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Kullgren J.T.,Veterans Affairs Center for Clinical Management Research | Troxel A.B.,Philadelphia University | Loewenstein G.,Carnegie Mellon University | Asch D.A.,University of Pennsylvania | And 5 more authors.
Annals of Internal Medicine | Year: 2013

Background: Data on the effectiveness of employer-sponsored fi-nancial incentives for employee weight loss are limited. Objective: To test the effectiveness of 2 financial incentive designs for promoting weight loss among obese employees. Design: Randomized, controlled trial. (ClinicalTrials.gov: NCT01208350) Setting: Children's Hospital of Philadelphia. Participants: 105 employees with a body mass index between 30 and 40 kg/m2. Intervention: 24 weeks of monthly weigh-ins (control group; n = 35); individual incentive, designed as $100 per person per month for meeting or exceeding weight-loss goals (n = 35); and group incentive, designed as $500 per month split among participants within groups of 5 who met or exceeded weight-loss goals (n= 35). Measurements: Weight loss after 24 weeks (primary outcome) and 36 weeks and changes in behavioral mediators of weight loss (secondary outcomes). Results: Group-incentive participants lost more weight than control participants (mean between-group difference, 4.4 kg [95% CI, 2.0 to 6.7 kg]; P < 0.001) and individual-incentive participants (mean between-group difference, 3.2 kg [CI, 0.9 to 5.5 kg]; P = 0.008). Twelve weeks after incentives ended and after adjustment for 3-group comparisons, group-incentive participants maintained greater weight loss than control group participants (mean between-group difference, 2.9 kg [CI, 0.5 to 5.3 kg]; P = 0.016) but not greater than individual-incentive participants (mean between-group difference, 2.7 kg [CI, 0.4 to 5.0 kg]; P = 0.024). Limitation: Single employer and short follow-up. Conclusion: A group-based financial incentive was more effective than an individual incentive and monthly weigh-ins at promoting weight loss among obese employees at 24 weeks. Primary Funding Source: National Institute on Aging. © 2013 American College of Physicians.


Levy H.,University of Michigan | Janke A.T.,Wayne State University | Langa K.M.,University of Michigan | Langa K.M.,Veterans Affairs Center for Clinical Management Research
Journal of General Internal Medicine | Year: 2015

Background: Among the requirements for meaningful use of electronic medical records (EMRs) is that patients must be able to interact online with information from their records. However, many older Americans may be unprepared to do this, particularly those with low levels of health literacy. Objective: The purpose of the study was to quantify the relationship between health literacy and use of the Internet for obtaining health information among Americans aged 65 and older. Design: We performed retrospective analysis of 2009 and 2010 data from the Health and Retirement Study, a longitudinal survey of a nationally representative sample of older Americans. Participants: Subjects were community-dwelling adults aged 65 years and older (824 individuals in the general population and 1,584 Internet users). Main Measures: Our analysis included measures of regular use of the Internet for any purpose and use of the Internet to obtain health or medical information; health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine–Revised (REALM-R) and self-reported confidence filling out medical forms. Key Results: Only 9.7 % of elderly individuals with low health literacy used the Internet to obtain health information, compared with 31.9 % of those with adequate health literacy. This gradient persisted after controlling for sociodemographic characteristics, health status, and general cognitive ability. The gradient arose both because individuals with low health literacy were less likely to use the Internet at all (OR = 0.36 [95 % CI 0.24 to 0.54]) and because, among those who did use the Internet, individuals with low health literacy were less likely to use it to get health or medical information (OR = 0.60 [95 % CI 0.47 to 0.77]). Conclusion: Low health literacy is associated with significantly less use of the Internet for health information among Americans aged 65 and older. Web-based health interventions targeting older adults must address barriers to substantive use by individuals with low health literacy, or risk exacerbating the digital divide. © 2014, Society of General Internal Medicine.


Sonnega A.,University of Michigan | Faul J.D.,University of Michigan | Ofstedal M.B.,University of Michigan | Langa K.M.,University of Michigan | And 3 more authors.
International Journal of Epidemiology | Year: 2014

The Health and Retirement Study (HRS) is a nationally representative longitudinal survey of more than 37 000 individuals over age 50 in 23 000 households in the USA. The survey, which has been fielded every 2 years since 1992, was established to provide a national resource for data on the changing health and economic circumstances associated with ageing at both individual and population levels. Its multidisciplinary approach is focused on four broad topics-income and wealth; health, cognition and use of healthcare services; work and retirement; and family connections. HRS data are also linked at the individual level to administrative records from Social Security and Medicare, Veteran's Administration, the National Death Index and employer-provided pension plan information. Since 2006, data collection has expanded to include biomarkers and genetics as well as much greater depth in psychology and social context. This blend of economic, health and psychosocial information provides unprecedented potential to study increasingly complex questions about ageing and retirement. The HRS has been a leading force for rapid release of data while simultaneously protecting the confidentiality of respondents. Three categories of data-public, sensitive and restricted-can be accessed through procedures described on the HRS website (hrsonline.isr.umich.edu). © The Author 2014; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.


Rubenstein J.H.,Veterans Affairs Center for Clinical Management Research | Rubenstein J.H.,University of Michigan | Thrift A.P.,Baylor College of Medicine | Thrift A.P.,Fred Hutchinson Cancer Research Center
Best Practice and Research: Clinical Gastroenterology | Year: 2015

Screening for Barrett's oesophagus is an attractive notion due to the rising incidence of oesophageal adenocarcinoma, the relative ease of acquiring tissue from the oesophagus, and the availability of endoscopic therapy for early neoplastic lesions. If screening is recommended, the question remains: which patients should be screened? Endoscopy is frequently performed in patients with symptoms of gastro-oesophageal reflux disease, but the vast majority of patients diagnosed with oesophageal adenocarcinoma have never undergone a prior endoscopy. The efficiency of screening needs to be improved. A number of tools for predicting the presence of Barrett's oesophagus or future risk of developing oesophageal adenocarcinoma are available. More research is needed to validate these tools and to identify the thresholds at which screening should be offered. © 2014 Elsevier Ltd. All rights reserved.


Sripada R.K.,University of Michigan | Sripada R.K.,Veterans Affairs Center for Clinical Management Research | Garfinkel S.N.,Brighton and Sussex Medical School | Liberzon I.,University of Michigan
Frontiers in Human Neuroscience | Year: 2013

Convergent evidence suggests that individuals with posttraumatic stress disorder (PTSD) exhibit exaggerated avoidance behaviors as well as abnormalities in Pavlonian fear conditioning. However, the link between the two features of this disorder is not well understood. In order to probe the brain basis of aberrant extinction learning in PTSD, we administered a multimodal classical fear conditioning/extinction paradigm that incorporated affectively relevant information from two sensory channels (visual and tactile) while participants underwent fMRI scanning. The sample consisted of fifteen OEF/OIF veterans with PTSD. In response to conditioned cues and contextual information, greater avoidance symptomatology was associated with greater activation in amygdala, hippocampus, vmPFC, dmPFC, and insula, during both fear acquisition and fear extinction. Heightened responses to previously conditioned stimuli in individuals with more severe PTSD could indicate a deficiency in safety learning, consistent with PTSD symptomatology. The close link between avoidance symptoms and fear circuit activation suggests that this symptom cluster may be a key component of fear extinction deficits in PTSD and/or may be particularly amenable to change through extinction-based therapies. © 2013 Sripada, Garfinkel and Liberzon.


Hayward R.A.,Veterans Affairs Center for Clinical Management Research | Reaven P.D.,Phoenix VA Health Care System | Wiitala W.L.,Veterans Affairs Center for Clinical Management Research | Bahn G.D.,Hines Veterans Administration Hospital | And 5 more authors.
New England Journal of Medicine | Year: 2015

BACKGROUND: The Veterans Affairs Diabetes Trial previously showed that intensive glucose lowering, as compared with standard therapy, did not significantly reduce the rate of major cardiovascular events among 1791 military veterans (median follow-up, 5.6 years). We report the extended follow-up of the study participants. METHODS: After the conclusion of the clinical trial, we followed participants, using central databases to identify procedures, hospitalizations, and deaths (complete cohort, with follow-up data for 92.4% of participants). Most participants agreed to additional data collection by means of annual surveys and periodic chart reviews (survey cohort, with 77.7% follow-up). The primary outcome was the time to the first major cardiovascular event (heart attack, stroke, new or worsening congestive heart failure, amputation for ischemic gangrene, or cardiovascular-related death). Secondary outcomes were cardiovascular mortality and all-cause mortality. RESULTS: The difference in glycated hemoglobin levels between the intensive-therapy group and the standard-therapy group averaged 1.5 percentage points during the trial (median level, 6.9% vs. 8.4%) and declined to 0.2 to 0.3 percentage points by 3 years after the trial ended. Over a median follow-up of 9.8 years, the intensive-therapy group had a significantly lower risk of the primary outcome than did the standardtherapy group (hazard ratio, 0.83; 95% confidence interval [CI], 0.70 to 0.99; P = 0.04), with an absolute reduction in risk of 8.6 major cardiovascular events per 1000 person-years, but did not have reduced cardiovascular mortality (hazard ratio, 0.88; 95% CI, 0.64 to 1.20; P = 0.42). No reduction in total mortality was evident (hazard ratio in the intensive-therapy group, 1.05; 95% CI, 0.89 to 1.25; P = 0.54; median follow-up, 11.8 years). CONCLUSIONS: After nearly 10 years of follow-up, patients with type 2 diabetes who had been randomly assigned to intensive glucose control for 5.6 years had 8.6 fewer major cardiovascular events per 1000 person-years than those assigned to standard therapy, but no improvement was seen in the rate of overall survival. (Funded by the VA Cooperative Studies Program and others; VADT ClinicalTrials.gov number, NCT00032487.) Copyright © 2015 Massachusetts Medical Society. All rights reserved.


Rubenstein J.H.,Veterans Affairs Center for Clinical Management Research | Rubenstein J.H.,University of Michigan | Shaheen N.J.,University of North Carolina at Chapel Hill
Gastroenterology | Year: 2015

Esophageal adenocarcinoma (EAC) is rapidly increasing in incidence in Western cultures. Barrett's esophagus is the presumed precursor lesion for this cancer. Several other risk factors for this cancer have been described, including chronic heartburn, tobacco use, white race, and obesity. Despite these known associations, most patients with EAC present with symptoms of dysphagia from late-stage tumors; only a small number of patients are identified by screening and surveillance programs. Diagnostic analysis of EAC usually commences with upper endoscopy followed by cross-sectional imaging. Endoscopic ultrasonography is useful to assess the local extent of disease as well as the involvement of regional lymph nodes. T1a EAC may be treated endoscopically, and some patients with T1b disease may also benefit from endoscopic therapy. Locally advanced disease is generally managed with esophagectomy, often accompanied by neoadjuvant chemoradiotherapy or chemotherapy. The prognosis is based on tumor stage; patients with T1a tumors have an excellent prognosis, whereas few patients with advanced disease have long-term survival. © 2015 by the AGA Institute.


Rubenstein J.H.,Veterans Affairs Center for Clinical Management Research | Rubenstein J.H.,University of Michigan | Chen J.W.,University of Michigan
Gastroenterology Clinics of North America | Year: 2014

The prevalence of gastroesophageal reflux disease (GERD) symptoms increased approximately 50% until the mid-1990s, when it plateaued. The incidence of complications related to GERD including hospitalization, esophageal strictures, esophageal adenocarcinoma, and mortality also increased during that time period, but the increase in esophageal adenocarcinoma has since slowed, and the incidence of strictures has decreased since the mid-1990s. GERD is responsible for the greatest direct costs in the United States of any gastrointestinal disease, and most of those expenditures are for pharmacotherapy. Risk factors for GERD include obesity, poor diet, lack of physical activity, consumption of tobacco and alcohol, and respiratory diseases. © 2014.


Kahn J.M.,University of Pittsburgh | Cicero B.D.,University of Pittsburgh | Wallace D.J.,University of Pittsburgh | Iwashyna T.J.,University of Michigan | Iwashyna T.J.,Veterans Affairs Center for Clinical Management Research
Critical Care Medicine | Year: 2014

OBJECTIVE:: ICU telemedicine is a novel approach for providing critical care services from a distance. We sought to study the extent of use and patterns of adoption of this technology in U.S. ICUs. DESIGN:: Retrospective study combining a systematic listing of ICU telemedicine installations with hospital characteristic data from the Centers for Medicare and Medicaid Services. We examined adoption over time and compared hospital characteristics between facilities that have adopted ICU telemedicine and those that have not. SETTING:: U.S. ICUs. SETTING:: U.S. hospitals from 2002 to 2010. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: The number of hospitals using ICU telemedicine increased from 16 (0.4% of total) to 213 (4.6% of total) between 2003 and 2010. The number of ICU beds covered by telemedicine increased from 598 (0.9% of total) to 5,799 (7.9% of total). The average annual rate of ICU bed coverage growth was 101% per year in the first four study years but slowed to 8.1% per year over the last four study years (p < 0.001 for difference in linear trend). Compared with non-adopting hospitals, hospitals adopting ICU telemedicine were more likely to be large (percentage with > 400 beds: 11.1% vs 3.7%, p < 0.001), teaching (percentage with resident coverage: 31.4% vs 21.9%, p = 0.003), and urban (percentage located in metropolitan statistical areas with more than 1 million residents: 45.3% vs 30.1%, p < 0.001). CONCLUSIONS:: ICU telemedicine adoption was initially rapid but recently slowed. Efforts are needed to uncover the barriers to future growth, particularly regarding the optimal strategy for using this technology most effectively and efficiently. © 2013 by the Society of Critical Care Medicine and Lippincott.


Langa K.M.,University of Michigan | Langa K.M.,Veterans Affairs Center for Clinical Management Research | Levine D.A.,University of Michigan | Levine D.A.,Veterans Affairs Center for Clinical Management Research
JAMA - Journal of the American Medical Association | Year: 2014

Conclusions and Relevance: Cognitive decline and MCI have important implications for patients and their families and will require that primary care clinicians be skilled in identifying and managing this common disorder as the number of older adults increases in coming decades. Current evidence supports aerobic exercise, mental activity, and cardiovascular risk factor control in patients with MCI.Importance: Cognitive decline is a common and feared aspect of aging. Mild cognitive impairment (MCI) is defined as the symptomatic predementia stage on the continuum of cognitive decline, characterized by objective impairment in cognition that is not severe enough to require help with usual activities of daily living.Objective: To present evidence on the diagnosis, treatment, and prognosis of MCI and to provide physicians with an evidence-based framework for caring for older patients with MCI and their caregivers.Evidence Acquisition: We searched PubMed for English-language articles in peer-reviewed journals and the Cochrane Library database from inception through July 2014. Relevant references from retrieved articles were also evaluated.Findings: The prevalence of MCI in adults aged 65 years and older is 10% to 20%; risk increases with age and men appear to be at higher risk than women. In older patients with MCI, clinicians should consider depression, polypharmacy, and uncontrolled cardiovascular risk factors, all of which may increase risk for cognitive impairment and other negative outcomes. Currently, no medications have proven effective for MCI; treatments and interventions should be aimed at reducing cardiovascular risk factors and prevention of stroke. Aerobic exercise, mental activity, and social engagement may help decrease risk of further cognitive decline. Although patients with MCI are at greater risk for developing dementia compared with the general population, there is currently substantial variation in risk estimates (from <5%to 20% annual conversion rates), depending on the population studied. Current research targets improving early detection and treatment of MCI, particularly in patients at high risk for progression to dementia.

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