Salt Lake City Veterans Affairs Health Care System

Salt Lake City, UT, United States

Salt Lake City Veterans Affairs Health Care System

Salt Lake City, UT, United States

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Nelson S.D.,Salt Lake City Veterans Affairs Health Care System | Nelson S.D.,University of Utah | Nelson R.E.,Salt Lake City Veterans Affairs Health Care System | Nelson R.E.,University of Utah | And 10 more authors.
Osteoporosis International | Year: 2014

Introduction: We evaluated the cost-effectiveness of training rural providers to identify and treat veterans at risk for fragility fractures relative to referring these patients to an urban medical center for specialist care. The model evaluated the impact of training on patient life years, quality-adjusted life years (QALYs), treatment rates, fracture incidence, and costs from the perspective of the Department of Veterans Affairs.Methods: We constructed a Markov microsimulation model to compare costs and outcomes of a hypothetical cohort of veterans seen by rural providers. Parameter estimates were derived from previously published studies, and we conducted one-way and probabilistic sensitivity analyses on the parameter inputs.Results: Base-case analysis showed that training resulted in no additional costs and an extra 0.083 life years (0.054 QALYs). Our model projected that as a result of training, more patients with osteoporosis would receive treatment (81.3 vs. 12.2 %), and all patients would have a lower incidence of fractures per 1,000 patient years (hip, 1.628 vs. 1.913; clinical vertebral, 0.566 vs. 1.037) when seen by a trained provider compared to an untrained provider. Results remained consistent in one-way sensitivity analysis and in probabilistic sensitivity analyses, training rural providers was cost-effective (less than $50,000/QALY) in 70 % of the simulations.Summary: This is a cost-effectiveness analysis of training rural providers to identify and treat osteoporosis. Results showed a slight cost savings, increase in life years, increase in treatment rates, and decrease in fracture incidence. However, the results were sensitive to small differences in effectiveness, being cost-effective in 70 % of simulations during probabilistic sensitivity analysis.Conclusions: Training rural providers to identify and treat veterans at risk for fragility fractures has a potential to be cost-effective, but the results are sensitive to small differences in effectiveness. It appears that provider education alone is not enough to make a significant difference in fragility fracture rates among veterans. © 2014, International Osteoporosis Foundation and National Osteoporosis Foundation.


Nelson R.E.,University of Utah | Battistone M.J.,University of Utah | Ashworth W.D.,Salt Lake City Veterans Affairs Health Care System | Barker A.M.,Salt Lake City Veterans Affairs Health Care System | And 5 more authors.
Arthritis Care and Research | Year: 2014

Objective Community-based outpatient clinics (CBOCs) have been established by the Department of Veterans Affairs (VA) to provide primary care services to veterans living in remote and rural regions. The objective of this study was to evaluate the cost effectiveness of training rural primary care providers to perform knee injections in CBOCs, thereby avoiding referring the patient to an urban medical center for an injection by rheumatology or orthopedic specialists. Methods We developed a decision-analysis model to compare costs and outcomes between rural providers who are trained to perform knee injections versus those who are not trained, therefore requiring a referral to a specialist to provide the injections. The model was run separately using costs from the perspective of the VA as well from the patient's perspective. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses were performed using 10,000 second-order Monte Carlo simulations. Results In our base-case analyses, the incremental cost-effectiveness ratio for trained rural providers was 21,190/QALY using costs from the perspective of the VA and 205/QALY using costs from the patient's perspective. Training rural providers was cost effective in 74.4% and 93.6% of 10,000 Monte Carlo simulations at a willingness-to-pay threshold of 50,000/QALY from the perspectives of the VA and the patient, respectively. Conclusion Training rural providers to perform knee injections for patients with knee pain secondary to osteoarthritis appears cost effective using the commonly used threshold of 50,000/QALY if more than 20 such patients per year are seen at rural primary care clinics. These results provide support for our ongoing efforts to implement such a training program. Copyright © 2014 by the American College of Rheumatology.


Kim T.-S.,University of Utah | Kim T.-S.,Catholic University of Korea | Kondo D.G.,University of Utah | Kondo D.G.,Salt Lake City Veterans Affairs Health Care System | And 3 more authors.
Psychiatry Investigation | Year: 2014

Objective Methamphetamine (MA) use rates in the United States (US) have consistently demonstrated geographical variation and have been higher in the West and Midwest. This uneven pattern of use could be explained by regional differences in MA manufacturing and distribution, but may also result from differences in altitude. The hypobaric hypoxia found at high altitude alters neurotransmitter synthesis in the brain, which may contribute to MA use. The present study investigated the relationship between mean altitude and MA use rate in the 48 contiguous US states and the District of Columbia. Methods : State-level estimates of past year MA use were extracted from the National Survey on Drug Use and Health report. The mean altitude of each state was calculated using the Shuttle Radar Topography Mission altitude data set. Results: There was a significant positive correlation between mean state altitude and MA use rate (r=0.66, p<0.0001). Multivariate linear regression analysis showed that altitude remained a significant predictor for MA use rate (β=0.36, p=0.02), after adjusting for age, ethnicity, education, socioeconomic level, employment, MA laboratory incidents, subpopulations, and other substance use. Conclusion: Altitude appears to a possible contributing factor for regional variation of MA use in the US. Further studies will be required to determine biological changes in neurotransmission resulting from chronic mild hypoxia at high altitude in MA users. © 2014 Korean Neuropsychiatric Association.


Fiedler K.K.,University of Utah | Kim N.,University of Ulsan | Kondo D.G.,University of Utah | Kondo D.G.,Salt Lake City Veterans Affairs Health Care System | And 2 more authors.
Journal of Addiction Medicine | Year: 2012

Objectives: Recently, increased rates of suicide in US counties at higher altitudes have been noted. Because of the documented association between cocaine use and suicide, we hypothesized that there would be a correlation between incidence of cocaine use and altitude of residence. Methods: Cocaine use data were obtained from the Substate Substance Abuse Estimates from the 1999-2001 National Surveys on Drug Use and Health. Data related to the percentages of people 12 years or older who used cocaine in the past year. Average elevation for US counties was calculated using the Shuttle Radar Topography Mission elevation data set, and subject region elevation was calculated by averaging the weighted elevations of each region's relevant counties. The correlation between elevation of a substate region and incidence of cocaine use in that region was calculated using Pearson correlation coefficients. Results: A significant correlation exists between mean altitude of a substate region and incidence of cocaine use in that region (r = 0.34; P < 0.0001). Regression analysis controlling for age, sex, race, education level, income, unemployment, and population density was performed. Altitude remained a significant factor (P = 0.007), whereas male sex (P = 0.008) and possessing less than a college education (P < 0.0001) were also significant predictors of self-reported cocaine use in the past year. It is important to note that cocaine use was assessed in isolation of other drugs of abuse, an additional confounding variable. Conclusions: This study demonstrates a significant correlation between altitude of substate region of residence and incidence of cocaine use. It is possible that stress response due to hypoxia is responsible; however, this requires further investigation. However, because other substance use was not assessed, specificity of this association is unknown. In addition, this correlation may help explain the increased rate of suicide in areas of higher elevation. Copyright © 2012 American Society of Addiction Medicine.


Huston H.K.,University of Utah | Abramowitz M.K.,Yeshiva University | Zhang Y.,University of Utah | Greene T.,University of Utah | And 2 more authors.
Nephrology | Year: 2015

Aim Low serum bicarbonate is a strong mortality risk factor in people with low estimated glomerular filtration rate (eGFR). It may also raise mortality risk in people with normal eGFR. This study investigated whether higher net endogenous acid production (NEAP), an estimate of net dietary acid intake and a risk factor for chronic kidney disease (CKD) progression, associates with higher mortality in people with and without low eGFR. Methods NEAP was calculated among adult participants in the Third National Health and Nutrition Examination Survey as -10.2 + 54.5 x (protein intake in grams per day/potassium intake in milliequivalent per day). Cox models were performed in the (i) total population and (ii) low eGFR and (iii) normal eGFR subgroups using the lowest NEAP quartile as the reference. Results Sixteen thousand nine hundred six participants were included in the analysis. The mortality hazard ratios (95% confidence interval) for the highest NEAP quartile (72-145 mEq/day) were: (i) 0.75 (0.62-0.90) in the total population; (ii) 0.77 (0.51-1.17) in the low eGFR subgroup; and (iii) 0.75 (0.61-0.93) in the normal eGFR subgroup after adjusting for demographics, serum bicarbonate, eGFR, albuminuria and comorbidities. The mortality hazard ratios in the second and third NEAP quartiles were similar to the lowest (reference) NEAP quartile in the total population and low and normal eGFR subgroups. Conclusions Higher NEAP is not associated with higher mortality in people with low or normal eGFR. Future studies should consider the effect of modifying dietary acid and alkali intake on mortality and CKD progression in people with reduced eGFR. © 2014 Asian Pacific Society of Nephrology.


Delmastro K.,University of Utah | Hellem T.,University of Utah | Kim N.,University of Utah | Kondo D.,University of Utah | And 4 more authors.
Journal of Affective Disorders | Year: 2011

Background: Major depressive disorder (MDD) is a common disorder that is often associated with suicide. We have recently suggested that elevation may play a role in regional variations in rates of suicide. We hypothesize that there is also a significant correlation between incidence of MDD and elevation of residence. Methods: The substate estimates from the 2004 to 2006 National Surveys on Drug Use and Health (NSDUH) report from SAMHSA was used to extract substate level data related to percentages of people 18 years or older who experienced serious psychological distress or a major depressive episode in the past year. Mean elevation of each substate region was calculated by averaging the weighted elevations of its relevant counties. Average elevation for United States counties was calculated using the Shuttle Radar Topography Mission (SRTM) elevation dataset. Pearson correlation coefficients were computed to investigate the association between average substate elevation and rate of serious psychological distress or major depressive episode. Results: There was a significant correlation between percentage of people experiencing serious psychological distress in the past year in a substate region and that substate region's mean elevation (r = 0.18; p = 0.0005), as well as between the percentage of people having at least one major depressive episode in the past year in a substate region and that substate region's mean elevation (r = 0.27; p 0.0001). Conclusions: Elevation appears to be a significant risk factor for MDD. Further studies are indicated to determine whether the increased incidence of depression with increased elevation may be due to the hypoxic effects on subjects with MDD. © 2010 Elsevier B.V. All rights reserved.

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