cardiovascular disease and diabetes are major contributors to racial disparities in life expectancy, the findings of this study and others underscore the urgency of focused efforts to improve intermediate outcomes among African Americans in the VA and other settings. © 2011 by Project HOPE - The People-to-People Health Foundation, Inc.


Thomas K.S.,Brown University | Thomas K.S.,Providence Veterans Affairs Medical Center | Mor V.,Brown University
Health Affairs | Year: 2013

Programs that help older adults live independently in the community can also deliver net savings to states on the costs of long-term supports and services. We estimate that if all states had increased by 1 percent the number of adults age sixty-five or older who received homedelivered meals in 2009 under Title III of the Older Americans Act, total annual savings to states' Medicaid programs could have exceeded $109 million. The projected savings primarily reflect decreased Medicaid spending for an estimated 1,722 older adults with low care needs who would no longer require nursing home care-instead, they could remain at home, sustained by home-delivered meals. Twenty-six states could have realized net savings in 2009 from the expansion of their home-delivered meals programs, while twenty-two states would have incurred net costs. Programs such as home-delivered meals have the potential to provide substantial savings to some states' Medicaid programs. © 2013 Project HOPE-The People-to-People Health Foundation, Inc.


Allen A.L.,Pennsylvania State University | Mcgeary J.E.,Providence Veterans Affairs Medical Center | Mcgeary J.E.,Rhode Island Hospital | Mcgeary J.E.,Brown University | Hayes J.E.,Pennsylvania State University
Alcoholism: Clinical and Experimental Research | Year: 2014

Background: Genetic variation in chemosensory genes can explain variability in individual's perception of and preference for many foods and beverages. To gain insight into variable preference and intake of alcoholic beverages, we explored individual variability in the responses to sampled ethanol (EtOH). In humans, EtOH elicits sweet, bitter, and burning sensations. Here, we explore the relationship between variation in EtOH sensations and polymorphisms in genes encoding bitter taste receptors (TAS2Rs) and a polymodal nociceptor (TRPV1). Methods: Caucasian participants (n = 93) were genotyped for 16 single nucleotide polymorphisms (SNPs) in TRPV1, 3 SNPs in TAS2R38, and 1 SNP in TAS2R13. Participants rated sampled EtOH on a generalized Labeled Magnitude Scale. Two stimuli were presented: a 16% EtOH whole-mouth sip-and-spit solution with a single time-point rating of overall intensity and a cotton swab saturated with 50% EtOH on the circumvallate papillae (CV) with ratings of multiple qualities over 3 minutes. Area-under-the-curve (AUC) was calculated for the time-intensity data. Results: The EtOH whole-mouth solution had overall intensity ratings near "very strong." Burning/stinging had the highest mean AUC values, followed by bitterness and sweetness. Whole-mouth intensity ratings were significantly associated with burning/stinging and bitterness AUC values on the CV. Three TRPV1 SNPs (rs224547, rs4780521, rs161364) were associated with EtOH sensations on the CV, with 2 (rs224547 and rs4780521) exhibiting strong linkage disequilibrium. Additionally, the TAS2R38 SNPs rs713598, rs1726866, and rs10246939 formed a haplotype, and were associated with bitterness on the CV. Last, overall intensity for whole-mouth EtOH associated with the TAS2R13 SNP rs1015443. Conclusions: These data suggest genetic variation in TRPV1 and TAS2Rs influence sensations from sampled EtOH and may potentially influence how individuals initially respond to alcoholic beverages. © 2014 by the Research Society on Alcoholism.


Teno J.M.,Brown University | Mitchell S.L.,Harvard University | Gozalo P.L.,Brown University | Dosa D.,Brown University | And 4 more authors.
JAMA - Journal of the American Medical Association | Year: 2010

Context: Tube-feeding is of questionable benefit for nursing home residents with advanced dementia. Approximately two-thirds of US nursing home residents who are tube fed had their feeding tube inserted during an acute care hospitalization. Objective: To identify US hospital characteristics associated with higher rates of feeding tube insertion in nursing home residents with advanced cognitive impairment. Design, Setting, and Patients: The sample included nursing home residents aged 66 years or older with advanced cognitive impairment admitted to acute care hospitals between 2000 and 2007. Rate of feeding tube placement was based on a 20% sample of all Medicare Claims files and was assessed in hospitals with at least 30 such admissions during the 8-year period. A multivariable model with the unit of the analysis being the hospital admission identified hospital-level factors independently associated with feeding tube insertion rates, including bed size, ownership, urban location, and medical school affiliation. Measures of each hospital's care practices for all patients with serious chronic illnesses were evaluated, including intensive care unit (ICU) use in the last 6 months of life, the use of hospice services, and the ratio of specialist to primary care physicians. Patient-level characteristics were also considered. Main Outcome Measure: Endoscopic or surgical insertion of a gastrostomy tube during a hospitalization. Results: In 2797 acute care hospitals with 280 869 admissions among 163 022 nursing home residents with advanced cognitive impairment, the rate of feeding tube insertion varied from 0 to 38.9 per 100 hospitalizations (mean [SD], 6.5 [5.3]; median [interquartile range], 5.3 [2.6-9.3]). The mean rate of feeding tube insertions per 100 admissions was 7.9 in 2000, decreasing to 6.2 in 2007. Higher insertion rates were associated with the following hospital features: for-profit ownership vs government owned (8.5 vs 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.21-1.46), larger size (>310 beds vs <101 beds: 8.0 vs 4.3 insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35-1.63), and greater ICU use in the last 6 months of life (highest vs lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20-3.06). These differences persisted after controlling for patient characteristics. Specialist to primary care ratio and hospice use were weakly or not associated with feeding tube placement. Conclusion: Among nursing home residents with advanced cognitive impairment admitted to acute care hospitals, for-profit ownership, larger hospital size, and greater ICU use was associated with increased rates of feeding tube insertion, even after adjusting for patient-level characteristics. ©2010 American Medical Association. All rights reserved.


Gozalo P.,Brown University | Plotzke M.,Abt Associates | Mor V.,Brown University | Mor V.,Providence Veterans Affairs Medical Center | And 2 more authors.
New England Journal of Medicine | Year: 2015

BACKGROUND: Nursing home residents' use of hospice has substantially increased. Whether this increase in hospice use reduces end-of-life expenditures is unknown. METHODS: The expansion of hospice between 2004 and 2009 created a natural experiment, allowing us to conduct a difference-in-differences matched analysis to examine changes in Medicare expenditures in the last year of life that were associated with this expansion. We also assessed intensive care unit (ICU) use in the last 30 days of life and, for patients with advanced dementia, feeding-tube use and hospital transfers within the last 90 days of life. We compared a subset of hospice users from 2009, whose use of hospice was attributed to hospice expansion, with a matched subset of non-hospice users from 2004, who were considered likely to have used hospice had they died in 2009. RESULTS: Of 786,328 nursing home decedents, 27.6% in 2004 and 39.8% in 2009 elected to use hospice. The 2004 and 2009 matched hospice and nonhospice cohorts were similar (mean age, 85 years; 35% male; 25% with cancer). The increase in hospice use was associated with significant decreases in the rates of hospital transfers (2.4 percentage-point reduction), feeding-tube use (1.2 percentage-point reduction), and ICU use (7.1 percentage-point reduction). The mean length of stay in hospice increased from 72.1 days in 2004 to 92.6 days in 2009. Between 2004 and 2009, the expansion of hospice was associated with a mean net increase in Medicare expenditures of $6,761 (95% confidence interval, 6,335 to 7,186), reflecting greater additional spending on hospice care ($10,191) than reduced spending on hospital and other care ($3,430). CONCLUSIONS: The growth in hospice care for nursing home residents was associated with less aggressive care near death but at an overall increase in Medicare expenditures. (Funded by the Centers for Medicare and Medicaid Services and the National Institute on Aging.) Copyright © 2015 Massachusetts Medical Society.


Frimpong J.A.,Columbia University | D'Aunno T.,Columbia University | Jiang L.,Providence Veterans Affairs Medical Center
American Journal of Public Health | Year: 2014

Objectives. We examined trends and organizational-level correlates of the availability of HCV testing in opioid treatment programs. Methods. We used generalized ordered logit models to examine associations between organizational characteristics of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey and HCV testing availability. Results. Between 2005 and 2011, the proportion of opioid treatment programs offering HCV testing increased but largely because of increases in off-site referrals rather than on-site testing. HCV testing availability was higher in opioid treatment programs affiliated with a hospital and those receiving federal funds. Opioid treatment programs providing both methadone and buprenorphine were more likely to offer any HCV testing, whereas opioid treatment programs providing only buprenorphine treatment were less likely to offer on-site testing. HCV testing availability was associated with more favorable staff-to-client ratios. Conclusions. The increasing use of off-site referrals for HCV testing in opioid treatment programs likely limits opportunities for case finding, prevention, and treatment. Declines in federal funding for opioid treatment programs may be a key determinant of the availability ofHCVtesting in opioid treatment programs.

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