Section of Health Services Research

Houston, TX, United States

Section of Health Services Research

Houston, TX, United States
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Khalaf N.,Baylor College of Medicine | Ramsey D.,Baylor College of Medicine | Kramer J.R.,Section of Health Services Research | El-Serag H.B.,Baylor College of Medicine | El-Serag H.B.,Michael bakey Va Medical Center
Diseases of the Esophagus | Year: 2015

Summary: The association between Barrett's esophagus (BE) and a personal or family history of cancer other than gastroesophageal remains unknown. To evaluate the effect of personal and family history of certain cancers and cancer treatments on the risk of BE, we analyzed data from a Veterans Affairs case-control study that included 264 men with definitive BE (cases) and 1486 men without BE (controls). Patients with history of esophageal or gastric cancer were excluded. Patients underwent elective esophagogastroduodenoscopy or a study esophagogastroduodenoscopy concurrently with screening colonoscopy to determine BE status. Personal and family history of several types of cancer was obtained from self-reported questionnaires, supplemented and verified by electronic medical-record reviews. We estimated the association between personal and family history of cancer or radiation/chemotherapy, and BE. Personal history of oropharyngeal cancer (1.5% vs. 0.4%) or prostate cancer (7.2% vs. 4.4%) was more frequently present in cases than controls. The association between BE and prostate cancer persisted in multivariable analyses (adjusted odds ratio 1.90; 95% confidence interval 1.07-3.38, P = 0.028) while that with oropharyngeal cancer (adjusted odds ratio 3.63; 95% confidence interval 0.92-14.29, P = 0.066) was attenuated after adjusting for retained covariates of age, race, gastroesophageal reflux disease, hiatal hernia, and proton pump inhibitor use. Within the subset of patients with cancer, prior treatment with radiation or chemotherapy was not associated with BE. There were no significant differences between cases and controls in the proportions of subjects with several specific malignancies in first- or second-degree relatives. In conclusion, the risk of BE in men may be elevated with prior personal history of oropharyngeal or prostate cancer. However, prior cancer treatments and family history of cancer were not associated with increased risk of BE. Further studies are needed to elucidate if there is a causative relationship or shared risk factors between prostate cancer and BE. © This article is a U.S. Government work and is in the public domain in the USA.


El-Serag H.B.,Michael bakey Va Medical Center | El-Serag H.B.,Baylor College of Medicine | Alsarraj A.,Section of Health Services Research | Alsarraj A.,Baylor College of Medicine | And 9 more authors.
Digestive Diseases and Sciences | Year: 2013

Background: Previous studies suggest low rates of hepatocellular carcinoma (HCC) screening in clinical practice. There is little information on the provider- and healthcare-facility-related factors that explain the use of HCC screening. Aims: We used data from the 2007 Survey to Assess Hepatitis C Care in Veterans Health Administration that collected information regarding the care of patients with hepatitis C virus (HCV) from 138 of 140 Veterans Administration healthcare facilities nationwide. Methods: All providers caring for veterans with HCV were invited to respond. In addition, each facility was asked to identify a lead HCV clinician to respond to facility-specific questions. Our outcome was a response concordant with HCC screening guidelines [HCC screening in patients with cirrhosis or in patients with chronic hepatitis B virus (HBV), and screening every 6 or 12 months]. Results: A total of 268 providers responded (98 % facility participation rate). Of these, 190 respondents (70.9 %) reported recommending HCC screening with guideline-concordant risk groups and frequency. Providers reporting guideline-concordant HCC screening practices were significantly more likely to have expertise in liver disease (MD, gastroenterologists or hepatologists), routinely screen for varices, prescribe HCV treatment, and refer or manage patients with liver transplant. The availability of HCC-specific treatments on site was the main facility factor associated with guideline-concordant HCC screening. Conclusions: Self-reported rates of guideline-concordant HCC screening are considerably higher than those seen in routine VA practice. Provider expertise in liver disease and the perceived availability of HCC treatment including transplantation in the local facility are important factors driving self-reported HCC screening practices. © 2013 Springer Science+Business Media New York.


Thirumurthi S.,Section of Health Services Research | Thirumurthi S.,Baylor College of Medicine | Chowdhury R.,Baylor College of Medicine | Richardson P.,Section of Health Services Research | And 5 more authors.
Digestive Diseases and Sciences | Year: 2010

Background: Inflammatory bowel disease (IBD) is well described among young whites and less so among the elderly and non-whites. Population-level data is required to assess outcomes among minority groups. Aim: To validate diagnostic codes for IBD from the Department of Veterans Affairs. Methods: National databases were used to identify local patients with Crohn's disease (CD) and ulcerative colitis (UC), the extra-intestinal manifestations and surgical procedures associated with IBD. Diagnosis was confirmed by manual chart abstraction. Multivariable logistic regression was used to derive diagnostic algorithms for CD and UC, which were then validated in an independent cohort. Results: The test cohort of 3,827 patients (1,316 potential cases, 2,511 random controls) was predominantly male (94%), white (56%), and of age of 58 (standard deviation 15). The positive predictive value (PPV) of CD codes was superior (88-100%) to UC (50-93%). The accuracy of extra-intestinal manifestations and surgeries was poor (PPV 0-29%). ICD-9-CM code 555.x without 560.9 had a PPV of 91% for CD in the validation cohort. Code 556.x with age, gender, and race factors was highly predictive of UC (c-statistic 0.9, PPV of 81%). Conclusion: VA administrative data can diagnose elderly and non-white patients with IBD. © 2009 Springer Science+Business Media, LLC.


El-Serag H.B.,Michael bakey Va Medical Center | El-Serag H.B.,Houston VA Health Services Research | El-Serag H.B.,Baylor College of Medicine | Kanwal F.,Michael bakey Va Medical Center | And 11 more authors.
Gastroenterology | Year: 2014

Background & Aims Serum levels of α-fetoprotein (AFP) are influenced not only by the presence of hepatocellular carcinoma (HCC), but also by the underlying severity and activity of liver disease, which is reflected by liver function tests. We constructed an AFP-based algorithm that included these factors to identify patients at risk for HCC, and tested its predictive ability in a large set of patients with cirrhosis. Methods We used the national Department of Veterans Affairs Hepatitis C Virus Clinical Case Registry to identify patients with cirrhosis, results from at least 1 AFP test, and 6 months of follow-up. Our algorithm included data on age; levels of aspartate aminotransferase, alanine aminotransferase (ALT), alkaline phosphatase, total bilirubin, albumin, creatinine, and hemoglobin; prothrombin time; and numbers of platelets and white cells. We examined the operating characteristics (calibration, discrimination, predictive values) of several different algorithms for identification of patients who would develop HCC within 6 months of the AFP test. We assessed our final model in the development and validation subsets. Results We identified 11,721 patients with hepatitis C virus-related cirrhosis in whom 35,494 AFP tests were performed, and 987 patients developed HCC. A predictive model that included data on levels of AFP, ALT, and platelets, along with age at time of AFP test (and interaction terms between AFP and ALT, and AFP and platelets), best discriminated between patients who did and did not develop HCC. Using this AFP-adjusted model, the predictive accuracy increased at different AFP cutoffs compared with AFP alone. At any given AFP value, low numbers of platelets and ALT and older age were associated with increased risk of HCC, and high levels of ALT and normal/high numbers of platelets were associated with low risk for HCC. For example, the probabilities of HCC, based only on 20 ng/mL and 120 ng/mL AFP, were 3.5% and 11.4%, respectively. However, patients with the same AFP values (20 ng/mL and 120 ng/mL) who were 70 years old, with ALT levels of 40 IU/mL and platelet counts of 100,000, had probabilities of developing HCC of 8.1% and 29.0%, respectively. Conclusions We developed and validated an algorithm based on levels of AFP, platelets, and ALT, along with age, which increased the predictive value for identifying patients with hepatitis C virus-associated cirrhosis likely to develop HCC within 6 months. If validated in other patient groups, this model would have immediate clinical applicability.


Shakhatreh M.H.,Section of Health Services Research | Shakhatreh M.H.,Baylor College of Medicine | Duan Z.,Section of Health Services Research | Avila N.,Section of Health Services Research | And 6 more authors.
Clinical Gastroenterology and Hepatology | Year: 2015

Background and Aims: Practice guidelines recommend a 1-time screening endoscopy for patients with gastroesophageal reflux disease (GERD) who are at high risk for Barrett's esophagus or malignancy. However, little is known about the risk of cancer in patients with negative findings from screening endoscopies. Methods: We conducted a retrospective cohort study using data from 121 Veterans Health Administration facilities nationwide to determine the incidence rate of esophageal adenocarcinoma (EA) separately, as well as any upper gastrointestinal cancers, in patients with an initial negative screening endoscopy (esophagogastroduodenoscopy [EGD]). We included veteran patients with GERD diagnosed between 2004 and 2009 who had a negative screening EGD within 1 year of diagnosis. We estimated the incidence rate of EA, and any upper gastrointestinal cancer, in patients with GERD who had a negative screening EGD. We examined differences in demographic, clinical, and facility factors among patients with and without cancer. Results: We identified 68,610 patients with GERD and a negative screening EGD (mean age, 55.5 y; 90% men; 67.5% white). During a mean follow-up period of 3.2 years, 10 patients developed EA and 29 patients developed any upper gastrointestinal malignancies, including EA. The incidence of subsequent EA in this group was 4.6/100,000 patient-years of follow-up evaluation, whereas the incidence of any upper gastrointestinal cancers was 13.2/100,000 patient-years of follow-up evaluation. Patients with a subsequent cancer were significantly older and had higher comorbidity scores than patients without cancer. Other clinical and facility factors did not differ significantly between these 2 groups. Conclusions: The risk of cancer is low, over a mean 3-year period, for patients with GERD who had a negative screening endoscopy. These findings justify recommendations for a 1-time screening endoscopy for patients with GERD. © 2015 AGA Institute.


Mittal S.,Baylor College of Medicine | Mittal S.,Section of Health Services Research | El-Serag H.B.,Baylor College of Medicine | El-Serag H.B.,Section of Health Services Research
Journal of Clinical Gastroenterology | Year: 2013

Hepatocellular carcinoma (HCC) is increasing in incidence and has a very high fatality rate. Cirrhosis due to chronic hepatitis B or hepatitis C is the leading risk factor for HCC. Global epidemiology of HCC is determined by the prevalence of dominant viral hepatitis and the age it is acquired in the underlying population. Upcoming risk factors include obesity, diabetes, and related nonalcoholic fatty liver disease. This review discusses the latest trends of HCC globally and in the United States. It also provides an evidence-based commentary on the risk factors and lists some of the preventive measures to reduce the incidence of HCC. © 2013 by Lippincott Williams & Wilkins.


Meyer A.N.D.,Section of Health Services Research | Meyer A.N.D.,Michael bakey Veterans Affairs Medical Center | Meyer A.N.D.,Baylor College of Medicine | Payne V.L.,Section of Health Services Research | And 10 more authors.
JAMA Internal Medicine | Year: 2013

IMPORTANCE: Little is known about the relationship between physicians' diagnostic accuracy and their confidence in that accuracy. OBJECTIVE: To evaluate how physicians' diagnostic calibration, defined as the relationship between diagnostic accuracy and confidence in that accuracy, changes with evolution of the diagnostic process and with increasing diagnostic difficulty of clinical case vignettes. DESIGN, SETTING, AND PARTICIPANTS: We recruited general internists from an online physician community and asked them to diagnose 4 previously validated case vignettes of variable difficulty (2 easier; 2 more difficult). Cases were presented in a web-based format and divided into 4 sequential phases simulating diagnosis evolution: history, physical examination, general diagnostic testing data, and definitive diagnostic testing. After each phase, physicians recorded 1 to 3 differential diagnoses and corresponding judgments of confidence. Before being presented with definitive diagnostic data, physicians were asked to identify additional resources they would require to diagnose each case (ie, additional tests, second opinions, curbside consultations, referrals, and reference materials). MAIN OUTCOMESAND MEASURES: Diagnostic accuracy (scored as 0 or 1), confidence in diagnostic accuracy (on a scale of 0-10), diagnostic calibration, and whether additional resources were requested (no or yes). RESULTS: A total of 118 physicians with broad geographical representation within the United States correctly diagnosed 55.3% of easier and 5.8% of more difficult cases (P <.001). Despite a large difference in diagnostic accuracy between easier and more difficult cases, the difference in confidence was relatively small (7.2 vs 6.4 out of 10, for easier and more difficult cases, respectively) (P <.001) and likely clinically insignificant. Overall, diagnostic calibration was worse for more difficult cases (P <.001) and characterized by overconfidence in accuracy. Higher confidence was related to decreased requests for additional diagnostic tests (P =.01); higher case difficulty was related to more requests for additional reference materials (P =.01). CONCLUSIONS AND RELEVANCE: Our study suggests that physicians' level of confidence may be relatively insensitive to both diagnostic accuracy and case difficulty. This mismatch might prevent physicians from reexamining difficult cases where their diagnosis may be incorrect. © 2013 American Medical Association. All rights reserved.


PubMed | Section of Health Services Research and Baylor College of Medicine
Type: Journal Article | Journal: Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association | Year: 2015

Practice guidelines recommend a 1-time screening endoscopy for patients with gastroesophageal reflux disease (GERD) who are at high risk for Barretts esophagus or malignancy. However, little is known about the risk of cancer in patients with negative findings from screening endoscopies.We conducted a retrospective cohort study using data from 121 Veterans Health Administration facilities nationwide to determine the incidence rate of esophageal adenocarcinoma (EA) separately, as well as any upper gastrointestinal cancers, in patients with an initial negative screening endoscopy (esophagogastroduodenoscopy [EGD]). We included veteran patients with GERD diagnosed between 2004 and 2009 who had a negative screening EGD within 1 year of diagnosis. We estimated the incidence rate of EA, and any upper gastrointestinal cancer, in patients with GERD who had a negative screening EGD. We examined differences in demographic, clinical, and facility factors among patients with and without cancer.We identified 68,610 patients with GERD and a negative screening EGD (mean age, 55.5 y; 90% men; 67.5% white). During a mean follow-up period of 3.2 years, 10 patients developed EA and 29 patients developed any upper gastrointestinal malignancies, including EA. The incidence of subsequent EA in this group was 4.6/100,000 patient-years of follow-up evaluation, whereas the incidence of any upper gastrointestinal cancers was 13.2/100,000 patient-years of follow-up evaluation. Patients with a subsequent cancer were significantly older and had higher comorbidity scores than patients without cancer. Other clinical and facility factors did not differ significantly between these 2 groups.The risk of cancer is low, over a mean 3-year period, for patients with GERD who had a negative screening endoscopy. These findings justify recommendations for a 1-time screening endoscopy for patients with GERD.


Nguyen D.M.,Section of Health Services Research | Richardson P.,Section of Health Services Research | El-Serag H.B.,Section of Health Services Research
Gastroenterology | Year: 2010

Background & Aims: Limited evidence suggests that proton pump inhibitors (PPI), nonsteroidal anti-inflammatory drugs (NSAID)/aspirin, and statins may be associated with a low risk of esophageal neoplasia. However, the possible effect these medications may have on the risk of esophageal adenocarcinoma (EAC) in patients with existing Barrett's esophagus (BE) is unclear. Methods: We conducted a nested case-control study in a cohort of patients with BE identified in the national Department of Veterans' Affairs computerized databases. Cases with incident EAC were matched by incidence density sampling to controls with BE who remained without EAC at the date of the EAC diagnosis for the corresponding case. We identified prescriptions for PPI, NSAIDs/aspirin, and statins that were filled between BE diagnosis and EAC diagnosis. Incidence density ratios were calculated using conditional logistic regression models that adjusted for race, outpatient encounters, a disease comorbidity index, and socioeconomic status. Results: In a cohort of 11,823 patients with first-time BE diagnosis, we examined 116 EAC cases and 696 matched controls. Most cases and controls had at least one filled PPI prescription (95% vs 94%; P = .5). In this setting of almost universal PPI use, filled NSAID/aspirin prescriptions were associated with a reduced risk of EAC (adjusted incidence density ratio, 0.64; 95% confidence interval, 0.42-0.97). Filled statin prescriptions also were associated with a reduction in EAC risk (0.55; 95% confidence interval, 0.36-0.86), with a significant trend toward greater risk reduction with longer duration of statin use. However, the strong inverse associations with even short periods of use raise concerns of uncontrolled confounding. Conclusions: This observational study indicates that in patients with BE using PPI, NSAID/aspirin, or statin therapy might reduce the risk of developing EAC. © 2010 AGA Institute.


PubMed | Section of Health Services Research
Type: Journal Article | Journal: Digestive diseases and sciences | Year: 2010

Inflammatory bowel disease (IBD) is well described among young whites and less so among the elderly and non-whites. Population-level data is required to assess outcomes among minority groups.To validate diagnostic codes for IBD from the Department of Veterans Affairs.National databases were used to identify local patients with Crohns disease (CD) and ulcerative colitis (UC), the extra-intestinal manifestations and surgical procedures associated with IBD. Diagnosis was confirmed by manual chart abstraction. Multivariable logistic regression was used to derive diagnostic algorithms for CD and UC, which were then validated in an independent cohort.The test cohort of 3,827 patients (1,316 potential cases, 2,511 random controls) was predominantly male (94%), white (56%), and of age of 58 (standard deviation 15). The positive predictive value (PPV) of CD codes was superior (88-100%) to UC (50-93%). The accuracy of extra-intestinal manifestations and surgeries was poor (PPV 0-29%). ICD-9-CM code 555.x without 560.9 had a PPV of 91% for CD in the validation cohort. Code 556.x with age, gender, and race factors was highly predictive of UC (c-statistic 0.9, PPV of 81%).VA administrative data can diagnose elderly and non-white patients with IBD.

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